CLINICL CSE single relaxing incision for penile curvature correction in Peyronie s disease, based on the geometric principle Ramírez-Pérez Erick lejandro, 1 Romero-rriola Hazael, 2 López-Silvestre Julio César. 3 bstract Peyronie s disease is a pathology that is characterized by a deformity of the penis during erection that can be curved, indented, hourglass-shaped, or shortened. It can also be accompanied with erectile dysfunction. Current treatment techniques consist of applying healthy tunica albuginea, which results in a shortening of the total length of the penis. The technique that we used is based on a single circumferential relaxing incision that is bifurcated at its ends. The single relaxing incision with the application of the geometric principle is a standard procedure that can be used to correct any type of penile curvature. Keywords: Peyronie s disease, surgical treatment, incision, new technique, Mexico. Resumen La enfermedad de Peyronie es una enfermedad que se caracteriza por una deformidad del pene durante la erección, ya sea curvatura, indentación, deformidad en forma de reloj de arena y acortamiento. Puede estar acompañada de disfunción eréctil. En la actualidad, las técnicas utilizadas consisten en aplicar la albugínea sana, lo que se traduce en un acortamiento de la longitud total del pene. La técnica que utilizamos a continuación, se basa en una sola incisión de relajación circunferencial, misma que se bifurca en sus extremos. La incisión de relajación única aplicando el principio geométrico es un procedimiento estándar, que puede ser utilizado para corregir cualquier tipo de curvatura peniana. Palabras clave: Enfermedad de Peyronie, tratamiento quirúrgico, incisión, técnica nueva, México. 1 Urologist, Hospital Ángeles Mocel y CEU México. Mexico City, Mexico. 2 Urologist, Hospital Ángeles Mocel. Mexico City, Mexico. 3 Urologist, Hospital Central Militar. Mexico City, Mexico. Corresponding author: Dr. Erick lejandro Ramírez Pérez. Hospital Ángeles Mocel. Gelati 29, San Miguel Chapultepec, consultorio 401-, C.P. 11850. México D.F, México. Telephones: (01 55) 5278 2300, (01 55) 5278 2300. E-mail: dr_erick08uro@hotmail.com Rev Mex Urol 2012;72(4):201-206 201
Introduction Congenital penile curvature or that caused by Peyronie s disease affects the length of the penis and can be associated with constriction of the penile circumference. It can also be accompanied with erectile dysfunction. Current techniques use the application of healthy tunica albuginea, which results in a shortening of the total penile length. In 30% of the patients with Peyronie s disease, the plaque is not palpable and can be multifocal; the changes in the tunica albuginea are diffuse and not limited to one single site. Plaque excision provides very uncertain results and the principle patient complaint is penile deformity. However, relaxing incisions in the tunica albuginea can correct any type of curvature associated or not with Peyronie s disease. Different types of incisions have been suggested, but there is no one ideal technique. The technique we are describing herein is based on a single circumferential relaxing incision that is bifurcated at its ends. Used in conjunction with the geometric principle, the exact incision site in the tunica albuginea is located and the incised wound will later be covered by a graft, almost perfectly correcting the curvature. The objective of this article is to show the technique and results in the management of penile curvature due to Peyronie s disease through the use of a single relaxing circumferential incision and the application of porcine intestinal submucosal graft, based on the geometric principle. Figure 1. Subcoronal incision and exposure of the length of the penis Figure 2. Erection induction Figure 3. ) Paraurethral incisions ) Dorsal neurovascular complex of the tunica albuginea along the circumference of the penis Case presentation 54-year-old man presented with a 45-degree angle penile curvature secondary to Peyronie s disease that made coitus impossible. The curvature was preoperatively evaluated with the application of intracavernous alprostadil. Surgical technique 1) subcoronal penile incision is made, and the entire length of the penis is denuded and exposed (Figure 1). 2) n erection is then induced through puncture and administration of saline solution in either one or both of the corpora cavernosa in order to find the point of maximum curvature (PMC) (Figure 2). 3) In any type of curvature, two paraurethral incisions (- ) are made, uck s fascia is dissected and separated, together with the dorsal neurovascular bundle of the tunica albuginea, along the circumference of the penis (Figure 3). 4) Two tangential lines are drawn on the straightest proximal (- ) and distal (C-C ) axis of the penis (Figure 4). circumferential line is drawn on the bisector angle formed by those lines (PCM). 5) The width (W) of the incised wound to be created should be equal to the difference between the longest (Figure 5) and the shortest (Figure 5) parts of the penis, corresponding to the difference between the distance separating the two circumferential lines perpendicular to the axis that was drawn on the straightest part of the penile segments; in other words, outside the area of the curvature. 6) The difference between D-E and D -E (W) is equal to the size of the incised wound on each side of the urethra, in the case of dorsal curvature (Figure 6). The length of the incised wound (L) is equal to the distance between the two paraurethral incisions (Figure 6). 202 Rev Mex Urol 2012;72(4):201-206
