Penile prosthesis implantation in the treatment of Peyronie's disease and erectile dysfunction

Transcription

1 (2000) 12, Suppl 4, S122±S126 ß 2000 Macmillan Publishers Ltd All rights reserved /00 $ Penile prosthesis implantation in the treatment of Peyronie's disease and erectile dysfunction 1 * 1 Division of Urology, University of North Carolina, North Carolina, USA Although men af icted with Peyronie's disease (PD) usually have a number of treatment options, those who also present with erectile dysfunction (ED) arising from unknown or iatrogenic causes are not easily treated. Surgical straightening procedures that have been used to treat PD may not restore erectile function and failure to straighten the penis with surgery may be the result of erectile inadequacy during the post-operative period. This paper discusses penile prosthesis implantation as a surgical option for patients with PD, placing emphasis on the choice of devices and surgical techniques. Several new techniques which hold the promise of high success rates and low morbidity are mentioned. (2000) 12, Suppl 4, S122±S126. Keywords: erectile dysfunction; surgical treatment; penile implants; Peyronie's disease, review Introduction There are many acceptable and effective treatment alternatives for men with Peyronie's disease (PD), but many of these procedures are not effective in the man with both PD and erectile dysfunction (ED). While penile straightening and grafting procedures can provide a straight penis in men with signi cant disabling curvature, a number of men with PD are not adequately treated with these procedures. Moreover, even if the penis is straightened, they may still be unable to have successful coitus because of inadequate erectile function, an hourglass deformity, severe penile curvature, or signi cant penile shortening. Because PD produces an increased incidence of penile veno-occlusive abnormalities accompanied by ED, straightening procedures may not restore erectile function. 1,2 Weidner et al reported that ED resulted from veno-occlusive disorders in 83.9% of men with PD, whereas arterial blood ow abnormalities were responsible for 48.2% of ED cases. 3 Some men will also fail straighteningg procedures because of post-operative erectile inadequacy. In these patients, penile prosthesis implantation may provide penile rigidity, penile straightening and even return them to normal coital ability. In discussing surgical treatment options with patients suffering from PD that require surgical intervention, it is important to include *Correspondence:, Division of Urology, University of North Carolina, 427 Burnett-Womack CB 7235, Chapel Hill, NC , USA. penile prosthesis implantation in the discussion. This single surgical procedure has demonstrated an excellent success rate and low morbidity; it can correct both the penile deformity and erectile dysfunction and importantly, high rates of patient satisfaction have been achieved. 4 Encouraging positive results have also been reported by a number of investigators using penile prosthesis implantation with and without corpus cavernosum (CC) reconstruction. 3±5 While CC reconstruction may be required to produce penile straightening, newer techniques such as penile modeling may be carried out with high expected success rates and low morbidity. Prosthetic devices utilized in patients with Peyronie's disease Penile prosthesis implantation in PD patients is best accomplished using an in atable type penile prosthesis. While several investigators have reported satisfactory functional results with both in atable and semi-rigid rod penile prostheses, Montorsi et al reported poor patient satisfaction with semi-rigid rods implanted for PD. 6 In my clinical practice, patients frequently request substitution of 3-piece in atable penile prostheses instead of semi-rigid rod devices. Ghanem et al showed that a common cause of patient and partner dissatisfaction with malleable penile implants used for PD was persistent curvature in 35% of men who were followed-up for 1 y

