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The management of peyronie's disease: evidencebased 2010 guidelines

The Management of Peyronie’s Disease: Evidence-based
2010 Guidelinesjsm_18502359.2374

David Ralph, MD,* Nestor Gonzalez-Cadavid, PhD,† Vincenzo Mirone, MD,‡ Sava Perovic, MD,§Michael Sohn, MD,¶ Mustafa Usta, MD,** and Laurence Levine, MD†† *Institute of Urology, London UK; †Department Urology, UCLA, CA, USA; ‡University of Naples “Federico II”, Naples,Italy; §University of Belgrade, Belgrade, Serbia; ¶University Aachen, Germany; **Akdeniz University School of Medicine,Antalya, Turkey; ††Rush Medical College, Chicago, IL, USA A B S T R A C T
Introduction. The field of Peyronie’s disease is evolving and there is need for a state-of-the-art information in this area.
Aim. To develop an evidence-based state-of-the-art consensus report on the management of Peyronie’s disease.
Methods. To provide state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical manage-
ment of Peyronie’s Disease, representing the opinion of leading experts developed in a consensus process over a
2-year period.
Main Outcome Measures. Expert opinion was based on grading of evidence-based medical literature, widespread
internal committee discussion, public presentation, and debate.
Conclusions. The real etiology of Peyronie’s disease and the mechanisms of formation of the plaque still remain
obscure. Although conservative management is obtaining a progressively larger consensus among the experts,
surgical correction still remains the mainstay treatment for this condition. Ralph D, Gonzalez-Cadavid N, Mirone
V, Perovic S, Sohn M, Usta M, and Levine L. The management of Peyronie’s disease: Evidence-based 2010
guidelines. J Sex Med 2010;7:2359–2374.

Key Words. Peyronie’s Disease; Guidelines; Surgery; Pathology
Introduction
the patient and partner may be significantlyaffected, with an increased risk of depression, low P eyronie’s disease (PD) is currently consid- self-esteem, and relationship difficulties being ered a wound healing disorder that presents common [1–3]. Overall, approximately 30% of with a fibrous inelastic scar of the tunica albug- patients will have diabetes, which has been found inea that is currently believed to occur in the to be associated with advanced curvatures and vasculogenic ED [4,5]. Two thirds of patients trauma to the penis. It is characterized by the with PD are likely to have risk factors for arterial development of a palpable scar, which in the disease and therefore worsening long-term erec- erect state causes a variety of deformities, includ- tile function [5]. PD is a progressive disorder ing curvature, shortening, narrowing, and hinge with up to 48% of men having disease progres- effect. In the early phase there is often an inflam- sion if left untreated [6]. In most cases, PD may matory component that causes pain. PD is also be divided into an acute inflammatory phase and frequently associated with erectile dysfunction a chronic phase. During the former, there may be (ED), and a variety of other comorbid disorders, penile pain and curvature progression although including diabetes, hypertension, dyslipidemia, the pain typically resolves spontaneously within and low testosterone. The quality of life of both 6–18 months from onset in most patients [6].
2010 International Society for Sexual Medicine may cause penile shortening with or without PD—OVERVIEW GRADE A
a penile deformity [10]. The consistency of the PD is a physically and psychologically devas-
plaque, be it soft, tender, calcified, or ossified tating problem manifest by a fibrous inelastic
should be noted as this may act as a guide to scar of the tunica albuginea, which results in
management. Calcification may occur at initial a penile deformity (e.g., bending, narrowing,
presentation or develop over time. It appears hinging, shortening), as well as painful erec-
that calcification is not a manifestation of a more tions, all of which may lead to difficulty with
mature plaque as previously thought. Rather it intromission. There are relatively few high-
may represent a different genetic subtype of PD level evidence-based therapeutic studies.
