Surgical Treatment of Peyronie s Disease: A Critical Analysis

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1 available at journal homepage: Review Sexual Medicine Surgical Treatment of Peyronie s Disease: A Critical Analysis Ates Kadioglu *, Tolga Akman, Oner Sanli, Levent Gurkan, Murat Cakan, Murat Celtik Section of Andrology, Department of Urology, Istanbul Faculty of Medicine, Istanbul University, Turkey Article info Article history: Accepted April 24, 2006 Published online ahead of print on May 11, 2006 Keywords: Peyronie s disease surgery Graft Prosthesis Abstract Objective: The present paper reviews surgical treatment alternatives for patients with Peyronie s disease using knowledge obtained from the contemporary literature. Methods: : All aspects of surgical treatment for Peyronie s disease were examined on the basis of MEDLINE database researches. Results: Surgical treatment should be delayed until the acute inflammatory phase has resolved and should be considered in patients with deformity that impairs sexual function. Currently, surgical treatment alternatives are reconstructive surgery by either lengthening the concave side (incision and grafting) or shortening the convex side (Nesbit procedure or plication) of the penis, and implantation of penile prosthesis with or without incision of the plaque. PD patients with good erectile capacity are candidates for reconstructive surgery. Meanwhile, implantation of penile prosthesis with or without remodeling should be considered for patients without adequate erectile capacity. Conclusions: The aim of the surgical treatment in Peyronie s disease is to correct the deformity while preserving or improving erectile capacity of the penis. Appropriate treatment options should be individualized according to the patients expectations and erectile capacity. # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. Section of Andrology, Department of Urology, Istanbul Faculty of Medicine, Istanbul University, Capa-Istanbul, Turkey. Tel ; Fax: address: itfabd@istanbul.edu.tr (A. Kadioglu). 1. Introduction Peyronie s disease (PD) is an acquired disorder of the tunica albuginea, characterized by formation of a plaque of fibrous tissue, which may be associated with erectile dysfunction and pain on erection. During the progression of PD, two discernible phases usually are noted. The acute inflammatory phase, usually lasting about months, is characterized mainly by pain on erection. It is then followed by the chronic or stable phase characterized by minimal pain and stable penile deformity. If the patient has difficulty with penetration because of the curvature, surgical treatment is required. Indications and /$ see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi: /j.eururo

2 236 Table 1 Surgical treatment alternatives Reconstructive surgery Shortening of the convex side Nesbit procedure, Yachia procedure, penile plication Lengthening of the concave side Incision of the plaque and grafting Penile prosthesis implantation Malleable penile prosthesis Inflatable penile prosthesis with or without manual modeling Inflatable penile prosthesis with incision and grafting associated conditions for surgical treatment are summarized as follows [1]: PD must be present for at least 12 months, or stable disease must be present for at least 3 months. Severe curvature or narrowing that causes difficulty in penetration must exist. Assessment of the erectile capacity is essential to decide the type of the operation (reconstruction vs prosthesis). Penile length should be taken into account while choosing the procedure. Patient expectation should be considered and informed consent should be obtained. Surgical treatment alternatives may be evaluated in two categories: as reconstructive surgery or penile prosthesis implantation with or without remodeling, depending on erectile status of the patient (Table 1). Criteria affecting the choice of surgical procedure are the degree of curvature, the localization of curvature, type of deformity, penile length and preoperative erectile status. There is no single surgical procedure suitable for all cases of PD. However, in 1997 a surgical algorithm was reported, which still is generally accepted [2]. Tunical shortening surgery is mainly for men with good erectile capacity, simple curvatures <608 and absence of hourglass deformity or hinge effect. On the other hand, tunical lengthening procedures should be used for men with adequate erectile capacity, complex curvatures, curvature >608, or presence of hourglass deformity or hinge effect. In addition, penile prosthesis is recommended for PD patients with diminished erectile capacity. The recommendations for the assessment of PD patients prior to surgery are described elsewhere [1]. Briefly the International Index of Erectile Function questionnaire, photographic documentation of the deformity at home or combined injection and stimulation test with or without color Doppler ultrasound (for evaluating the collaterals between deep dorsal and cavernosal artery in dorsal curvatures) in an office setting may be performed. Finally, patients are directed to the appropriate type of surgery on the basis of their erectile status. 2. Reconstructive surgery 2.1. Shortening of the convex side Nesbit procedure The original technique was described by Nesbit [3] in The procedure itself is based on shortening the long side of the penis by excision of an elliptic portion at the most prominent part of the curvature. The dorsal neurovascular bundle (NVB) or ventrally located corpus spongiosum would need to be mobilized depending on the side of the curvature. Generally, for the correction of ventral deformities, the NVB can be mobilized in two different techniques, medially or laterally. In the lateral dissection technique, NVB is mobilized by a longitudinal lateral incision of the Buck fascia above the urethra at 5 and 7 o clock positions with a bilateral approach. For the shortening procedures, lateral dissection may be more suitable. While mobilizing the NVB, meticulous dissection should be performed with optic magnification (3) (5), because sensory changes attributable to traumatisation of NVB may occur after surgery. More than one ellipse of tunica may need to be excised to correct the deformity completely, depending on the degree of curvature. Correction of the deformity with an Allis clamp during erection is an appropriate way to decide the number of tunical ellipses that need to be excised. The distance between the upper and lower bite lines of the Allis clamp is the height of the ellipse. Saline induced erection with low-dose vasoactive agent is a better way to evaluate the curvature, because an erection induced by full-dose vasoactive agent may be too firm to grasp the tunica with an Allis clamp. There is no universal cutoff value for the height of the elliptic portion, but the height of the ellipse or the sum of the height of the ellipses should be the difference between the lengths of the convex and concave sides of the penis. In addition, during the excision procedure, ellipses <1 cm in height should be excised. Otherwise, a dog-ear deformity at the ends of the excised ellipses may develop. In series evaluating outcomes of the Nesbit procedure, the success rate of penile straightening ranged from 79% to 100%, with an overall satisfaction rate between 67% to 100% (Table 2) [4 12]. In these series, penile shortening was reported in 17.4% to 100% of the patients. It is inevitable that the penile length would be equal to the length of the concave side (short side) at the end of the procedure.