Figure 4. Distal and proximal tangential lines and the circumferential line of the penis for marking the point of maximum curvature (PCM) Figure 5. ) Measurement of the greatest curvature (yellow line), taking the existing reference of the perpendicular lines (E-D) as the limit ) Measurement of the least curvature (yellow line), taking the existing reference of the perpendicular lines (E -D ) as the limit 7) The incised circumferential line, bifurcated at its ends, forms a rectangular incised wound marked as F and F. Its position is the distance that is equivalent to one fourth of the W (incised wound width) from the paraurethral incisions (Figure 7). The resulting bifurcation angle is 120º, producing a simple and stable incised wound (Figure 7). 8) The penis acquires a straight form once a 5 mm incision is made on each side of the intracavernous septum, at its intersection with the transverse incision. 5 mm dissection is carried out under the edges of the tunica albuginea between the corpora cavernosa and the four sides of the incised wound in order to facilitate suturing with the graft to be used (Figure 8). 9) The previously measured graft is symmetrically sutured with 5-0 Monocryl and continuous sutures on the incised wound made in the tunica albuginea (Figure 9). 10) n artificial erection is again created to evaluate the definitive curvature correction (Figure 10). 11) The prepuce is placed in its normal position and sutured with the habitual technique of chromic 4-0 simple interrupted suture (Figure 11). Figure 6. ) Graft ) The length of the graft is equal to the distance between the two paraurethral incisions (-). Rev Mex Urol 2012;72(4):201-206 203
Figure 7. ) The position of the circumferential line is the distance equal to one fourth of the W (width of the incised wound) from the paraurethral incisions. ) single relaxing incision is made on the marked line and bifurcates at its ends, leaving a rectangular incised wound. Figure 8. The rectangular incised wound (D) created with a single incision on the tunica albuginea at the previously marked point of maximum curvature (PCM), leaving the erectile tissue (ET) exposed and not involving the neurovascular complex (NVC) Discussion During the last decade there have been great advances in the understanding and management of Peyronie s disease and the improvements in medical and surgical management are obvious. In general, Peyronie s disease is a pathology that is characterized by a deformity of the penis during erection that can be curved, indented, hourglass-shaped, and shortened. This condition commonly presents with a palpable induration or penile plaque, with or without pain during erection. The mean age at which Peyronie s disease presents is 53 years and its prevalence is 0.4%. 1 It has been associated with certain pathologies such as Dupuytren s contracture, plantar fascial contractures, tympanosclerosis, diabetes, trauma, urethral instrumentation, gout, Paget s disease, the use of beta blockers, and familial inheritance. 2 In the past Peyronie s disease was thought to have a gradual resolution, but today some case series report that 14% of the patients with this pathology resolve it spontaneously, 40% have disease progression, and 47% present with disease stabilization. 3 The pain that presents with erection has been observed to gradually decrease over time. Up to 77% of the patients with this disease are affected by it psychologically. 3 Peyronie s disease is commonly associated with erectile dysfunction. The four factors contributing to this are: severe deformity, mainly in lateral or ventral curvatures, that impedes coitus; penile instability that is produced in patients with extensive disease and conditioned by circumferential plaque; anxiety or depression caused by having the disease; and vascular dysfunction that presents in 30% of the patients. This latter could be secondary to arterial disease or veno-occlusive dysfunction, 4 conditioned by a reduction in tunica albuginea compliance that does not allow for adequate compression of those veins during erection. Trauma has been associated as a triggering factor for Peyronie s disease. 5 Excessive penile flexion or local trauma can cause microscopic vascular injury with subsequent bleeding in the space below the tunica albuginea or a tear in that structure at the level of the septum. This sets off aberrant local cicatrization mechanisms that begin to act with an excessive fibrin deposit and cytokine and tissular growth factor overexpression that stimulate matrix protein overproduction and inhibit the action of the metalloproteinases. This generates the production of disorganized elastic collagen fibers that condition the loss of elasticity in the tunica albuginea. The clinical presentation of the disease is classified as early and late. Patients in the early phase normally present with a nodule or some plaque and painful erection that may or may not be accompanied with deformity. The symptom triad is hardened plaque, a stable deformed penis during erection, and erectile dysfunction. Diagnosis is based on medical and psychosexual interrogation that should include discerning whether there is rigidity during erection, shortening of the penis, induration, hourglass-shaped deformity, pain with or without erection, and the psychological impact of the disease. The majority of patients with Peyronie s disease can be treated with no need for vascular evaluation. 204 Rev Mex Urol 2012;72(4):201-206