An assessment of the curvature on erection is PREVALENCE OF PD GRADE B
best made by an intracavernosal injection of a Multiple demographic studies have been
vasoactive agent; a home photograph or a vacuum performed world-wide indicating a preva-
assisted erection test can be also useful in the diag- lence rate of 3–9% in adult men. Therefore,
nosis [12]. This also allows complex curvatures to PD is not a rare disorder.
be assessed and will aid in the decision for the typeof treatment best suited to the individual. The NATURAL HISTORY GRADE C
severe emotional distress that occurs is, in part, a The natural history of PD has been evaluated
result of the deformity, but mainly because of the in only a few level 2 and 3 studies indicating
penile shortening that occurs in almost all patients that spontaneous deformity resolution is not
with up to 50% of them being clinically depressed.
common and remains less than 13%.
It is imperative therefore that the stretched penilelength is measured preoperatively so that thepatients realize that the length loss postoperatively Patient Evaluation
is mainly a result of the disease itself and not to the The diagnosis of PD is usually apparent from the surgery [13–15]. ED associated with PD has been patient history and penile examination. The main reported in up to 58% of men [2,5]. It is not points to gather from the history are whether the uncommon for unsuspected PD to be diagnosed at disease is still active, the nature of the curvature the time of investigation of their ED [16,17]. Since and the presence of ED. Patients with short ED is a common finding in patients with PD [18].
disease duration (<12 months), penile pain, or a A detailed history of any arterial risk factors for recent change in penile deformity are still likely to ED should be noted and an assessment of erectile have active inflammatory disease and therefore are function best made by the validated International not surgical candidates and would be more likely Index of Erectile Function-5 questionnaire [19]. A to benefit from medical therapy. Penile pain may PD-specific questionnaire is in development and be persistent in the inflammatory stage of the should aid in the assessment of the man with PD disease but is usually only present during erection.
and may prove useful in evaluating quality of like- The pain is not usually severe in nature but may related changes following treatment.
interfere with sexual function although spontane-ous improvement usually occurs as the inflamma- tion settles within 6 months and almost all men Ultrasound is used to identify the site and con- will experience pain resolution by 18 months (94% sistency of the plaque and is a useful tool in the of 246 men treated conservatively) [6–9].
clinical trial setting to assess penile vascular blood- All the patients have either a well defined plaque flow parameters. It can also determine the extent or an area of induration that is palpable on phy- of plaque calcification as those men with extensive sical examination, even though patients may be calcification have historically been noted to not unaware of it [8]. The plaque is located on the respond well to nonsurgical therapies. Extensive dorsal surface of the penis in two thirds of patients calcification appears to be a primary indication for with a corresponding dorsal penile deformity [9].
surgical correction as these plaques do not respond Lateral and ventral sited plaques are not as to medical therapy. It is a minimally-invasive tech- common but result in more coital difficulties as nique that is more accurate than X-ray, CT scan, there is a greater deviation from the natural coital or MRI [20]. A vascular assessment should be per- angle. Multiple plaques located on opposite sides formed in all patients with ED as well as those of the penis or plaques appearing in the septum undergoing surgery and is best done using duplex ultrasound [21]. The results of this investigation affecting 39% of PD patients vs. only 1.2% in the can often show vascular disease in patients who report normal potency which may influence the Epidemiological studies showed that PD is significantly associated with diabetes [3,5,31,32,34,37,41–43]. Some of these reports provideddata supporting a significant association of PDwith obesity [34,38,43], hypertension [3,5,36,41], CLINICAL
DIAGNOSIS—OVERVIEW
hyperlipidemia [3,5,33,34,37,38], smoking [32,34, 37,38,42,43], and pelvic surgery [42].
There is no international standard for
evaluation or reporting on treatment out-
comes for PD. A detailed history should be

COMMON COMORBIDITIES GRADE D
obtained focusing on onset, duration, pain,
Multiple comorbidities have been identi-
and deformity.
fied, including ED, hypertension, diabetes
mellitus, hyperlipidenia, low testosterone,

CLINICAL
DIAGNOSIS—OBJECTIVE
and Dupuytren’s disease. It remains unclear
ASSESSMENT GRADE D
whether any of these contribute to the
Suggested objective measures include: mea-
development of PD.
suring stretched penile length, and describ-
ing plaque location (dorsal, ventral, septal,
proximal, distal, etc.)