3 237 Table 2 Outcome of Nesbit and Yachia procedures for Peyronie s disease Authors Operation Suture material No. of pts (n) Mean follow-up (mo) Overall satisfaction Penile straightening Penile shortening Sensory changes Postop ED Savoca et al. [4] Bokarica et al. [5] Syed et al. [6] Ralph et al. [7] Licht et al. [8] Nesbit or modified Nesbit NA Nesbit 4-0 polyglactin NA Nesbit Polydioxanone Nesbit Polydioxanone NA NA 1.6 Nesbit Yachia polypropylene NA NA NA Yachia [9] Yachia 3-0 polydioxanone Daitch et al. [10] Rehman et al. [11] Mufti et al. [12] Yachia 3-0 polydioxanone NA 7 Yachia 2-0 polytetrafluoroethylene (Gortex) Nesbit Polypropylene NA NA NA NA Yachia or Polyglycolic NA NA NA NA acid ED = erectile dysfunction; NA = not available; postop = postoperative; pts = patients. In a study, Ralph et al. [7] evaluated 16 years experience with 359 patients who underwent the Nesbit procedure. Despite the fact that all patients had penile shortening, only 6 (1.6%) patients had difficulty with penetration. When the normative value of penile length is considered, a minimum 13- cm penile length on the concave side during erection is required for considering this procedure [13 15]. With the Nesbit procedure, the failure rate ranges from 7% to 21%. Failure of the procedure can be outlined as breaking of sutures, too tight ligatures and problems arising from use of absorbable sutures. Two-zero polyglactin (Vicryl), polyglycolic acid (Dexon) sutures or sutures with a slower absorption rate such as polydioxanone (PDS) may be used to close the tunical defect with interrupting sutures. For the postoperative period, there is no universally accepted method for preventing nocturnal erections. Wearing an elastic bandage for approximately 10 days is advocated. Other less frequently reported complications after a Nesbit procedure are penile hematomas, urethral injuries, phimosis, penile narrowing and indentation, herniations and suture granulomas [7] Yachia procedure The Nesbit procedure has been modified by Yachia [9] and Lemberger et al. [16]. In the Yachia procedure, a large longitudinal incision or multiple smaller longitudinal incisions made in the tunica albuginea are closed horizontally in a Heineke- Mikulicz fashion instead of removing an elliptic portion of the tunica. The tunica may be incised between the bite lines of an Allis clamp with the use of a no. 11 scalpel. This procedure can be performed rapidly and easily as an additional procedure to grafting techniques. Giammusso et al. [17] used modified corporoplasty in 12 patients with ventral penile curvatures. While the authors reported a 100% success rate in patient satisfaction and achieving penile straightening, and a 92% rate of maintenance of erectile capacity, eight (67%) patients reported penile shortening of cm in this study [17] Penile plication The Nesbit and Yachia procedures require extensive dissection of NVB and corpus spongiosum. Instead, penile plication is a relatively noninvasive method for the correction of penile curvatures. This technique was described by Nesbit [3], and popularized by Essed and Schroeder [18] and Ebbehoj and Mets [19]. In this technique, nonabsorbable, braided sutures are placed on the convex side of the tunica albuginea without excising the tunica to correct penile curvature in menwithpd.in1989brezaetal.[20] demonstrated a 3-mm space between the deep dorsal vein and adjacent dorsal arteries. Considering this anatomic definition, Donatucci and Lue [21] revised the plication technique and performed it in ventral curvature without dissecting the NVB. In this

4 238 technique, before the surgical intervention, artificial penile erection is achieved with intracavernosal saline injection using a 19-gauge needle with tourniquet to assess the direction and degree of the curvature. After the circumcision incision, penile skin and the subcutaneous layer is degloved to the base of the penis. In ventral curvatures, the Buck fascia is incised longitudinally above the deep dorsal vein, and an intervascular space is developed by meticulous dissection under optic magnification. Peridorsal vein sutures are placed in the above-mentioned 3-mm intervascular space. If development of the intervascular space is difficult, the dorsal vein may be dissected and excised so that the plication sutures can be placed at the bed of the dorsal vein. For those with lateral penile curvatures, however, the tunica albuginea on the opposite side of the curvature is exposed and grasped with an Allis clamp. Subsequently, two plication sutures [2-zero nonabsorbable synthetic braided polyester (Ethibond, Mersilene, Dacron, Ticron)] are placed between bites of the Allis clamp on the tunica albuginea at intervals not wider than 0.5 cm to avoid overlapping of tissue. Prolene sutures should not be used, because the suture knots may be felt under the skin. The sutures should be tied with minimal tension to prevent tissue strangulation, which may result in cutting through the tunica during spontaneous rigid erection. After artificial penile erection is achieved again, the degree of correction (overcorrection and undercorrection) of the curvature is inspected visually. In cases in which