2 after surgery. 7 In contrast, Eigner et al, Knoll et al, O'Donnell and Carson have individually reported excellent results combining penile prosthesis implantation with plastic surgical correction of penile curvature. 8±12 Of 35 patients reported by Eigner et al, 88% were satis ed with the result of their treatment and were able to actively engage in sexual intercourse for a mean follow-up period of 6.9 y. 8 In a large multicenter study of penile prosthesis implantation with the AMS 700 CX, men implanted for PD had no increase in morbidity or decreased satisfaction when compared with men implanted for other indications. 13 For most men with PD, implantation of a penile prosthesis alone will correct penile curvature and other deformities resulting from CC dilation and prosthesis cylinder placement. However, continued angulation may require other surgical techniques. Penile prostheses are surgically implanted in a standard fashion using either penoscrotal or infrapubic approaches. If signi cant penile curvature persists after cylinder placement, several options have been used to complete penile straightening. These options include: corporal plication, glanuloplasty, formal plaque incision or excision with or without grafting or penile modeling. 11 Penile modeling When there is signi cant residual curvature after cylinder placement, penile straightening should be initiated using the modeling procedure described by Wilson and Delk. 14 This technique, when used with in atable penile prostheses, requires a high pressure cylinder such as the AMS 700 CX or Mentor Alpha-1 cylinders. It has been reported that results with the AMS 700 Ultrex cylinders are not as satisfactory and modeling may induce an aneurysmal dilation or S- shaped deformity. 15 Aneurysmal dilatation has also been reported following implantation of the Mentor Bio ex cylinders and is suggestive that aneurysmal dilatation may be a potential, although rare sequelae of penile modeling. 16 Safe modeling procedures require full cylinder in ation and clamping of the input tubes with shodded clamps to protect the in atable pump. High pressure on tubing and tubing connectors may risk later uid leak. The technique involves grasping the penis with both hands and bending it over the in ated cylinders at the area of maximum curvature. De ection should be maintained for 90 seconds. The shape of the penis is reevaluated after additional in ation, then repeating the de ection and modeling, if necessary. Success of this modeling procedure has been reported. 11,14,17 In their original description of penile modeling, Wilson and Delk described 138 men with PD and implanted penile prostheses with residual curvature who underwent the penile modeling procedure. 14 Of these patients, 118 (86%) achieved a straight, rigid erection; penile plaque incisions were required in only 11 (8%). Complications included urethral perforation in four patients (3%) and infection in four (3%). Continued straight erections were con- rmed in 124 patients who were followed-up for a mean of 34 months. Montague et al also reported a high success rate with penile modeling using the AMS 700 CX cylinders, 17 and in their report, all 34 patients implanted with these cylinders were successfully straightened with modeling alone. In 38 patients implanted with Ultrex cylinders, however, complete straightening with modeling could not be achieved in 10 patients, requiring simultaneous corporoplasty. With the increased risk of S-shaped deformity, corpus cavernosum weakness, and the results demonstrating dif culty with penile straightening, CX cylinders appear to be the best choice of devices for penile modeling in patients with PD. At the University of North Carolina at Chapel Hill, 28 of 30 patients who underwent penile straightening and modeling procedures achieved complete straightening with modeling alone. 11 Glanuloplasty was required in two (of the 28) patients to reposition the glans penis in order to accomplish complete straightening. The remaining two patients had severe curvature and dense plaques requiring plaque incision; one of whom had a GorTex graft placed for reinforcement of his tunical defect. No patient had post-operative infections, mechanical malfunctions, or experienced urethral erosion. Penile straightening and satisfactory erectile function continued during the 3 ± 32 month (mean 8.6) follow-up period (see Table 1). Patient satisfaction Montorsi and colleagues conducted a patient ± partner satisfaction study of the AMS 700 CX in atable penile prosthesis for patients with PD in S123 Table 1 Penile prosthesis implantation and modeling for the treatment of Peyronie's disease and ED Author Prosthesis Patients (n) Straightening (%) Plaque incision (%) Complications (%) Wilson 14 AMS 700 CX (86) 11 (8) 8 (6) Montague 17 AMS 700 CX (100) 0 (0) Ð Montague 17 AMS Ultrex (74) 10 (26) Ð Carson 11 AMS 700 CX (93) 2 (7) 0 (0)