Etiology and HistopathologyA widely accepted hypothesis on the etiology CLINICAL DIAGNOSIS—PLAQUE SIZE
of the PD plaque is that it originates from trauma or microtrauma to the erect penis [44–55] in Plaque measurement is inaccurate by any
patients with genetic predisposition to form modality, as well as operator dependent and
localized fibrosis as a response to trauma.
therefore is not a reliable assessment for
[56–62]. The main pathological process is tissue treatment response.
fibrosis with disorganization of elastic fibers,combined in most cases with fibrin accumulation CLINICAL
DIAGNOSIS—DUPLEX
and different degrees of inflammation [48,50, ULTRASOUND GRADE D
63–75]. Consequently, spontaneous regression is Dynamic duplex ultrasound provides assess-
ment of plaque calcification, vascular flow
Recent studies on an animal model suggest parameters, and objective measures of defor-
that transforming growth factor beta (TGFb1) mity. It is a useful but not necessary test.
74,81–83,87–95] play an important role in the for-mation of PD plaques. TGFb1 is also found in the Epidemiology: Prevalence and Comorbidities human PD plaque and is the main profibrotic Recent studies suggest a prevalence of PD in the factor in multiple tissues [84], while myofibro- population that can reach up to 9% [22–33], much blasts are a common feature in most tissue fibrosis and in abnormal wound healing [96], and their The mean age of onset of the condition in these persistence by the inhibition of programmed cell studies was 55–60 years, and penile curvature was death leads to scar formation [51]. Moreover, the present in over 80% of patients whereas pain- tunica albuginea is known to contain pluripotent ful erection was reported by over half of them stem cells that are potentially able to differentiate into myofibroblasts, smooth muscle cells, and History of a penile trauma has been reported by osteoblasts, and in a paracrine fashion to modulate the differentiation of a multipotent cell line into Some studies have revealed a significant asso- osteoblasts and myofibroblasts [11,97–109]. The ciation with ED in comparison to the non-PD presence of stem cells in the normal tunica albug- population [35,38,39,41]. The association with inea may explain the fibrotic and osteogenic pro- Dupuytren’s disease was only investigated since gression of the PD plaque upon the release of 1999 in two studies, where it was shown to be cytokines following microtrauma to the penis that highly significant in the older population [3], and would stimulate this cell lineage commitment.
the use of potassium paraminobenozoate, more PD—PATHOGENESIS GRADE C
recent articles showed a significant reduction in PD is a wound healing disorder occurring
plaque size but no change in pain or improvement in a presumed genetically susceptible in-
of the curvature [112]. These results, although dividual whose tunica albuginea responds
encouraging, will need to be confirmed in future inappropriately to an inciting event (i.e.,
trauma) with a proliferative, fibrotic reac-
tion resulting in an exuberant, inelastic scar.

A closer understanding of the etiopatho-
physiology is not yet established.
therapy prescribed by urologists for treating PD[113]. However, recent double-blind, placebo con-trolled, randomized studies showed nonsignificant improvement in pain, curvature, and plaque size, As a result of the lack of a clear understanding when compared with placebo [114,115].
of the etiopathophysiology, a cure has not beenfound. Therefore, a variety of treatment options have been used. The most current therapies are In 1992, Ralph et al. confirmed that the daily reviewed. The value of many published reports has administration of Tamoxifen 20 mg twice daily been questioned as most were not well controlled, can induce significant improvement in penile often had a small number of subjects in various pain, curvature, and plaque size in the early phases of stability and with limited reports on stages of the disease [116]. However, these objective measures of deformity change. Studies encouraging results have not been confirmed by focus on reduction of pain that appears to resolve with time untreated, and reduction of plaque size,which has never been found to correlate with curvature improvement. In the opinion of the Although initial studies showed that colchicine authors reduction of erect penile deformity (i.e., might be also effective in the early phase of the curve, narrowing, shortening) is the most critical disease according to the finding of two recent studies [118,119], recent series have showed thatcolchicine is no better than placebo [120].
CANDIDATES
NONSURGICAL
THERAPY GRADE C
Although the administration of vitamin E and Men with early phase disease (i.e., <12
colchicine in isolation has been proved to be inef- months induration) manifest by unstable or
fective, a recent double-blind randomized study progressive deformity and painful erections
has showed that the administration of a combina- as well as those not psychologically ready
tion of vitamin E and colchicine can induce sig- or interested in surgery may be considered
nificant improvement in plaque size, curvature, candidates for nonsurgical therapy.
and pain during the initial phase of PD [121].