curvature correction procedures have failed, additional plication sutures can be placed until complete penile straightening is accomplished. The Buck fascia should be closed to diminish bother from the suture knots. Loose elastic bandages must be applied for at least 7 10 days postoperatively [22]. Gholami and Lue [23] reported the use of a 16- (two pairs of plication) or 24-dot (three pairs of plication) technique with minimal tension plication under local anesthesia for 116 cases with PD and 16 cases with congenital penile curvature with a mean follow-up of 2.6 years. The authors achieved a 96% rate of satisfaction and a 93% rate of achieving a completely straight penis. In this series, shortening of the penis was noted in 41%, recurrent curvature in 15%, pain with erection in 11%, narrowing or indentation of the penis in 9% and decrease in penile sensation in 6% of the patients. In the literature, complete straightening rates differ widely from 57% to 91% (Table 3) [2,23 28]. Schultheiss et al. [28] reviewed 61 patients and reported that failure rates were higher in PD (42.9%) patients, compared with the group with congenital penile curvatures (22.5%). This issue may be due to alterations in the whole tunica in patients with PD. Tunical shortening procedures generally are suitable for patients with adequate penile length, curvature <608, good erectile function and absence of hourglass or narrowing type of deformity. The advantage of this procedure is that extensive surgical experience except with ventral curvatures is not needed. Table 3 Outcome of penile plication for Peyronie s disease Authors No. of pts (n) Suture material Mean follow-up (mo) Satisfaction Penile straightening Penile shortening Postop ED Sensory changes Gholami and Lue [23] Chahal et al. [24] Geertsen et al. [25] Thiounn et al. [26] Van Der Horst et al. [27] Schultheiss et al. [28] Levine and Lenting [2] braided polyester (Ticron) NA 49 NA polypropylene (Prolene) polypropylene (Prolene) NA : cosmetically satisfactory cosmetic 62: functionally satisfactory polypropylene polypropylene 39.8 NA NA (Prolene) 22 NA 19.5 NA ED = erectile dysfunction; NA = not available; postop = postoperative; pts = patients.

5 Lengthening of the concave side Tunical lengthening procedures involve the use of reconstructive techniques to lengthen the concave side by incising or excising (no longer recommended) the plaque and placing graft material to cover the defect. Lengthening procedures are indicated mainly in patients with severe penile curvatures, and/or narrowing or hourglass deformities. In 1991, Gelbard and Hayden [29] suggested a plaque incision instead of full plaque excision, because PD is a disease of the whole tunica albuginea and excision of the plaque may have deleterious effects on the veno-occlusive mechanism and cavernosal function of the penis. In addition after excision, the plaque may be left at a microscopic level in the tunica albuginea and may cause graft contracture, which is probably responsible for late recurrences. For these reasons, plaque excision has not been proposed because of its higher rate of erectile dysfunction, contracture of the graft and late recurrences. The major steps of Peyronie s plaque incision and grafting procedure may be summarized as follows: 1. Restoration of the length of NVB, which may be performed with medial or lateral dissection. 2. Incision of the plaque. 3. Grafting. After a circumcising incision is made, the skin is degloved to the base of the penis. The Buck fascia is opened at the dorsal side of the penis, and the deep dorsal vein is removed at the most prominent location of the curvature. The neurovascular bundle on the dorsolateral aspect of the corpora cavernosa was carefully dissected off free, 1 cm long up to the healthy tissue with medial or lateral dissection of the underlying tunica albuginea with loupe magnification. According to the authors of this review, for dorsal Peyronie s plaques, a medial dissection technique that approaches the dorsal plaque through the bed of the dorsal vein is preferred to lateral dissection. In PD surgery, lateral dissection may leave part of the Peyronie s plaque attached to the NVB, but medial dissection of the NVB enables total cleaning of the NVB from the Peyronie s plaque without leaving Peyronie s tissue behind. Subsequently, the Peyronie s plaque is incised, extending the ends to an H shape, and graft material is interposed and sutured with continuous 4:0 polydiaxanone (PDS) sutures to restore tunical tissue integrity. If one uses an interposing vein graft, it should be prepared 20% larger than the defect to achieve comfortable suturing. In case a single patch is not enough to cover the defect, the harvested vein may be divided into several segments and assembled again to create a larger graft. Recently, a single-incision technique applying geometrical principles was proposed as a standard procedure for all patients. Egydio et al. [30] described the use of a single, almost complete circumferentialrelaxing incision, forked at the end. Tripod-shaped forks of 1208 produce a simpler configuration of the tunical defect, resulting in geometrically shaped grafts that can be