Management of Peyronie's Disease in the Aging Male

Rany Shamloul; Anthony J Bella

Aging Health. 2011;7(1):65-78.

Surgical Treatment

Indications

Primarily, a surgical option is considered for PD if the penile curvature/deformity compromises sexual function, and there is no response to medical treatment (generally accepted to be 1 year of therapy). Penile curvature may be severe enough to prevent intromission, or at least make penetration painful for either partner. Furthermore, with narrowing of the penile shaft, a compromise of erection hardness may occur, leading to ED. Finally, some men with PD express their dissatisfaction with the physical appearance of their penis and seek surgical correction.

Preoperative Evaluation & Counseling

Expectations for surgery are a straightened penis that allows the return of a functional erection; specifically, a penis that is rigid enough for penetration. However, the return of pre-PD penile length is difficult, if not impossible – the stretched preoperative penile length is a practical means of estimating postoperative penile length.

Assessment of erectile function, severity and degree of penile curvature, as well as patients' expectations, are essential information before determining surgical suitability and selection of the procedure of choice. Photographs of the erect penis should be provided, either by the patient or examiner, and can be performed in the clinic after an injection-induced erection. Assessment of abnormal erectile function may be performed by penile duplex ultrasound to measure peak systolic and end diastolic velocities of both cavernous arteries.

Surgical Options

Different techniques are available for penile straightening in men with PD. Currently, there is no evidence to suggest one technique is more favorable than another, as well-designed head-to-head trials are not available. For men with PD and normal erectile function, plication straightening or graft reconstruction of the penis is the most appropriate surgical option.^[61] For men with PD and compromised erectile capacity, the placement of a penile prosthesis is warranted, with or without ancillary molding, plication, plaque incision or grafting.^[62] The preference for a patient with good erectile function and adequate penile length is a minimally invasive pure plication approach (also known as the Lue procedure).

Tunical-shortening Procedures Tunical-shortening procedures were originally described by Nesbit in 1965, requiring the excision of an ellipse of tunica albuginea at the most prominent point of curvature.^[63] Closure of the defect in the tunica causes shortening of the convex side of the penis, with resultant straightening. A modification of this technique, the Yachia procedure, utilizes the same principle of convex shortening, but avoids tissue excision by making a longitudinal incision in the tunica, which is subsequently closed horizontally.^[64] Despite high satisfaction rates, ranging from 80 to 100%, the need to interfere with the neurovascular bundle (NVB) and to disrupt the integrity of the corpus cavernosa, which can lead to sensory loss and ED, are two major reasons for postoperative dissatisfaction. Indeed, in some series, loss of sensation and postoperative ED have been reported in as many as 24 and 12% of cases, respectively.^[1,65–67]

Pure Penile Plication (Lue procedure) Straightening the penis with plication is achieved by shortening the convex side of the penis (i.e., opposite the plaque), and should only be performed in men with adequate penile length; traditionally, it was thought that the limit of curvature for this approach was 60°, although multiplanar deformity and greater angulations can be corrected with this approach as well. All plication procedures result in symmetry of the tunica albuginea, as plication of the longer side matches the shorter side – the inherent limitation is that there is no ability to recover lost penile length.^[63] The 16-dot technique, originated by Lue, is a pure plication procedure, consisting of two or three pairs of plications on the convex side, which do not disrupt tunical integrity (Figures 5–7).^[68,69] Paired, mattress sutures are placed in the tunica albuginea, and the tension is adjusted to straighten the curvature prior to completing the ties. Although originally described for cases of dorsal curvature, lateral or even dorsal placement of sutures with NVB mobilization, it can correct most deformities.

(Enlarge Image)

Figure 5.