NONSURGICAL TREATMENT OVER-
VIEW GRADE C
Although initial studies fail to demonstrate any Nonsurgical treatment has limited evidence
efficacy of this combination in the treatment of benefit, but multiple reports of deformity
of PD, recent data suggest that propionyl-l- stabilization or reduction makes it reason-
carnitine and verapamil are effective in terms of able to offer EMDA, and/or intralesional
plaque size reduction, pain, and penile curvature injection of verapamil or interferon, and/or
traction therapy.
PentoxifyllineIncreased levels of nitric oxide levels may be effec- tive in preventing progression of PD or revers- ing its fibrosis as described by Brant et al. [124].
Although initial studies [110,111] showed only a Further studies will be required to confirm these minimal improvement in symptoms of PD with ORAL THERAPY GRADE B
TREATMENT—INJECTION THERAPY
There is evidence that there is no benefit
Intralesional injection may be used with the
with respect to deformity reduction with
following:
any oral therapy, including Vitamin E,
Steroids—no objective measures of thera-
potassium
aminobenzoate,
colchicine,
peutic benefit. GRADE D
tamoxifen, and carnitine.
Verapamil—appears to make scientific sense
but no large scale placebo-controlled
Although six studies using injectable corticoster- Interferon—One
placebo-
oids for the treatment of PD showed positive out- controlled trial showed an outcome
comes from treatment, the authors believe that the interferon
therapeutic effects were because of the mechanical effects of the injection and not to the drug action Collagenase—Several small noncontrolled
trials showed limited benefit. It is cur-
rently being studied in a phase 2b trial.

Although the prospective, randomized, placebo-controlled study of Gelbard failed to demonstrate Other Noninvasive Therapy
any clinical benefit with the use of intralesionalinjections of collagenase [104], a recent study has reported significant decreases in deviation angle, Although initial studies failed to demonstrate any efficacy of extracorporeal shock wave therapy(ESWT) for the treatment of PD [142–144], more recent studies suggest a possible role of ESWL in In vitro studies verapamil has been shown to inter- fere with Peyronie’s plaque derived fibroblast cel-lular proliferation and Levine et al. reported that TREATMENT—SHOCK
intralesional verapamil injection induces a signi- THERAPY GRADE B
ficant reduction in penile curvature [133–136].
There is evidence that ESWT does not
These encouraging results have been confirmed by improve PD-related deformity.
two subsequent studies, while one failed to dem-onstrate any effectiveness of this treatment [137– Athough two studies proved the efficacy of ionto- Although large scale, placebo-controlled trials phoresis using dexamethasone, verapamil, and have not been conducted, intralesional Verapamil lidocaine in terms of reductions of pain, plaque size, injections could be recommended for the treat- and curvature [148,149], a recent series of Green- ment of noncalcified acute or chronic plaques to stein and Levine suggests that the only role for stabilize disease progression or possibly reduce iontophoresis is for the improvement of pain [150].
TREATMENT—TOPICAL VERAPAMIL
Hellstrom and associates conducted a singleblind, multicenter, placebo-controlled parallel study that As there are no independent controlled
showed that intralesional interferon alpha-2B may trials and no evidence of adequate levels
be beneficial for men with PD [140]. These find- within the tunica albuginea, no recommen-
ings offer the largest and best-controlled trial of dation is possible for topical Verapamil.
intralesional therapy for PD, as well as supports its TREATMENT—TOPICAL ENERGY–
use and demonstrates the lack of clinical benefit IONTOPHORESIS GRADE C
following intralesional injection of saline. It is sig- controlled
evidence
nificantly more costly than verapamil and has been of reduced deformity following ionto-
associated with flu-like side effects. However, a phoresis treatment using verapamil and
recent study failed to demonstrate any efficacy of dexamethasone.
