Surgical approaches for advanced Peyronie's disease patients

Systematic evidence-based analysis of plaque injection therapy for Peyronie's disease

OBJECTIVE

We evaluated the peer-reviewed urology literature for intraplaque injection of medication for Peyronie's disease and assessed the quality of studies via rigorous evidence-based medicine criteria.

METHODS

We performed a search of peer-reviewed literature looking at all agents used to treat Peyronie's disease by intraplaque injections. These were then evaluated using the Oxford Centre for Evidence-Based Medicine criteria, which ranks studies from strongest (level 1) to weakest (level 5) strength of evidence.

RESULTS

Of the 19 studies found involving injection therapy for Peyronie's disease, 17 showed positive results. Six studies using injectable corticosteroids were identified and though all showed positive results, they were of level 4 quality. Two collagenase injection studies (one level 4 and one level 2 study) were identified, both of which showed positive results. All four verapamil injection studies found (three level 4 and one level 2 study) showed positive results. Seven papers involving interferon alpha2-beta injections were evaluated (six level 4 and one level 1 study), five of which showed positive outcomes and two of which showed no significant benefit.

CONCLUSIONS

Ninety percent of the studies regarding Peyronie's disease showed positive outcomes. Unfortunately, most of these have not offered convincing evidence-based data, with only one positive study meeting level 1 Oxford criteria for clinical efficacy. Standardised outcome measures were not used, making comparisons difficult. These results reveal the need for the development of validated outcome measures and well-designed controlled trials to determine optimal therapeutic intervention for this disorder.

The dorsal lamina of the rectus sheath: a suitable grafting material for the penile tunica albuginea in Peyronie's disease?

OBJECTIVE

To estimate the morphological suitability of human connective tissue structures from different regions as graft material in Peyronie's disease, and to present preliminary results from 12 patients with grafting of corporal bodies using autologous rectus sheath.

PATIENTS AND METHODS

In five male cadavers the penile tunica albuginea was compared with the dorsal lamina of the rectus sheath, the palmar aponeurosis, the iliotibial tract and the Achilles tendon by using histological sections stained with haematoxylin and eosin, Crossmon's trichrome stain and resorcin-fuchsin. Surgical results and complication rates were investigated in 12 patients with Peyronie's disease after grafting the corporal bodies with autologous rectus sheath to correct their penile curvature.

RESULTS

On histology, the penile tunica albuginea showed a three-dimensional meshwork of collagenous and elastic fibres. The dorsal lamina of the rectus sheath had a remarkably similar fibre structure. The other tissues had a different histology, with long collagenous fibres in parallel orientation and elastic fibres restricted to the loose connective tissue around blood vessels and nerves. Clinically, the penile deviation was successfully corrected in 10 patients; there were two residual deviations (15 degrees and 35 degrees ). There were minor complications after surgery in six patients, not requiring surgery.

CONCLUSIONS

The dorsal lamina of the rectus sheath has similar morphological characteristics to the tunica albuginea, and therefore represents an ideal autologous graft; the first clinical results are promising.

Surgical treatment of Peyronie's disease based on penile length and degree of curvature

The aim of the study was to present the selection criteria for surgical techniques for the treatment of patients with Peyronie's disease. A total of 55 men with Peyronie's disease were surgically treated. We created specific criteria for selection of the appropriate surgical technique. All patients had a stable disease for 6 months and impossible vaginal intromission. All patients had subjective (as reported by the patient) and/or objective normal penile rigidity (as observed after intracavernous administration of alprostadil). Also, they all underwent drug therapy, which was unsuccessful. Among them, 40 patients with penile curvature of <60 degrees and erect penile length of >13 cm underwent Nesbit's operation, whereas plaque excision and grafting with polytetrafluoroethylene patch was performed in 15 patients with penile curvature of > or =60 degrees and/or erect penile length of < or =13 cm. At a mean (+/-s.d.) follow-up of 81.1+/-33.8 and 78.7+/-32.8 months, respectively, straightening of the penis was achieved in 35 out of 40 (87.5%) and 12 out of 15 (80%) patients, respectively, whereas erectile dysfunction developed in two out of 40 (5%) and one out of 15 (6%), respectively. Shortening of the penis occurred in all 40 patients undergoing Nesbit's operation, and in none of the patients undergoing plaque excision. Six out of 40 (15%) patients undergoing Nesbit's operation reported subjective perception of penis shortening, whereas none of the patients undergoing plaque excision complained of this discomfort. In conclusion, we recommend the selection of surgical technique based on penile length and degree of curvature. Nesbit's operation is an appropriate surgical technique for the treatment of patients with erect penile length of >13 and deviation of <60 degrees , whereas the plaque excision and grafting with polytetraflouroethylene patch is a technique of choice in the treatment of patients with erect penile length of < or =13 and/or deviation of > or =60 degrees.