Minimally invasive Peyronie's repair (Lue 16-dot technique). As in other plication-based therapies, penile length already lost to underlying disease cannot be reclaimed. Additionally, indentations or hourglass deformities cannot be corrected with this technique. However, there are some very compelling advantages to this procedure. It may be performed under a local anesthetic, there is essentially no risk of de novo erectile dysfunction, and it can often be performed using a longitudinal incision, which is particularly helpful in an uncircumcised patient wishing to retain his prepuce. The figures illustrate ventral longitudinal incision for dorsal curvature. In cases of ventral curvature, a longitudinal or circumcision incision is used to expose the dorsal neurovascular bundle. A hemostat clamp is used to create the space (dot) between the deep dorsal vein and the paired dorsal arteries for the placement of sutures.
Reproduced with permission from.⁶⁸

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Figure 6.

Minimally invasive Peyronie's repair (Lue 16-dot technique).
One advantage of this technique is that the dots are easily repositioned, allowing fine adjustments to be made. Each set of four dots consists of an 'in–out, in–out' suture placement. Sutures should be soft, braided, permanent material such as 2-0 Ticron (Davis and Geck, NJ, USA) or Tevdex (Deknatal, Inc., MA, USA). Enough tension is placed to straighten the curvature, and a clamp with a 'shod' is placed at the half-knot to hold it in position. This allows fine adjustments to be made once all sutures are satisfactorily in place. After placement of all shodded-clamps, the erect penis is inspected from all angles for alignment, with adjustments made to tension of sutures as needed. A smooth clamp is placed under each half-knot to prevent overtightening, and the remaining four knots are thrown.
Reproduced with permission from.⁶⁸

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Figure 7.

Minimally invasive Peyronie's repair (Lue 16-dot technique). To prevent postoperative edema and ecchymoses, a petroleum-soaked gauze strip is placed over the incision, then a gauze sponge is folded into a strip and wrapped gently around the penis. A self-adhesive compression dressing is wrapped from just under the glans to the base of the penis – snug but not tight. Ice-packs should be used liberally in the postoperative period, and the dressing changed by a physician the next day and daily by the patient for 4 more days. Sexual intercourse can be resumed 5–6 weeks after surgery.
Reproduced with permission from.⁶⁸

Tunical-lengthening Procedures (incision & grafting) In general, penile-lengthening procedures should be reserved for men with severe penile length loss, curvature greater than 60° or pronounced hourglass deformities.^[70] Such procedures involve the incision of the plaque, with insertion of graft material to repair the defect. This approach should be employed in men with normal erectile capacity that can tolerate disrupting the integrity of the tunica albuginea. The risks include ED, sensory deficit and length loss (owing to contracting graft). The standard approach includes mobilizing an appropriate segment of the NVB, typically 1 cm proximal and distal to the plaque, using either a medial or lateral surgical mobilization approach. Opening the tunica albuginea often worsens erectile function, and patients must be aware of this risk. Following management of the plaque, a graft is placed. The choice of graft material depends upon several factors, including type of deformity, efficacy and availability.^[71] Grafting materials include:

Autologous tissue (e.g., saphenous vein, fascia lata, rectus fascia, tunica vaginalis, dermis and buccal mucosa): vein patch is the most commonly used autograft material, and is harvested from the distal saphenous vein. If a larger graft is needed, the proximal saphenous vein can be used. Saphenous vein is spared in patients with significant cardiovascular disease, and these patients may need the saphenous vein for future bypass grafting;
Allograft or xenograft materials (e.g., cadaveric or bovine pericardium, engineered dermal graft and porcine small intestinal submucosa):^[72–74] these acellular matrices allow regenerative ingrowth of native tissues. The main advantage of allograft tissues is elimination of the need for tissue harvesting;
Synthetic grafts (e.g., polytetrafluoroethylene): the use of synthetic materials is discouraged, owing to increased incidence of infection and postoperative inflammation, leading to perigraft fibrosis.^[74] Synthetic grafts are not used regularly in contemporary practice.