It is well-documented that gradual expansion of I. When rigidity adequate preoperatively with or without tissue by traction, also known as mechanotrans- duction, results in the formation of new connective tissue by cellular proliferation in several tissue models including bone, muscle, and Dupuytren’s iii. Predicted loss of length < 20% erect length scar [151–153]. However, penile traction has B. Plaque Incision/ Partial Excision and grafting when proved to have insignificant role in the manage- TREATMENT—TRACTION THERAPY
GRADE C

of postoperative ED. The incision and grafting Early evidence from two small noncon-
technique appears to increase the risk of postopera- trolled prospective trials have reported a
tive ED, and therefore men who have borderline to reduction of deformity and increased penile
inadequate erections preoperatively, which do not length with traction therapy.
respond to pharmacological therapy, should avoidgrafting procedures or be prepared to need subse-quent penile prosthesis implantation [159]. Lastly, Surgical Treatment
there is a risk of decreased sexual sensation. This has been infrequently reported in the published Surgery is indicated when the curvature impedes literature, but it seems for the most part it rarely adequate sexual penetration or there is an associ- compromises orgasm and ejaculation. Surgical ated ED that fails to respond to medical treatment algorithms have been published to guide the choice and should be offered only once the disease has of surgical approach ([160], Table 2).
stabilized. In addition, patients who have extensive Two main preoperative factors contribute to plaque calcification are typically best treated with this decision, including penile rigidity and severity surgery, as nonsurgical approaches have not been of deformity [161–163]. When rigidity is adequate, shown to be beneficial in this circumstance. Lastly, with or without drug assistance, two approaches the patient who wants the most rapid and reliable have been suggested including tunica plication result should select a surgical approach [26,156] techniques, which are recommended when there is a simple curvature of less than 60–70°, and no hour Many of these men are depressed, have marked glass deformity, and when the presumed loss of reduction of self-esteem, and oftentimes have unat- length caused by the plication will be less than tainable expectations regarding the outcome from 20% of total erect length. For men who have more surgical reconstruction [15]. Therefore, a detailed complex curvature greater than 60°, and/or a discussion on persistent or recurrent curvature destabilizing hourglass or hinge effect then plaque should be initiated with the accepted goal of incision, or partial plaque excision and grafting making the patient “functionally straight,” which is is preferred. It is important to stress that this loosely defined as a curvature of less than 20° [157].
approach is recommended for men who have good Loss of length is most likely to occur with plication procedures, particularly in those with ventral cur-vature [158]. In addition, there may be diminishedrigidity, which has been shown to occur regardless SURGICAL TREATMENT GRADE C
of the surgical approach. Clearly, those who have Surgery remains the gold standard for cor-
suboptimal preoperative rigidity have a higher risk recting erect penile deformity in the man
with stable disease.

INDICATIONS
SURGICAL
Stable disease (6 months with no pain and stable deformity) RECONSTRUCTION GRADE C
Compromised or inability to engage in coitusExtensive plaque calcification Surgical reconstruction is indicated in
the man who has stable disease for _ 6
months, painless deformity, compromised,
or inability to engage in coitus secondary
from the convex (longer) side, then the edges to deformity and/or inadequate rigidity,
are reaproximated to create the shortening effect when there is extensive plaque calcification,
[164]. Currently, there are many variations of the and for the man who desires the most rapid
plication procedure, which include procedures and reliable result.
where a portion of the tunica is not excised, butinstead plicated such as the Essed-Schroeder SURGERY—PREOPERATIVE
technique [165]. The Yachia technique utilizes CONSENT GRADE D
the Heinke-Mikowitz principle where a vertical The preoperative consent is critical to
incision is closed transversely so as to shorten the set proper outcome expectations for the
convex side of the penis [166]. The tunica albug- patient. It is imperative to have a discussion
inea plication technique corrects the deformity on the risks of persistent or recurrent
by plicating a series of paired incisions into the curvature, loss of erect length, diminished
tunica without exposing the underlying cavern- rigidity, and decreased sexual sensation.
osal tissue [157]. The 16-dot procedure utilizesan extended Lembert type of suturing technique SURGICAL ALGORITHM GRADE C
[167]. In this procedure, a dorsal curve is cor- Several surgical algorithms have been pub-
rected with sutures placed into the tunic on both lished with general agreement that for men
sides of the urethra, then progressively tied down with adequate preoperative rigidity, some
so as to create shortening and straightening.