sutured easily while grafting. On the other hand, Darewicz et al. [31] described an approach to Peyronie s plaque inside the tunica albuginea. Despite the authors high success rate, we believe that there may not be always a place between Peyronie s plaque and healthy tunica albuginea to enucleate the plaque Grafts Graft material is an important issue in Peyronie s reconstructive surgery. Features of an ideal graft material should be as follows: readily available, easily sutured, pliable and compliant, inexpensive, low risk for infection and antigenicity, well tolerated with low morbidity and minimal tissue reaction [32]. However, no one material is capable of meeting all these criteria. Various graft materials have been used in the surgical treatment of PD and may be classified into two major classes Autologous grafts. In 1950 Lowsley and Boyce [33] first applied autologous grafts in PD. Subsequently in 1974 Devine and Horton [34] used a dermal-grafting procedure after excision of the Peyronie s plaque to cover the corporal defect. A number of published studies [35] reported success rates up to 70% of the men treated. However, in these series, dermal grafting after excision of Peyronie s plaque was found to be associated with decreased potency postoperatively. Another drawback of the dermal patch was the difficulty in harvesting the graft, which causes significant morbidity [36 38]. In addition to dermal grafts, various up-to-date autologous graft materials have been used, such as tunica vaginalis flap, autologous fascia lata, temporal fascia, muscular aponeurosis, buccal mucosa, tunica albuginea and veins, with different outcomes (Table 4) [2,29,35,38 48,87]. Among these, deep dorsal vein, saphenous vein and tunica albuginea grafts are the matter of interest for the authors of this review. Currently, the vein patch is the most commonly used autograft material in lengthening procedures. It has a number of advantages, such as increased elasticity attributable to muscle coat and elastic

6 240 Table 4 Results of autologous grafting (except saphenous vein graft) Authors No. of pts Graft material Mean follow-up (mo) Penile straightening Postop ED Penile shortening Patient satisfaction Wild et al. [35] 50 Dermal graft NA 70 Melman and Holland [38] 7 Dermal graft > NA 0 Levine and Lenting [2] 48 Dermal graft NA O Donnell [39] 25 Tunica vaginalis graft NA Das [40] 15 Tunica vaginalis graft NA 100 Kargi et al. [41] 12 Facia lata graft Gelbard and Hayden [29] 12 Temporal fascia graft NA NA 100 Bruschini and Mitre [42] 4 Muscular aponeurosis NA NA 100 Shioshvili et al. [43] 26 Buccal mucosa graft NA Teloken et al. [44] 7 Crural tunica albuginea graft Schwarzer [45] 31 Proximal tunica NA albuginea graft Da Ros et al. [46] 27 Crural tunica NA NA 70.4 albuginea graft Kim and McVary [47] 6 Deep dorsal vein graft Hsu et al. [48] 24 Deep dorsal vein graft NA 100 Craatz et al. [87] 12 Rectus sheath NA NA 58.3 ED = erectile dysfunction; NA: not available; postop = postoperative; pts = patients. fibers, inexpensive cost and no risk of a foreign body reaction. Moreover, since the wall of the vein is <1 mm in thickness, it can establish blood supply from the lumen of corpus cavernosum, which prevents graft contracture and ischemia [49]. In addition, anticoagulant factor nitric oxide (NO) released from the endothelium prevents hematoma formation under the graft site [50,51]. In addition, it was demonstrated that tunica albuginea reforms over the vein patch site [52]. For these reasons, in agreement with the 2nd Consultation on Sexual Dysfunction, we find the use of vein grafts more desirable. The graft tissue usually is harvested from proximal or distal sapheneous vein. Normally, it is suitable to obtain the graft from the distal sapheneous vein, but, if the defect is too large, a distal vein may not be sufficient to cover the defect [53]. In these cases, a proximal saphenous vein can be obtained from a femoral incision. After the initial report of Brock et al. [53], in the first large series, El-Sakka et al. [54] reported the outcome of 112 of 145 patients with follow-up available. In 95.5% (108) of patients, the penis became straight. Of the patients who were potent preoperatively, 88% experienced the same or better erectile quality after surgery. Currently many authors have reported overall success rates for straightening of the penis with the use of saphenous vein grafting to be between 66.6% and 96%. Generally penile shortening occurs in 17 40% of the PD patients and erectile dysfunction in up to 15% of the patients. In addition, the patient satisfaction rate ranged from 88% to 100% [53,55 62] (Table 5). The need for a second incision to harvest the vein is Table 5 Results of plaque incision with saphenous vein graft interposition Authors No. of pts Mean follow-up (mo) Straightening of penis Postop ED Shortening of penis Additional plication suture Patient satisfaction El-Sakka and Lue [53] Kalsi et al. [55] Akman et al. [56] NA 20.9 NA Adeniyi et al. [57] Akkus et al. et al. [59] De Stefani et al. [60] Yurkanin et al. [61] NA Montorsi et al. [62] 50 > ED = erectile dysfunction; NA: not available; postop = postoperative; pts = patients.