3 S124 which they questioned 33 men implanted with the device and their partners. 18 At week six of followup, complete penile straightening had been obtained in 23 patients (70%) with adequate penile rigidity reported by all 33 implanted patients. Penile shortening was reported by 10 patients (30%) and continued scrotal or penile discomfort continued in ve patients, who also happened to be diabetic. Results of the patient ± partner satisfaction survey revealed that ve of 23 patients (21%) and three of 13 partners (25%) were not completely satis ed with the penile length, shape, and miscellaneous other items. In a long term, multicenter study of the AMS 700 CX penile prosthesis in men followed-up for a mean of 47.7 months, patients with PD were compared with men implanted for other reasons. 13 Cylinder erosion occurred more frequently in the subset of patients with PD (10.5%) compared to the proportion of patients in the overall population (2.3%) who present with this complication (P ˆ 0.001). Other morbidities reported were not different and no patient with PD had glans hypesthesia compared with 2.9% of the others. Infection occurred in 5.2% of Peyronie's compared with 3.2% of the total group, a difference that was not signi cant. Satisfaction rates for device function were excellent; measured on a scale where 1 ˆ unsatisfactory and 5 ˆ extremely satisfactory, the mean scores were 3.6 and 4.2 in PD patients and in other men, respectively. The majority of patients in both groups (76.9% of Peyronie's and 87.6% of others) stated they would have the implant again. Of those men with sexual partners, 65.4% of patients with PD and 65.7% of the other men used their device at least twice monthly for coitus. 13 Alternative procedures: plaque incisions and grafting If penile prosthesis implantation and modeling fails to provide adequate penile straightening, plaque incision with or without grafting may be considered. 11,19,20 Full in ation of the penile prosthesis with exposure of the area of maximum curvature is carried out to allow incision over the in ated penile prosthesis using electrocautery to preserve cylinder integrity. For very proximal penile curvature, an infrapubic or penoscrotal incision may be extended to expose the curved area. If the curvature is more distal, however, a ventral penile incision or circumcoronal incision with penile skin retraction may be necessary. Incision of a dorsal curvature requires careful dissection of the dorsal neurovascular bundle. This dissection is carried out by ligating the deep dorsal vein of the penis, dissecting Buck's fascia away from the dorsal neurovascular bundle, located in the bed of the deep dorsal vein. This is necessary to preserve the dorsal nerves of the penis. Following exposure of the tunica albuginea, the area of maximum curvature is incised with electrocautery until complete straightening has been achieved. A signi cant incision at the area of the intercorporal septum is usually necessary as the tethering frequently occurs in this septum deep to the most super cial portion of the tunica albuginea. Ventral curvature may require mobilization of the corpus spongiosum and urethra. Once the incision has been completed, the penis will straighten during full prosthesis in ation. Grafting of the defect created by curve incision must be considered, if the defect is a large one, especially if using non-controlled expansion in atable cylinders. Grafting of the defect may improve the post-operative prosthesis cosmetic result as well as strengthen the penile shaft. Fishman suggests that defects greater than 50% of the corporal circumference should be grafted. 20 Our experience suggests that grafting defects which are readily palpable through the replaced skin provides an improved cosmetic appearance and feel for the patient and partner. 