form of tunica plication procedure is best
There is no tunica incision or tissue excision per- for those with curvature less than 60° and
formed; therefore, the correction of deformity with no hour-glass deformity resulting in
relies upon the nonabsorbable sutures. All these a hinge effect. For those with more severe
procedures appear to adequately straighten the deformity (>60° and/or hourglass) and good
penis with little risk of compromising erectile preoperative rigidity, incision or partial
function. It is critical that during the per- excision and grafting is recommended.
formance of any straightening procedure thesurgeon is able to induce an erection, usually byneedle injection of saline by pump or syringe(Table 3).
Surgical Approaches
The advantages to the plication approach are that they are simple, minimally invasive, and tend This review of surgical approaches begins with to preserve potency in most patients. The disad- the plication procedures, which are designed to vantages are that they can result in penile shorten- shorten the longer side of the penis. If the cur- ing, which has been shown to be exacerbated by vature is in a dorsal direction, the plaque causes correction of curvature greater than 60°, and/or shortening of the dorsal aspect, and therefore a ventral curvature where dorsal plication is to correct the curvature with plication, the ventral aspect is shortened. This approach is Lastly, plication procedures may worsen an based upon the Nesbit procedure where an erec- existing hour-glass or hinge effect, particularly if tion is created and a wedge of tunica is excised Peyronie’s Disease published reports-plication procedures most frequently used autologous graft currently SURGERY—PLICATION PROCEDURES
in use is saphenous vein, which requires a separate incision to harvest, adding a risk of local side There is no evidence that one surgical
effects, and longer operating time with a second approach provides better outcomes over
incision to heal. Synthetic grafts were used histori- another, but curvature correction can be
cally, including polyester and polytetraflouroe- expected with low risk of new ED or sensory
thylene, but these have not been met with enthusiasm because of the increased risk of infec-tion, an unnatural feel and may have the potential Incision or Partial Excision and Grafting Techniques for more local inflammation and fibrosis [179].
Surgical grafting techniques include plaque inci- The modern era of grafts include off-the-shelf sion or partial excision. Historically, total plaque processed human cadaveric tissue or xenografts.
excision was designed to “remove the diseased These are felt to be advantageous because they can tunica,” but this causes an unacceptably high rate reduce operating time substantially, they appear to of postoperative ED. This has been suggested to have similar midterm outcome results as compared occur as a result of a compromised veno-occlusive with autologous grafts, and there is no harvest mechanism, because of the changes in the relation- comorbidity. These grafts include human and ship between the cavernosal tissue and the overly- bovine pericardium, porcine small intestinal sub- ing tunic or graft [173]. Therefore, minimizing the mucosa, and porcine and human dermis. All these excision or making simple releasing incisions have grafts undergo an extensive processing to clear the been recommended so a smaller graft may be used tissue of cells, bacteria, viruses, and presumably prions. As of this time there has been no report The search for the ideal graft continues. As of of host viral infection secondary to processed this time, no ideal graft has been identified, which allograft or xenograft implantation. The operative would take reliably, not contract, be resistant to procedure is done essentially the same for all graft- infection and preserve erectile capacity [175] ing techniques—an artificial erection is created demonstrating the curvature and the penis is typi- Currently, it appears that the nature of the graft cally degloved using a circumcising incision allow- is less likely the determining factor with respect to ing exposure of the entire shaft of the penis. In the postoperative ED. On the other hand, it is most area of maximum curvature, Buck’s fascia contain- likely a result of patient selection with respect to ing the neurovascular bundle is elevated, either preoperative erectile status and operative tech- from a pair of parallel incisions lateral to the ure- nique [159]. Larger grafts, men older than 60 years thral ridge allowing elevation of Buck’s fascia old, and those with ventral grafting also appear to dorsally, or by coming through the bed of the have a higher risk of postoperative ED [162,175– deep dorsal vein. It is felt that the deep dorsal vein 177]. A variety of autologous grafts have been approach may not offer adequate lateral exposure, used including dermis, tunica vaginalis, temporalis which would be especially important for patients fascia, buccal mucosa, and fascia lata [178]. The who have severe lateral indentation or hour-glassdeformity. The elevation process is best performedwith loupe magnification and bi-polar electrocau- tery so as to reduce the likelihood of injury to theneurovascular tissues. Once Buck’s fascia is pro- I. Autologous
perly elevated an artificial erection is recreated, demonstrating the area of maximum deformity.