7 241 the major drawback of this procedure. Other problems include bulging of the graft, indentations or hourglass deformities, sensory loss and persistent pain. Although short-term results of plaque incision with saphenous vein grafting is satisfactory, a less satisfactory long-term outcome was reported recently by Montorsi et al. [62]. Withatleasta5- year follow up, complete penile straightening of the penis and minor residual curvatures (308) were observed in 72% and 16% of patients, respectively. Only 60% of patients were satisfied with the results of the procedure. In another recent report, Kalsi et al., achieved an 80% rate of penile straightening and 86% rate of patient satisfaction usingthesametechniquein51menover5yearsof follow-up [55]. In both studies, 22% of the patients reported significant decrease in penile rigidity after surgical treatment, which is the main component of dissatisfaction. Other reported causes of dissatisfactions were penile shortening and deterioration in orgasmic function [62]. Possible causes of deterioration of erectile function after grafting may be due to unrealistic expectations of the patients and worsening of coexisting vascular insufficiency [53]. The latter condition may be due to the comorbidities of PD patients, such as diabetes, hypertension and hypercholesterolemia or large vein grafts that needed to cover large tunical defects, leading to veno-occlusive dysfunction. Also, the role of the dissection type of the NVB (medial vs. lateral) in long-term success is yet to be determined. On the other hand, the use of reconstructive surgery in PD patients with good erectile function or in patients with adequate erectile function with oral pharmacotherapy is a matter of debate. In an experimental animal study, Brannigan et al. [52] compared the histologic and cavernosometric changes of the dorsal penile vein, silicone patch and dermal patch. The vein patch specimens revealed moderate fibrosis without evidence of obliteration of the corpus cavernosum as in the dermal patch. Moreover, there was no sign of localized vascular thrombosis as seen in the silicone patch. Overall, there was not much difference in cavernosometric parameters in all patches. Of note, the authors confirmed the reformation of the tunica over the vein patch site [52]. Inanother animal study, long-term efficacies of cadaveric pericardium, dermis, vein and Gore-Tex for tunical substitution were compared by Leungwattanakij et al. [63]. While minimal fibrosis was found in the vein, pericardial and dermal grafts, moderate fibrosis was evident in the Gore-Tex graft after 6 months. Erectile function, assessed by cavernosal nerve stimulation, did not differ significantly in any of the groups. Recently Teloken et al. [44] has used the tunica albuginea as a graft material harvested from the patients proximal crura through a perineal incision. In this series, the author reported satisfactory penile straightening in six of seven patients. Subsequently, Schwarzer [45] published the outcome of 31 patients in whom 26 had a straight penis and four had minimal residual curvature less than 208. Unlike Teloken et al., these authors used an infrapubic incision to gain access to both proximal crura. Outcome of the studies using allograft materials, except saphenous vein graft, is given in Table Allograft tissues and synthetic materials. The use of many allograft tissues with a satisfactory outcome was described in the literature. Among these graft materials, cadaveric or bovine pericardium is the most widely used. Major advantages of cadaveric pericardium are an acellular matrix that allows host tissue to grow in and occupy the matrix with minimal inflammatory response. In addition, the graft is packed in various sizes and avoids harvestsite injury. Egydio et al. [64] used bovine pericardium as an interposition graft in 78 patients with PD; the authors achieved an 88.4% rate of penile correction with a mean increase of 2.21 cm (1 4 cm) in functional penile length. Chun et al. [65] compared the dermal graft with the pericardial graft and reported similar functional results and patient satisfaction, but operation time was shorter with the pericardial graft. Usta et al. [66] reported the use of pericardial grafting after excision or incision in 19 men with PD. Three (15.7%) patients in this series had postoperative residual curvature. In these patients, curvatures were found to be located laterally in all patients. The authors concluded that, in patients with lateral curvature, this technique should be avoided. Results of incision/excision and grafting in patients with PD are given in Table6[64 69]. Among synthetic materials, the Dacron, polytetrafluoroethylene patch (Gore-Tex) was used [70 73]. However, synthetic graft materials cause significant postoperative inflammation, which leads to fibrosis around the graft site and possibly is associated with an increased rate of infection. In some cases, Nesbit or Yachia procedures or penile plication in addition to incision and grafting may be necessary to correct the curvature. However, one should keep in mind that these additional procedures may cause further penile shortening.

