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The management of peyronie's disease: evidencebased 2010 guidelines
The Management of Peyronie’s Disease: Evidence-based
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
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.
Peyronie’s Disease; Guidelines; Surgery; Pathology
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 . 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 . 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 .
2010 International Society for Sexual Medicine
may cause penile shortening with or without
PD—OVERVIEW GRADE A
a penile deformity . 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 . 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
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 .
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 . 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 . 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 .
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 . 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 . 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],
hyperlipidemia [3,5,33,34,37,38], smoking [32,34,
37,38,42,43], and pelvic surgery .
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-
fied, including ED, hypertension, diabetes
mellitus, hyperlipidenia, low testosterone,
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 Histopathology
A 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
ﬁbrosis with disorganization of elastic ﬁbers,combined in most cases with ﬁbrin accumulation
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 , 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 , 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 . 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 , 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 . 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. 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 . 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 .
THERAPY GRADE C
Although the administration of vitamin E and
Men with early phase disease (i.e.,
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 .
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
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. .
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
There is evidence that there is no benefit
Intralesional injection may be used with the
with respect to deformity reduction with
any oral therapy, including Vitamin E,
Steroids—no objective measures of thera-
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-
oids for the treatment of PD showed positive out-
controlled trial showed an outcome
comes from treatment, the authors believe that the
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 , 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
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 .
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 . 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
use and demonstrates the lack of clinical beneﬁt
IONTOPHORESIS GRADE C
following intralesional injection of saline. It is sig-
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
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-
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 . Lastly,
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 (, 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 . 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° .
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 . 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.
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,
. 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
technique . 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 . 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 . The 16-dot procedure utilizesan extended Lembert type of suturing technique
SURGICAL ALGORITHM GRADE C
. 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
>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).
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
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 .
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 . 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 
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 . 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 . 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-
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
the area of maximum curvature or whether partial
plaque excision is recommended, particularly
when there is signiﬁcant indentation and/or calci-
ﬁcation. Regardless, the goal is to remove as little
plaque as possible, but to allow proper correction
of the deformity by expanding the tunic in both
Porcine small intestinal submucosa
girth and length. Edygio has championed the geo-
metric principle approach to graft sizing .
This technique has proven useful in his hands, but
and a loss of length was noted in 35% . At the
a recent report suggested a higher risk of postop-
2004 Annual Meeting of the American Urological
erative ED . 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% .
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
. Postoperative traction therapy had not been
erections, stretch the tissue, encourage nourish-
ment of the graft , 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 .
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 . 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
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
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 . Manualmodeling should be performed with care. Once
the prosthesis is placed and the corporotomies are
closed, the prosthesis is inﬂated with a surrogate
(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 (
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.
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Site sponsored by Safe Harbor, a nonprofit corporation President, Institute for Optimum Nutrition (ION) Food and Mood Poster T-Shirts, Bumper Stickers Janet was diagnosed with manic depression at the age of 15. At times she would become completely hyperactive and manic, and at other times become completely depressed. She was put on three drugs - Lithium, Tegretol and
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