19 Autogenous or synthetic graft material may be used to support these defects, including dermis, GorTex, cadaveric pericardium or other materials. We prefer GorTex or cadaveric pericardium for this procedure since these are easily available and easily tailored. A GorTex patch is obtained and tailored to a size of approximately 25% larger than the size of the defect to be lled to allow for penile extension and contraction. The graft is than tailored to the size and shape of the defect and secured in place with running sutures of 4-0 GorTex. Cadaveric pericardium has been successfully used with little morbidity by others, 21 is readily available in most operating rooms and can be easily tailored and sutured in place with a 4-0 PDS suture. Closure, drainage and dressing can be carried out in the standard fashion, using a small suction drain at the area of incision to decrease postoperative swelling and hematoma. Compression dressings should not be used when a penile prosthesis is implanted since compression may result in avascular necrosis of the glans penis or loss of the penile shaft skin. If further curvature of the most distal portion of the penis is present, glanuloplasty may improve the nal post-operative result as described by Ball. 22 Glanuloplasty performed on the corpora cavernosa lateral to the dorsal neurovascular structures and ventral corpus spongiosum will eliminate distal penile curvature and SST deformity. Penile incisions for straightening appear to yield quite excellent results and we continue to reproduce our previously reported results with these procedures. In the last 48 months, 18 patients underwent penile prosthesis implantation using AMS 700 CX cylinders with incision into the penile curvature for penile straightening. 23 Straightening of the penis with adequate rigidity of the penile prosthesis were

4 obtained in all patients. GorTex reinforcement grafts were placed in 10 of these patients and only one of these GorTex grafts was explanted because of a penile prosthesis infection. One patient complained of persistent glans hyposensitivity; in another patient, an AMS 700 CX cylinder leak occurred requiring prosthesis revision with replacement of penile cylinders. In spite of the leak, his postoperative result was satisfactory. None of the cylinders implanted exhibited aneurysmal dilatation, S-shaped deformity, or damage at the time of penile prosthesis implantation. Clearly, the added complications of penile straightening for penile prosthesis implantation in PD requires that the surgeon adequately informs their patients about the possibility of penile prosthesis infection, pain, and distal penile hypesthesia. The use of GorTex grafts for reinforcement of areas with incision or excision of penile plaque also increases the incidence of infection. In our own previously reported results, the risk of infection for initial penile prosthesis implantation was 2.2% compared with 22.2% of patients with GorTex grafts. 23 Conclusion The increased risk of infection and other morbidities associated with surgical intervention leads us to suggest that modeling may be the most appropriate initial procedure for penile straightening following penile prosthesis implantation for correction of Peyronie's disease. Plaque incision or excision with or without grafting should be reserved for those patients whose curvature does not respond to a closed modeling procedure. References 1 Chiang PH et al. Study of the changes in collagen of the tunica albuginea in venogenic impotence and Peyronie's disease. Eur Urol 1996; 21: 48 ± Gentile V et al. Ultrastructural and immunohistochemical characterization of the tunica albuginea in Peyronie's disease and veno-ccclusive dysfunction. J Androl 1997; 17: 96 ± Weidner W, Schroeder-Printzen I, Weiske WH, Vosshenrich R. Sexual dysfunction in Peyronie's disease: an analysis of 222 patients without previous local plaque therapy. J Urol 1997; 157: 325 ± Levine LA, Lenting EL. A surgical algorithm for the treatment of Peyronie's disease. J Urol 1997; 158: 2149 ± Carson CC, Hodge GB, Anderson EE. Penile prosthesis and Peyronie's disease. Br J Urol 1983; 55: 417 ± Eigner EB, Kabalin JN, Kessler R. Penile implants in the treatment of Peyronie's disease. J Urol 1991; 145: 69 ± Knoll LD, Furlow WL, Benson RC. Management of Peyronie's disease by implantation of in atable penile prosthesis. Urology 1990; 36: 406 ± Carson CC. Penile prosthesis implantation in the treatment of Peyronie's disease. Int J Impot Res 1998; 10: 125 ± Carson CC, Mulcahy JJ, Govier FA. Penile prosthesis and Peyronie's disease: comparison of longevity, morbidity, and satisfaction outcomes in a long-term multicenter study. J Urol (in press). 