Surgeons differ in their approach as to whether a simple modified H-like incision should be made to II. Nonautologous; allografts
the area of maximum curvature or whether partial plaque excision is recommended, particularly Pericardium
Dermis
when there is significant indentation and/or calci- Fascia lata
fication. Regardless, the goal is to remove as little Dura mater
plaque as possible, but to allow proper correction Bovine pericardium
of the deformity by expanding the tunic in both Porcine small intestinal submucosa
girth and length. Edygio has championed the geo- Porcine dermis
metric principle approach to graft sizing [180].
This technique has proven useful in his hands, but and a loss of length was noted in 35% [188]. At the a recent report suggested a higher risk of postop- 2004 Annual Meeting of the American Urological erative ED [177]. Once the graft is positioned, Association Society, Montorsi et al. reported on 50 Buck’s fascia is reapproximated to provide support patients with a 5-year follow-up after venous graft- and a vascularized cover over the graft.
ing where there was either persistent or recurrentcurvature in 12%, length loss in 100%, post- Postoperative Care and Rehabilitation operative ED in 22%, diminished orgasm in 41%, Following surgery, postoperative rehabilitation and overall patient satisfaction of only 60% [189].
is recommended to enhance recovery of erectile Taylor and Levine recently reported a mean function. Massage and stretch therapy, is per- follow-up of just short of 5 years on 111 patients formed by grasping the glans penis and pulling it undergoing partial plaque excision with processed gently and repeatedly away from the body while human pericardial grafting where the patients also gently massaging the graft area. This is initi- reported persistent or recurrent curvature of ated 2 weeks after surgery and performed twice a greater than 20° in 8% (none required surgical day for 4 weeks. It is advised that the patient’s correction), a measured loss of stretched penile partner get involved in the rehabilitation process to length was found in 47%, but was subjectively lessen the anxiety associated with the resumption of reported by 65% of patients. The postoperative sexual activity for both partners. Bedtime phos- ED rate was 24% with 31% noting diminished phodiesterase inhibitors have been recommended sensation, but 89% experienced normal orgasm.
to begin 7–10 days after surgery and to be main- Overall, patient satisfaction was reported at 76% tained for 6 weeks, in order to enhance nocturnal [157]. Postoperative traction therapy had not been erections, stretch the tissue, encourage nourish- ment of the graft [159], and possibly reduce the risk Recent studies have also examined the risk of of postoperative ED. Finally, the use of external postoperative ED following penile grafting proce- penile traction therapy has been noted to reduce dures [175,177]. For the most part, no significant postoperative penile shortening for patients who contribution was found because of the duration of have undergone either placation or grafting pro- disease, vascular risk factors (including diabetes, cedures. Traction is initiated 2–3 weeks post- hypertension, elevated lipids, and smoking), a operatively when the circumcising incision has dorsal or lateral curvature, graft or tunica defect adequately healed and is performed on a daily basis size, or whether there was preoperative narrowing for a minimum of 2–8 hours for 3 months [181].
or hinge effect. A higher risk of ED was found in Table 5 outlines the results from published those who underwent grafting for ventral curva- reports on grafting, on average 74–100% of ture and there was a trend toward increased ED patients were adequately straight, with a post- risk for men over the age of 60 [159]. In this published analysis, the primary component that Kalsi et al. studied 40 patients who underwent helped predict an increased risk of postoperative vein grafting and followed for at least 5 years.