Figure 9. The graft is placed symmetrically on the created wound and sutured with 5-0 Monocryl continuous stitches Figure 10. rtificial erection is induced to observe the curvature correction Figure 11. Final aspect of the penis in a flaccid state after skin closure with simple interrupted stitches However, ultrasound is useful for studying the site and amount of plaque and whether or not there is calcification. If a corrective procedure with graft is being planned, Doppler ultrasound with intracavernous medication is suggested for evaluating vascular function and collateral venous flow between the dorsal and cavernous arteries. 6 Treatment of Peyronie s disease is variable. There are multiple therapies for its management that are described in different publications that range from conservative medical treatment to radiation, shockwave, diathermic, and surgical managements, among others. Surgical management is reserved for those patients with important curvatures (> 45º) or narrowing of the tunica albuginea that interferes with coitus. Penile reconstruction should be carried out once the disease has stabilized, which is generally 12 to 18 months after its onset. Preoperative evaluation of erectile function is very important for defining the best management. In general, surgical procedures in these cases in particular are divided into three categories: procedures to shorten the tunica albuginea, procedures to lengthen the tunica albuginea, and prosthetic procedures. The procedures for shortening the tunica albuginea are performed on the convex side of the penis, on the side that is contralateral to the plaque. Nesbit was the first to discover this principle, 7 and over time certain modifications have been made that have created new techniques, but the principle is the same. Generally this procedure is adequate for patients that have no erectile function alterations and that have sufficient length with no deformity or narrowing of the circumference of the penis. The procedures for lengthening the tunica albuginea, as in our present case, are more demanding because they involve more complex reconstruction maneuvers. These procedures are indicated for more complicated situations in which there is important penile curvature and deformity. Devine and Horton 8 successfully began the use of free grafts. Many types of autologous grafts have been used that include temporalis fascia, dura mater, tunica vaginalis, saphenous, and more recently, mucosal grafts. Cadaveric grafts have also been used such as those from porcine intestinal submucosa, bovine pericardium, and synthetic grafts made from polyester and polytetrafluorethylene, all with a wide variety of results. Plaque excision used to be considered standard technique. However, new surgical management options were sought due to the excision-associated complication of erectile dysfunction. In 1991 Gelbard and Hayden proposed tunica albuginea incision only plus the free graft application and erectile dysfunction was considerable reduced. 9 There are different types of incisions, such as the H incision, with success rates from 75 to 95%. 10 Egydio et al. have also proposed the relaxing incision using the geometric principal 11, like the procedure in this publication, with very satisfactory results. We believe this technique can correct any type of penile curvature whether or not it is associated with Peyronie s disease. No material yet exists that has the same characteristics as the tunica albuginea, however, the studies focused on the understanding of Peyronie s disease are promising. In the meantime, we have to know and understand this pathology in order to offer our patients the best therapeutic option. Conclusions The single relaxing incision using the geometric principle is a standard procedure that can be used to correct any type of penile curvature, regardless of the characteristics of Peyronie s plaque, without affecting the total length of the penis. References 1. Lindsay M, Schain DM, Grambsch P, et al. The incidence of Peyronie s disease in Rochester, Minnesota, 1950 through 1984. J Urol 1991;146(4):1007-1009. Rev Mex Urol 2012;72(4):201-206 205
2. Nyberg LM Jr, ias W, Hochberg MC, et al. Identification of an inherited form of Peyronie s disease with autosomal dominant inheritance and association with Dupuytren s contracture and histocompatibility 7 cross-reacting antigens. J Urol 1982;128(1):48-51. 3. Gelbard MK, Dorey F, James K. The natural history of Peyronie s disease. J Urol 1990;144(6):1376-1379. 4. Lopez J, Jarow JP. Penile vascular evaluation in old men with Peyronie s disease. J Urol 1993;149(1):53-55. 5. Devine CJ Jr, Somers KD, Jordan SG, et al. Proposal: trauma as the cause of the Peyronie s lesion. J Urol 1997;157(1):285-290. 6. Ralph DJ, Hughes T, Lees WR, et al. Preoperative assessment of Peyronie s disease using colour Doppler sonography. r J Urol 1992;69(6):629-632. 7. Nesbit RM. Congenital curvature of the phallus: report of three cases with description of corrective operation. J Urol 1965;93:230-232. 8. Devine CJ Jr, Horton CE. Surgical treatment of Peyronie s disease with a dermal graft. J Urol 1974;111(1):44-49. 9. Gelbard MK, Hayden. Expanding contractures of the tunica albuginea due to Peyronie s disease with temporalis fascia free grafts. J Urol 1991;145(4):772-776. 10. Montorsi F, Salonia, Maga T, et al. Evidence based assessment of long-term results of plaque incision and vein grafting for Peyronie s disease. J Urol 2000;163(6):1704-1708. 11. Egydio PH, Lucon M, rap S. Single relaxing incision to correct different types of penile deformity. JU Int 2004;94(7):1147-1157. 206 Rev Mex Urol 2012;72(4):201-206