8 242 Table 6 Results of allograft or xenograft cadaveric tissues Authors No. of pts Graft material Mean follow-up (mo) Straightening of penis Postop ED Shortening of the penis Satisfaction rate Egydio et al. [64] 78 Bovine pericardium NA Chun et al. [65] 9 Cadaveric Pericardium NA Dermal graft (preop in 56.5) Usta et al. [66] 19 Cadaveric pericardium Levine and 40 Cadaveric pericardium Estrada [67] Knoll [68] 97 Intestinal submucosa NA Sampaio et al. [69] 40 Dura mater ED = erectile dysfunction; NA: not available; postop = postoperative; preop = preoperative; pts = patients. Instead of these procedures, placement of a second graft should be considered when shortening of the penis is a concern Penile prosthesis implantation The concomitant implantation of penile prosthesis is indicated in PD patients with severe erectile dysfunction who did not respond to oral or intracavernosal pharmacotherapy. Both malleable and inflatable prostheses were used in Peyronie s surgery. However, implantation of malleable penile prosthesis in PD patients has lower patient satisfaction and higher residual curvature rates than inflatable penile prosthesis. On the basis of their experience in 48 men over a mean follow up of 5 years, Montorsi et al. [74] reported a 52% dissatisfaction rate with the malleable implants. Of these patients, 11 (24%) reported that the prosthesis did not mimic natural erection, 6 (12%) reported persistent slight penile deformity, 4 (8%) were bothered about the poor concealment of the implants, and 4 (8%) complained of either decreased sensitivity or coldness in the glans penis. The partners of these patients reported a 60% dissatisfaction rate for various reasons including insufficient penile girth, coldness of the glans, unnatural sensation attributable to the device and dyspareunia. Ghanem et al. [75] reported that implantation of the malleable penile prosthesis straightened the penile shaft without additional plaque surgery in all cases. However, a variable degree of deviation of the glans penis persisted in 35% (7 of 20) of the cases. In addition, of the 16 patients who were followed for 1 year, two were dissatisfied with the outcome. The use of an inflatable prosthesis has been successful in this patient population. Straightening of the penis with a penile prosthesis may be accomplished with the following procedures. 1. Implantation of the penile prosthesis without any additional procedure. 2. Manual modeling. 3. Incision of the Peyronie s plaque with or without grafting. In mild to moderate curvatures, penile straightening may be achieved with insertion of a penile prosthesis alone. If this procedure does not correct the curvature, manual modeling should be attempted. However, if these two initial procedures fail to correct the deformity, incision of the tunical defect, with or without grafting of the defective tunica albuginea, may be needed in men with persistent, severe penile curvature after prosthesis implantation. Briefly, manual modeling, plaque incision, and plaque incision and grafting were required in 54%, 26% and 20% of the patients, respectively [76]. In 1994, Wilson and Delk [77] described manual modeling over the prosthesis. In this technique, after placement of the cylinders, closure of the corporotomies, placement of the reservoir and connection of all components, the prosthesis is inflated to the maximum distension. Then the penis is bent forcibly in the direction opposite the curvature and the bend is held for at least 90 seconds. This maneuver results in splitting and rupturing of the Peyronie s plaques. Manual modeling of more than two sessions is not advised. With this technique alone, the authors achieved successful straightening in 118 (86%) of 138 patients, whereas 11 (8%) patients required further plaque surgery to achieve adequate straightening. This technique requires a high-pressure cylinder such as the AMS 700 CX or Mentor Alpha-1 cylinders. The use of AMS Ultrex should be avoided, because the results are not satisfactory and modeling may induce an aneurismal dilatation or S-shaped deformity [78,79].