ED was when the patient reported preoperative They reported a postoperative ED rate of 22.5% internal tissue expander and will likely result in SURGERY—GRAFTING PROCEDURES
correction of deformity in 6–9 months. On the other hand, if there is substantial residual curva- There is no evidence that surgical outcomes
ture, then releasing incisions can be made on the are consistently better with one graft type,
concave side, often times through the same scrotal and overall there is an increased risk of post-
incision or may require degloving of the penis with operative ED. Autologous grafts require
elevation of Buck’s fascia. If these incisions create more time and a second incision. Allograft
a tunic defect greater than 2 cm in any dimension, and Xenograft procedures appear shorter
patching is recommended to decrease the risk of in duration with no reported transmission
cicatrix contracture resulting in recurrent curva- of disease. Synthetic grafts increase the risk
ture or herniation of the cylinders. An off-the-shelf of infection and are not recommended.
graft is now recommended to fix the tunic defect.
Freshly harvested dermal grafts are not recom-mended as there is risk of transferring bacteria Penile Prosthesis Implantation with within the dermal tissue increasing the possibility Finally, for those men who have poor qualityerections and/or do not respond adequatelyto pharmacological therapy for their ED, penile SURGERY—PENILE
PROSTHESIS
prosthesis implantation is recommended. Table 6 reviews the recommended surgical algorithm for Penile prosthesis implantation with addi-
tional maneuvers to correct the deformity is
Prosthesis alone may result in satisfactory recommended when there is preoperative
straightening of the penis for those with mild defor- ED not responsive to oral medication (phos-
mity, but when residual curvature is more than 30°, phodiesterase type 5 Inhibitors)
manual modeling is recommended [190]. Manualmodeling should be performed with care. Once SURGERY—PENILE
PROSTHESIS
the prosthesis is placed and the corporotomies are closed, the prosthesis is inflated with a surrogate Following
prosthesis
implantation
(i.e., outside the body) reservoir of saline to dem- following maneuvers are recommended
onstrate the deformity. The surgeon will then including manual modeling followed by
model the penis by bending it in the contralateral plaque incision if the residual erect curva-
direction to the curvature maintaining the pressure ture exceeds 30°. If a tunica defect in excess
on the bent penis for 30–60 seconds. The tubing of 2 cm is noted after incision, then grafting
between the pump and the cylinders should be the defect is recommended to reduce the
occluded with rubber shod hemostats, so as to risk of postoperative recurrent curvature
protect the pump from high pressure damage. In or cylinder herniation. Autologous dermal
addition, when performing the modeling process, grafts should not be placed over a prosthesis
pressure on the glans penis should be avoided to as a result of the increased risk of infection.
prevent a urethral erosion by the cylinder tip. Analternative approach is to pre-place pliation sutures PD SURGERY—OVERVIEW GRADE D
in the 16-dot method before implanting the pros- Following published surgical algorithms is
thesis and then tying them down to correct the imperative, as well as obtaining a preopera-
curvature. Regardless of the approach, if there is tive consent to set proper outcome expecta-
residual curve less than 30°, no further treatment tions for the patient. A plication procedure
is recommended, as the prosthesis will act as an is indicated for less severe deformity (<60°)
and when there is borderline ED, while
grafting is reserved for severe deformity

Surgical algorithm with penile prosthesis (>60–70° Ϯ hinge with normal erectile func-
tion) and requires an experienced surgical
• Manual modeling if residual curve >30° team. Lastly, prosthesis placement is indi-
• Plaque releasing incision if residual curve after modeling >30° cated with additional maneuvers for those
• Graft tunica if defect >2.0 cm to prevent implant herniation or men with refractory ED and PD.
Conclusion
5 Kadioglu A, Tefekli A, Erol B, Oktar T, Tunc M, Tellaloglu S.
A retrospective review of 307 men with Peyronie’s disease.
This review is intended to be a guide to making decisions about surgical correction of PD. The 6 Mulhall JP, Schiff J, Guhring P. An analysis of the natural intent is that it will be useful to the practicing history of Peyronie’s disease. J Urol 2006;175:2115–8.
7 Levine LA, Greenfield JM. Establishing a standardized evalu- surgeon so that they may provide appropriate ation of the man with Peyronie’s disease. Int J Impot Res advice to their patients regarding the proper surgical procedure. The most critical part of 8 Pryor J, Akkus E, Alter G, Jordan G, Lebret T, Levine L, the surgeon’s role in the preoperative phase is to Mulhall J, Perovic S, Ralph D, Stackl W. Peyronie’s disease.
J Sex Med 2004;1:110–5.
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