10 Ghanem HM, Fahmy I, el-meliegy A. Malleable penile implants without plaque surgery in the treatment of Peyronie's disease. Int J Impot Res 1998; 10: 171 ± Montorsi F, Guazzoni G, Bergamaschi F, Rigatti P. Patient ± partner satisfaction with semi-rigid penile prosthesis for Peyronie's disease: a ve year follow-up study. J Urol 1993; 150: 1819 ± O'Donell PD. Results of surgical management of Peyronie's disease. J Urol 1992; 148: 1184 ± Morganstern SL. Long-term experience with the AMS 700CX in atable penile prosthesis in the treatment of Peyronie's disease. Tech Urol 1997; 3: 86 ± Wilson SK, Delk JR. A new treatment for Peyronie's disease: modeling the penis over an in atable penile prosthesis. J Urol 1994; 152: 1121 ± Wilson SK, Cleves NA, Delk JR. Ultrex cylinders: problems with uncontrolled lengthening (the S-shaped deformity). J Urol 1996; 155: 135 ± Garbea BB. Mentor Alpha-1 penile prosthesis cylinder aneurysm: an unusual complication. Int J Impot Res 1995; 7: 13 ± Montague DK, Angermeier KW, Lakin MM, Ingleright BJ. AMS 3-piece in atable penile prosthesis implantation in men with Peyronie's disease: comparison of CX and Ultrex cylinders. J Urol 1996; 156: 1633 ± Montorsi F et al. AMS 700 CX in atable penile implants for Peyronie's disease: functional results, morbidity, and patient ± partner satisfaction. Int J Impot Res 1996; 8: 81 ± Bertram RA, Carson CC, Altaffer LF. Severe penile curvature after implantation of in atable penile prosthesis. J Urol 1988; 139: 743 ± Fishman IJ. Corporal reconstruction for penile prosthesis implantation. Prob Urol 1993; 7: 350 ± Reddy SK, VandenBerg TL, Hellstrom WJG. Use of cadaveric pericardium in the surgical therapy of Peyronie's disease. J Urol 1999; 161: 206(A). 22 Ball TP. Surgical repair of penile SST deformity. Urology 1980; 15: 603 ± Carson CC. Increased infection risks with corpus cavernosum reconstruction and penile prosthesis implantation with corporal brosis. Int J Impot Res 1996; 8: 155. S125

5 S126 Appendix Open discussion following Dr Carson's presentation Dr Pryor: Is there a degree of curvature that's so severe that you wouldn't attempt modelling and instead put a graft in? Dr Broderick: In the modeling, where is the cracking actually occurring? Are you splitting the plaque itself or the tunica albuginea at the junction between the plaque and the normal tunica? Do you see hematomas from tears or injury to the deep dorsal venous system? Do you see neuropraxia? Dr Carson: I think the plaque is splitting. I can feel the snap, crackle and pop between my hands and it's more than just normal tissue would change. We occasionally get hematomas over the area of modeling, but it's less than half the patients. I've not had any neuropraxias with this, while I have had neuropraxias with the plaque incision, with or without grafting. There's certainly still a possibility of neuropraxia and numb glans, but it's a lot less with modelling than with an incision procedure. Dr Wilson: I've never seen any nerve damage or even had a patient complain of numbness after the procedure for a period of time. But we still have about 4% driving the cylinder into the urethra. Dr Eid: The point about driving the tip of the cylinder through the urethra is important, and it should be communicated to the urologist who is not very experienced with implants. They don't need to be very aggressive if the curvature is such that it's not going to impair intercourse. Dr Carson: No, we always try it rst and if there's not enough straightening, I would do an incision and perhaps a graft. Dr Moreland: How much Peyronie's disease is due to trauma; or do you believe that genetics is enough to account for the incidence of Peyronie's? Dr Carson: Those are not mutually exclusive. It's the people who are predisposed to scarring who develop the scar tissue in Peyronie's disease, I think there is a relationship. We're doing a chromosome screen. They use 300 markers and chromosome one is apparently the one with the principal genes that make collagens. We want to know if there's an abnormal expression of collagen-making genes in the tissue of Peyronie's disease. Dr Moreland: Do patients with keloids have a high incidence of Peyronie's? Dr Carson: No, but we also published the Paget's disease study. The rheumatologists think that there's an increased circulating IL-12 concentration in patients with Paget's disease that causes abnormal collagen formation.