9 243 Table 7 Outcome of penile prosthesis implantation in Peyronie s disease Authors No. of pts Mean follow-up (mo) Type of penile prosthesis Additional plaque surgery Overall satisfaction Rate of success Montorsi et al. [74] 48 >60 Malleable penile prosthesis Ghanem et al. [75] Malleable penile prosthesis Levine et al. [76] AMS prosthesis (CX 700, Ambicor or Dynaflex) Wilson and Delk [77] Inflatable penile prosthesis (Mentor a-1, AMS 700 CX, Mentor, AMS 700 Ultrex 48% % (manual modeling) NA (plaque incision) 20 (incision/grafting) 8 (plaque incision NA 86 or graft) Carson [78] AMS 700CX 7 (incision) NA 93 Chaudhary et al. [83] AMS 700 CX (n =17) 61 (manual modeling) or Mentor a-1 (n = 29) Akman et al. [86] AMS 700 CX or 12.7 (grafting) Mentor a-1 Montorsi et al. [88] 33 NA AMS 700CX 33.3 (incision) (excision/grafting) Austoni et al. [89] Virilis 1 prosthesis and SSDA (Gis) type prosthesis 77.9 (single incision) (double incisions) 8.9 (plaque excision) Agrawal et al. [90] Malleable (n =10 24 NA 82 Inflatable (n = 11) Montaque et al. [91] 72 NA AMS Ultrex (n = 38) 26.3 (incision) NA 74 AMS 700CX (n = 34) Usta et al. [66] AMS 700 CX or Mentor a-1 NA = not available. 74 (modeling) 88 (modeling) (grafting) 81.8 (grafting) (modeling) 81.1 (grafting) Currently it is well established that, in experienced hands, penile prosthesis with manual modeling is an effective and durable method for correcting moderate penile curvatures in men with dorsal plaques. However, additional plaque surgery may be required in about one fourth of penile prosthesis implantations with PD (Table 7). If the curvature is >208 after the Wilson maneuver, multiple small incisions can be made in the curvature side over the AMS 700 CX or Mentor Alpha prosthesis [80]. Electrocautery can be used safely to create a tunical incision with any underlying inflatable cylinder. To avoid electrocautery injury, one should deflate the cylinder before electrocautery and use coagulation current at 35 watts. The electrocautery should be applied only to the outer tunical layer, not to the whole thickness of the tunica. Afterwards, the plaque is split by bending the penis [81]. Different types of inflatable penile prostheses have been used in surgical management of Peyronie s disease. Wilson et al. [82] implanted AMS 700 CX or Mentor Alpha 1 in 104 patients with Peyronie s disease and erectile dysfunction with a patient satisfaction rate of 90%. The authors concluded that, although Mentor Alpha 1 prosthesis required more revision than AMS 700 prosthesis, patient satisfaction and infection rates did not differ significantly between the two groups. The same authors compared the use of penile prosthesis implantation in erectile dysfunction with or without (104 vs 905 patients) PD. They reported that patient satisfaction, infection and mechanical failure rates did not differ significantly between penile prosthesis implants used for patients with or without PD [82]. Chaudhary et al. [83] reported functional success and patient satisfaction rates of 93%, and noted no significant long-term differences between the mechanical reliability of the AMS 700CX and Mentor Alpha 1 prostheses in 46 severely affected PD patients with erectile dysfunction. If implantation of the prosthesis, manual modeling or incision of the plaque without grafting fails to provide adequate penile straightening, interposing grafts should be considered. On the basis of their experience, Puri and Hellstrom [84] suggested incision-excision/grafting in men with more severe

10 244 penile curvatures (>608), large dorsal plaques (>4 cm), ventral plaques or residual curvature after manual modeling. For this purpose, autologous tissues or allograft materials, such as rectus fascia, dermis, saphenous vein, cadaveric pericardium and porcine jejunal submucosa, may be used. In our opinion, autologous rectus fascia, cadaveric pericardium and porcine jejunal submucosal tissue grafts are more suitable, compared with dermis and vein grafts, because the latter have only one surface available for imbibition [80]. After harvesting and preparation, the graft is assembled to the tunica albuginea with long-term absorbable sutures. Pathak et al. [85] reported 14 of 15 patients with interposing autologous rectus fascia in their series had satisfactory sexual intercourse at 18 months of follow-up. The authors advocated the use of autologous rectus fascia, because the procedure does not require an additional incision for tissue harvesting and the outcome obtained with the pubovaginal sling is better with the use of rectus fascia, compared with other materials. If a pubic incision is used for implantation of the penile prosthesis, no additional incision is required. Akman et al. [86] reported about seven patients who underwent implantation of penile prosthesis and remodelling using rectus facia graft. All patients had satisfactory sexual intercourse during a mean follow-up of 14 months (range, 3 30 months). Recently Craatz et al. [87] reported that, among human connective tissue structures, the dorsal lamina of the rectus sheath is most similar to the tunica albuginea. Furthermore, fascia inherently is resistant to ischemia, secondary to its low metabolic demands. In a study using pericardial graft for plaque surgery, Usta et al. [66] reviewed the results of 42 patients treated with either AMS 700CX or Mentor alpha-1 inflatable penile prostheses. Nineteen men needed manual modeling, and 11 needed pericardial patch grafting for correction of the residual curvature. While a 93.5% (29 of 31) correction rate (residual curvature <308) of penile curvature was achieved with penile prosthesis implantations + manual modeling, only 81.8% (9 of 11) of the patients treated with the prosthesis and pericardial patch grafting combination had straight penises. The