Collagenase clostridium histolyticum is no longer available in Europe: what does this mean for our patients with Peyronie's Disease?

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.

Impact of Collagenase Injection on Dupuytren Disease Treatment in Japan: A Comprehensive Survey of Trends

BACKGROUND

Collagenase Clostridium histolyticum (CCH) injection, an effective enzymatic fasciotomy treatment for Dupuytren disease (DD), was abruptly withdrawn from the healthcare market outside the United States in 2020. The impact on patients, physicians and hospitals of this helpful surgical alternative no longer being available has been little studied.

METHODS

To investigate the impact of the withdrawal of CCH in Japan, we used the National Database Open Data Japan from 2014 to 2020. Published by the government, it contains summary data of the National Database of Health Insurance Claims and Specific Health Checkups of Japan. We extracted the numbers of CCH injections with Xiaflex, the product name in Japan, and surgeries identified by "Dupuytren contracture surgery codes." Each treatment was further parsed into one of 12 predefined regions in which it had taken place and by whether it had been delivered on an inpatient or outpatient basis.

RESULTS

From its introduction in 2015, the number of DD patients treated with CCH increased in each successive year, reaching a peak in 2019, while the number of surgeries decreased with time. After the withdrawal in 2020, the number of surgeries increased to 1.5 times the 2019 number notwithstanding the impact of COVID-19, but the total number of patients treated decreased by 43%. In the initial regional analysis, CCH accounted for approximately 40% of all DD treatments in the less populous areas, with the exception of the Tohoku region, and more than 50% in the other regions. By 2019, the share of CCH treatment had increased in all regions. There was no significant correlation between the number of hand surgeons authorized to use CCH and the number of CCH cases within each region.

CONCLUSIONS

CCH increased treatment options for patients and surgeons. The withdrawal of this valuable pharmaceutical resulted in an increase in the number of surgeries amidst a decrease in the total number of treatments and lost opportunities for patients.

New protocol in the treatment of Peyronie's disease by combining platelet-rich plasma, percutaneous needle tunneling, and penile modeling: Preliminary results

INTRODUCTION

Intra-lesional injections of collagenase (Xiapex®) were the only non-invasive treatment option for Peyronie's disease (PD), until their withdrawal from the European market.

OBJECTIVE

To evaluate the feasibility, efficacy, and safety of a combined treatment of percutaneous needle tunnelling (PNT) with penile modelling (PM) and the injection of platelet-rich plasma (PRP) under general anesthesia in the treatment of PD.

PATIENTS AND METHOD

A prospective case series study included patients with PD in a stable phase who underwent this procedure between March 2020 and January 2023. The main outcome was an improvement in curvature.

RESULT

Thirty-six patients underwent this novel approach for the treatment of PD. The pretreatment mean±standard deviation (SD) curvature degree was 57.5±20.61° (range 20-90°). After the protocol, the mean curvature degree was 40.86±25.13° (range 0-90°). The curvature angle improved significantly (P=0.0001), with a mean improvement difference of 16.85±14.81° (range 0-50°) and a mean improvement percentage of 47.7±40.29% (range 0-100%).

CONCLUSION

Our preliminary experience suggests that PNT and PRP injections with PM are effective and safe for the treatment of penile deformity of PD.

LEVEL OF EVIDENCE

4: case series study.

Peyronie's disease - outcomes of collagenase clostridium histolyticum injection: A systematic review

Objective

To review recent literature pertaining to collagenase clostridium histolyticum (CCh)and other intralesional (IL) therapies for the treatment of Peyronie’s disease (PD). 

Methods

A systematic search of literature was performed using MEDLINE and PubMed.‘Peyronie’s Disease Clostridium Histolyticum’, ‘Peyronie’s Disease Intralesional’, ‘Peyronie’sDisease Causes’, and ‘Atypical Peyronie’s Disease’ were used as query entries. Inclusion criteriarequired English text from 1980 onwards and have a full text available. Records were reviewed for study power, accuracy, and relevance to our research topic. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.

Results

Recent literature supports the notion that CCh is the most effective IL treatment forpatients with typical and atypical PD. The capstone CCh study was the IMPRESS trial thatshowed a 34% reduction in curvature with a mean (SD) – 17.0 (14.8)° reduction with IL CCh,while men in the placebo saw an average 18.2% decrease in penile bend with a mean (SD) – 9.3 (13.6)° per person (P < 0.001). A shortened protocol for IL CCh treatment offered a 31.4%reduction in curvature, while decreasing cost and office visits, potentially increasing patientcompliance. Lastly, literature shows CCh is used most in atypical cases, with ~64.8% of patients being treated with CCh, probably because of the high efficacy and safetyprofile that it offers. Serious complications associated with CCh include urethralinjury, corporal rupture, and penile fracture.

Conclusion

Since the approval of CCh by the United States Food and Drug Administration in2013, it has been a staple in the treatment of PD, and here we report the continuedsuperiority of this therapy. CCh is an effective, minimally invasive option in most PDpopulations; however, recent changes have made CCh unavailable for commercial use outside the United States, impacting many patients who have previously benefited.