There is no best graft material, as each graft type has its advantages and disadvantages. The choice of graft material should be based upon the surgeon's and patient's preferences after a detailed discussion of risks, benefits and alternatives.^[74]

Postoperative Care

During recovery, some authorities advocate administering bedtime phosphodiesterase inhibitors 1 week after surgery, and then for the following 6 weeks, to enhance vascular supply to the corpora cavernosa and graft tissue,^[75] or using manual self-traction or a penile traction device to reduce postoperative penile shortening.^[76]

Several studies examined the long-term effects of tunical excision and venous grafting for PD. Montorsi et al. reported on 50 patients with a 5-year follow-up after venous grafting, where there was either persistent or recurrent curvature in 12%, length loss in 100%, postoperative ED in 22% and diminished orgasm in 41%, and an overall patient satisfaction of only 60% of patients.^[77] Another study by Taylor and Levine reported similar results, with persistent or recurrent curvature of greater than 20° in 8%, ED rate of 24% and patient overall satisfaction of 76% of patients.^[78]

Penile Prosthetics The treatment of choice for patients with PD and significant ED is placement of a penile prosthetic implant, with or without manual modeling, and with or without penile reconstruction. Patient and partner satisfaction rates are high; however, implants are generally underutilized owing to lack of patient and physician information. Patient satisfaction is higher with an inflatable penile prostheses than malleable devices, with the primary reason for the latter being economic.^[79] Either a two-piece or three-piece prosthetic is used.

The correction of penile curvature can be accomplished solely by implantation of the penile prosthesis in patients with mild-to-moderate curvature. Manual modeling over the prosthesis may be required to correct more severe deformities (e.g., >30° curvature).^[80] Manual modeling is a process by which the tunica plaque is stretched/fractured over the inflated prosthetic cylinder at the time of implantation. The penis is forcibly bent in the direction opposite to the curvature.^[80] Bending pressure is maintained on the penis for 90 s. When successful, the modeling procedure causes splitting and rupturing of the fibrotic plaques.

Placement of plication sutures for more severe curvature or penile reconstruction (plaque incision/grafting) can be performed in patients with severe or complex deformities, or calcified Peyronie's plaque to allow for satisfactory correction.^[81]

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Box Executive summary
Peyronie's disease (PD) involves the development of inelastic scar of the tunica albuginea of the penis, resulting in penile curvature, deformity and sexual dysfunction. The underlying pathogenesis of PD is unknown, and most likely represents a combination of factors, including chronic minor injury and genetic susceptibility. The presenting symptoms of PD are penile pain, induration, curvature and/or sexual dysfunction. Patient and partner quality of life are significantly impacted, as men with PD are at an increased risk of depression, relationship difficulties and body-image issues. Diagnosis is usually apparent from patient history and penile examination. On examination, clinicians may observe a penile plaque and penile curvature or deformity. When primary-care clinicians have limited experience in managing PD, they should refer the patient to an urologist once the diagnosis of PD is established, or in any patient with a penile deformity. For patients who do not have penile deformity compromising sexual function, and whose PD has persisted for less than 12 months, we suggest medical management rather than surgical management. For men with stable, mild curvature (≤30°), who have satisfactory erectile function, we suggest observation. If mild curvature worsens, or causes sexual dysfunction, we suggest medical and/or surgical management. Surgical management is indicated for patients whose PD has persisted for more than 12 months, and is associated with a penile deformity compromising sexual function. The length of the penis, nature (e.g., hourglass or curved), and severity of the deformity, erectile capacity and patient expectations, are important factors to consider when determining the surgical approach. Surgical techniques used for penile reconstruction in PD include plication, grafting or placement of a penile prosthesis. Plication shortens the convex side of the penis, whereas grafting techniques lengthen the concave side. Penile implants are used in patients with pre-existing erectile dysfunction (ED). Plaque incision is often combined with these techniques to improve the mobility of the plaque. Erectile dysfunction occurs in up 20% of patients following nonplication surgical reconstruction for PD, and can occur without a prior history of ED; however, ED is more likely to complicate procedures requiring dissection of the neurovascular bundle, or in patients with pre-existing ED.

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