patient and partner satisfaction rates were reported as 88% and 80% for prosthesis implantation with manual modeling, and 81.8% and 72% with pericardial patch grafting, respectively. Many authors [66,76 78,83,86,88 91] reported high rates of a straight penis, higher patient and partner satisfaction, and lower complications rate with the use of a penile prosthesis (Table 7). Reported complications after penile prosthesis implantation for PD were prosthesis and wound infection, urethral perforation, decreased penile sensation, penile shortening, delayed ejaculation and mechanical failure Novel procedures Circular venous grafting and daily intermittent stretching with a vacuum erection device may be used for patients with significant penile shortening in severe PD. Lue and El-Sakka [92] performed a complete circumferential tunical incision and covered the defect with a circular venous graft in four patients who preoperatively complained of penile shortening and erectile dysfunction. Investigators recommended that all patients stretch the penis with a vacuum device for 30 minutes daily for 6 months starting 1 month after surgery. Penile length was 1 inch longer in the patient with only a 6-month follow-up who did not use the vacuum device, and 2 inches longer in the other three patients who used the device. This technique may be an alternative for patients with severe disease and significant penile shortening. Another new technique, penile disassembly, was introduced by Perovic and Djordjevic [93]. Briefly in this technique, the corporal bodies are separated from the glans, NVB and urethra. The authors claimed that the technique enables complete preservation of the NVB. After the penis is separated from its component parts, the Peyronie s plaque is incised, and a dermal or vein graft is interposed. With this technique, the authors reported an 87% (40 of 46) rate of completely straight penises. The remaining patients had minimal deformity. No significant complication was reported. The authors concluded that, despite its complexity, this technique is a good alternative for complex PD. In another study, Brock et al. [94] introduced the minimally invasive treatment of PD. In this technique, NVB structures are partially mobilized for all dorsally located plaques. A small incision lateral to the plaque allows introduction of a 5-mm diamond blade knife into the corpora. The blade is passed within the corporal body to the site of the plaque, and the inner portion of the plaque was incised. Limited plication sutures are placed to keep the plaque open, and small corporotomy is repaired. Of 23 patients with a mean angle curvature of 628, all patients except two had successful curvature correction with a mean follow-up of 11 months. In another aspect, Hauck et al. [95] defined a combined procedure of plaque thinning using a

11 245 dental drill with carbide burs, small transversal plaque incision and venous grafting in 13 patients with complex curvature. Despite satisfactory shortterm results (62%), the authors found that the technique was associated with significant recurrence of PD (38%) and penile shortening (54%), probably because of activation of the disease. Montorsi et al. [96] introduced the concept of multiple relaxing incisions of the tunica albuginea followed by the penile prosthesis implantation for preventing penile shortening. With this technique, the authors achieved penile straightening in 9 of 10 patients. Meanwhile, the average penile length was increased 2.3 and 3 cm for flaccid and erect penises, respectively. In addition, the authors concluded that this technique may be a surgical alternative for patients with severe penile curvature, shortening and erectile dysfunction attributable to penile fibrosis. Recently, Rahman et al. [97] described a technique using combined penile plication and placement of an inflatable penile prosthesis. In this technique, one or two pairs of plication sutures are placed to correct the curvature, but left untied. After placing and inflating the prosthesis, the plication sutures are tied with one knot, and the curvature is assessed. If the penis is straight, additional suture knots are tied. The authors achieved correct penile curvatures in five patients with follow-up ranging 3 36 months with this technique. 3. Conclusion Surgical treatment in PD is advised for patients with disabling deformities in the chronic phase of the disease. Tunical-shortening procedures may be applied to patients with mild to moderate deformities with satisfactory erectile function. Penile length should be taken into account during consideration of these procedures. Among the tunical-shortening procedures, penile plication is an easy, minimal invasive technique suitable mainly for simple deformities. Furthermore, this technique does not need extended surgical expertise. Tunical-lengthening procedures are advised for patients with severe or complex deformities. Among the various graft materials, saphenous vein, tunica albuginea and cadaveric pericardium seem to be more desirable. For the treatment of PD with a penile prosthesis, a prosthesis with limited girth-expanding properties such as AMS 700CX and Mentor Alfa-1 is preferred. Manual modeling is a well-established method for correcting the majority of the persistent curvatures after implantation of the penile prosthesis. When manual modeling fails, a plaque incision with or without grafting should be performed. For this purpose, autologous rectus fascia, cadaveric pericardium and porcine jejunal submucosal tissue grafts are more suitable. References [1] Pryor J, Akkus E, Alter G, et al. Priapism, Peyronie s disease, penile reconstructive surgery. In: Lue TF, Basson R, Rosen R, Giiliano F, Khoury S, Montorsi F, editors. 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