Improved Peyronie's Disease Curvature Outcomes Using a Novel Collagenase Administration Protocol

Contemporary nonsurgical management of Peyronie's disease

PURPOSE OF REVIEW

Peyronie's disease characterizes a condition in which there is angular curvature of the penis. We know that the most patients with Peyronie's disease will not have spontaneous resolution of their penile curvature. As such, patients who desire treatment can elect for either surgical or nonsurgical therapy. Herein, we discuss the contemporary nonsurgical management options for Peyronie's disease.

RECENT FINDINGS

Nonsurgical management options for Peyronie's disease include oral therapy, intra-lesional injections, and penile traction therapy. At the time of this review, there is essentially no high-level evidence demonstrating any benefit for oral therapy. Penile traction therapy has evolved over the past decade with second-generation devices demonstrating strong efficacy and more convenient treatment regimens. Intra-lesional options include collagenase Clostridium histolyticum (CCH), verapamil, and interferon alpha-2b. The IMPRESS trial garnered the strongest level of evidence (two randomized, double-blind, placebo-controlled trials) to support the safety and efficacy of CCH. Verapamil is an option supported by several urological societies; however, the evidence supporting its efficacy is inconsistent between several notable series and randomized studies. IFN alpha 2b can produce modest improvement in curvature, however, is not available for use in North America.

SUMMARY

Herein, we will discuss notable advances in nonsurgical management of Peyronie's disease.

An illustrated description of a modified collagenase Clostridium histolyticum protocol for Peyronie's disease

BACKGROUND

Our team recently published outcomes of a novel technique for the administration of Collagenase Clostridium histolyticum (CCH), which resulted in improved curvature outcomes and reduced number of CCH injections required.

AIM

To provide a detailed and illustrated description of our CCH-administration technique.

METHODS

A descriptive summary is provided of the technique, including drug administration, protocol modifications, and post-treatment protocols. Additional details are provided on measurement techniques and disease classification.

OUTCOMES

Key outcomes include a written and illustrated description of the injection technique and pre-, and postinjection management.

RESULTS

The use of a modified CCH-administration technique has previously been shown to result in mean improvements of 54%-58% in penile curvature while significantly reducing the total number of injections applied. These findings represent the largest improvements published to date. Key aspects of the technique include back-to-back day administration of 0.9 mg suspended in 0.8 mL, application to an ~3 × 1 cm region, inclusion of the dorsal septum (exempting ventral curves), administration during a full erection (day 1), repeat artificial erections with the first injection of each series, in-office modeling (day 2), and post-treatment use of PDE5s and Restorex traction. Appropriate patient counseling on expectations and necessity of complying with all treatment protocols (including post-treatment wrapping) is critical to optimizing outcomes. Common side effects may include ecchymoses, hematomas, blood blisters, impacts on erections and penile sensation, bronzing of the skin, and skin scarring, while more severe complications are rare (<1%).

CLINICAL IMPLICATIONS

The current manuscript provides a more detailed description of previously published techniques to aid providers in implementation and to mitigate potential adverse events.

STRENGTHS AND LIMITATIONS

Strengths include reliance on the largest single-team series published on CCH outcomes, rigorous study methodology, prospective/sequential series, and step-wise improvements. Limitations include data obtained from a single center.

CONCLUSION

The current manuscript provides a detailed narrative and illustrated description of our current CCH-administration technique.

Changes in Point of Maximal Curvature During Collagenase Clostridium Histolyticum Injections for Peyronie's Disease

OBJECTIVE

To determine change in the point of maximal curvature (POMC) during Collagenase Clostridium histolyticum (CCH) injections for Peyronie's disease (PD).

METHODS

A prospective database has been maintained of all men undergoing CCH injections since March 2014. For the current study, data were abstracted on the POMC with each curve assessment and correlated with demographic and clinical factors. Maximal changes were defined as the largest change in POMC from baseline.

RESULTS

Six hundred and eighteen men underwent ≥1 series of CCH, with 313 having a baseline and subsequent POMC measurements available. Median baseline curvature was 60.0° and POMC 2.8 cm. Among 189 men who were satisfied or completed 8 CCH injections, the median improvement in penile curvature was -27.5° (40.9%). The median maximal change in POMC during CCH treatment was 1.0 cm (interquartile range, 0.5, 1.8). Overall, 55.6% had changes in POMC of ≥1 cm, 23.6% ≥2 cm, 8.9% ≥3 cm, and 3.8% ≥4 cm. Multivariate logistic regression identified ventral curvature as a predictor of larger change in POMC, after controlling for other variables. Study limitations included the observational, non-randomized study design and potential for intra- and inter-individual measurement variability. Strengths are the inclusion of an all-comer population, large series, prospective database, and routine objective assessments.

CONCLUSION

Approximately half of men with PD undergoing CCH experience ≥1 cm of change in POMC during the treatment course, with nearly 1/4 experiencing ≥2 cm. Findings suggest that patients may benefit from repeat curvature assessments with each CCH series to optimize accuracy of drug administration.

Outcomes of collagenase Clostridium histolyticum in men with ventral curvatures: an updated series

BACKGROUND

The efficacy and safety of collagenase Clostridium histolyticum (CCH) have been demonstrated in the treatment of men with Peyronie's disease (PD); however, the pivotal clinical trials excluded men with ventral penile curvature.

AIM

The study sought to evaluate outcomes of CCH treatment in men with ventral curvatures secondary to PD.

METHODS

Men with PD treated with CCH were identified from a prospective database. Patients received up to 4 series of CCH injections using a progressively modified protocol over time. Results were compared between those with baseline ventral vs nonventral penile curvatures.

OUTCOMES

Changes in penile curvature, Peyronie's Disease Questionnaire scores, International Index of Erectile Function scores, nonstandardized assessments, and adverse events.

RESULTS

A total of 560 men with PD (85 ventral curvature, 475 nonventral curvature) were included in the analysis. Baseline median curvature was 60.0° (interquartile range, 48.8°-75.0°) in the ventral cohort and 65.0° (interquartile range, 45.0°-80.0°) in the nonventral cohort. Median change from baseline penile curvature was -25.0° in the ventral cohort vs -24.0° in the nonventral cohort (P = .08, between-group comparison), which corresponded to curvature reductions of 44.7% and 33.6%, respectively (P = .03). In the subset of patients who completed CCH treatment (ie, received 8 injections or discontinued early because of patient satisfaction with curvature reduction), median change from baseline was -35.0° in the ventral cohort vs -25.0° in the nonventral cohort (P < .05); median percent improvement was 48.3% and 37.5%, respectively (P = .11). Median change from baseline in Peyronie's Disease Questionnaire and International Index of Erectile Function domain scores and adverse events were similar between cohorts, with the exception of possibly higher hematoma rates in the nonventral group (50% vs 37%; P = .05). No urethral injuries were sustained in either cohort.

CLINICAL IMPLICATIONS

Data support the use of CCH for the treatment of ventral as well as nonventral penile curvatures in men with PD.

STRENGTHS AND LIMITATIONS

Study strengths are the inclusion of a general clinical population of men with PD, the prospective design, and the relatively large series of men with ventral curvature. Limitations include the single-center and observational nature of the study.

CONCLUSION

CCH was safe and effective in the treatment of both ventral and nonventral penile curvatures in men with PD.