Procedures for Peyronie Disease

Introduction

Penile surgery for Peyronie disease is continually evolving. Since the publication of the last edition of this surgical atlas, there has been a paradigm shift in our approach to Peyronie disease and penile deformity. Previously, there was no good medical treatment for Peyronie disease. In December of 2013, collagenase Clostridium histolyticum (Xiaflex; Auxilium Pharmaceuticals, Chesterbrook, PA) was approved by the U.S. Food and Drug Administration (FDA), allowing for nonsurgical treatment of Peyronie disease. Now collagenase is incorporated into our treatment algorithm and allows many patients to avoid surgery. Previously, we performed surgery with the intent of removing and replacing the diseased tunica albuginea. Now we focus on preserving the fundamental structure of the penis with minimal disruption of the tunica albuginea and therefore minimal risk of erectile dysfunction (ED). The interventions we currently use reduce anesthesia times; reduce recovery times; and minimize the long-term risks of impotence, hypoesthesia, and paresthesia.

Surgical Approach to the Patient

A thorough sexual history, including erectile rigidity, is essential for operative planning. Obtain a detailed history and physical examination, including examination for other fibroproliferative conditions such as Dupuytren contracture (palms) and Ledderhose disease (plantar surfaces of feet). Evaluate the penile deformity using either a photograph that the patient provides of his erect penis or perform a clinical examination of the erect penis after injection of a vasoactive agent. The latter is preferable because it allows for more objective assessment of rigidity and deformity. Document the degree and direction of curvature; penile girth; and any other deformity, including description of hourglass or hinge effect if present. Obtain stretched penile length and girth measurements and assess penile sensation. Photograph the erect penis when possible for treatment planning and postoperative comparative analysis.

Penile ultrasonography is a clinical adjunct that is familiar to urologists and is readily available in most urology offices. Scan the flaccid penis along both the dorsal and ventral surfaces using a high-frequency probe. This allows for systematic, three-dimensional evaluation of plaques, septal fibrosis, intracorporal fibrosis, and the shape and size of both corpora cavernosa. It is important to note if plaques are calcified and to measure the tunica thickness superficial to calcified plaques to determine if a tunica-sparing plaque excision might be an option. If a grafting procedure is planned, a color duplex ultrasound study of penile arterial and venous function as well collateral circulation between the branches of penile artery is also recommended.

Delay surgery until the patient is in the chronic phase of the disease, usually 12 to 18 months after disease onset, and the deformity has been stable for at least 3 to 6 months. If conservative therapies and medical interventions have been ineffective, surgery is indicated for deformities that prevent penetrative sexual intercourse, for extensive or painful ossified penile plaques, or for patients who desire rapid results.

One of the most important aspects of surgical planning for Peyronie disease patients is establishing realistic patient expectations regarding surgical outcomes. Ensure that the patient understands that the goal of surgery is to restore penile function, not to return the penis to its pre–Peyronie disease state. Explain the risks of penile surgery to include penile shortening, recurrence of deformity, decreased sensation, persistent pain, postoperative ED, and possibly poor cosmesis.

Treatment Algorithm

Operative planning is based on location and degree of deformity (curvature, hourglass, hinge effect), preoperative erectile function, stretched penile length, and patient and surgeon preference. We rarely choose tunical lengthening surgical procedures (plaque incision or partial excision with grafting) because these procedures have been supplanted by collagenase injection. Because these procedures are associated with increased overall morbidity and increased risk of postoperative ED, we use them infrequently but recognize that they are appropriate in well-selected candidates, who are counseled thoroughly regarding the risks and benefits of the procedures.

1.

For patients who have adequate penile rigidity for sexual intercourse, we usually offer collagenase injections to correct curvature related to dorsal plaques.
2.

If collagenase is ineffective or does not correct the curvature completely, we offer plication surgery to correct the residual curvature.
3.

For patients with an hourglass deformity, we offer a tunica reinforcement procedure, or thickening procedure with an allograft, to prevent the need for surgical disruption of the tunica albuginea. We refer to this procedure as an extratunical grafting procedure.
4.

For patients with a bothersome calcified plaque, we offer tunica-sparing excision of the calcified plaque along with surgical correction (as above) for the remaining deformity at the same surgical setting.
5.

For patients with preoperative ED that is not responsive to erectogenic medications, we recommend penile prosthesis placement.
6.

Patients with ED that is responsive to erectogenic medications may be candidates for reconstruction but must understand that they may require increased doses of medication or may no longer respond to medications postoperatively.

Collagenase Injection

Collagenase is our preferred initial treatment for patients with adequate erectile function and penile curvature (dorsal, dorsal-lateral, or hourglass deformity) related to dorsal penile plaques. Xiaflex should only be administered by a health care provider experienced in the management of Peyronie disease who has been certified via the Xiaflex Risk Evaluation and Mitigation Strategy (REMS). A treatment cycle consists of two collagenase injection procedures separated by 1 to 3 days followed by 6 weeks of penile modeling (or stretching) procedures. Each treatment cycle may be repeated at approximately 6-week or longer intervals. Up to four treatment cycles may be administered for each plaque causing the curvature deformity. If the curvature is not clinically significant or is not bothersome to the patient after his first cycle, additional treatment cycle may not be necessary.

Injection Procedure

Induce a pharmacologic penile erection rigid enough to identify and mark the target area in the Peyronie plaque to be injected. The penis should be in a flaccid state before injecting Xiaflex. Inject local anesthetic such as bupivacaine 0.25% into the local area of the plaque. Wait for 5 to 10 minutes for the local anesthetic to become effective. Before use, reconstitute the Xiaflex lyophilized powder with 0.39 cc of the supplied diluent according to the manufacturer’s instructions. Using a new hubless syringe containing 0.01-mL graduations with a permanently fixed 27-gauge, -inch needle, withdraw a volume of 0.25 mL of reconstituted solution (containing 0.58 mg of Xiaflex). Next, grasp the plaque between the forefinger and thumb of your nondominant hand. Apply antiseptic at the site of the injection and allow the skin to dry. Insert the needle transversely through the width of the dorsal plaque or until the needle cannot be advanced farther, which indicates that the needle is in the middle of the plaque ( Fig. 126.1 ). Proper position is confirmed by noting resistance to minimal depression of the syringe plunger. Inject 0.58 mg of reconstituted Xiaflex into the target plaque of the flaccid penis once on each of two days, 1 to 3 days apart ( Fig. 126.2 ). Although not recommended by the pharmaceutical company, we have successfully treated men with severe ventral curvature and thick ventral plaque. In these men, we prefer to insert the needle longitudinally to the plaque to avoid injury to the corpus spongiosum or urethra.

Modeling Procedures

Perform a penile modeling procedure 1 to 3 days after the second injection of each treatment cycle to stretch the plaque and teach the patient how to stretch the plaque. Our recommendations for modeling are slightly different from those of the manufacturer and are based on personal clinical experience. Ensure that you are familiar with the manufacturer’s recommendations before administration of Xiaflex. We recommend that the patient stretch the flaccid penis 10 times per day, for 60 seconds each time, for the 6 weeks after treatment to maximize the length that he will gain from the collagenase injection. If the patient has an hourglass deformity, we recommend that he begin use of the manual vacuum erection device (without the constriction ring) beginning after 3 days or after bruising has improved after the second injection of the cycle. He should slowly erect the penis until slightly uncomfortable and maintain in this position for 3 minutes then release to allow the erection to subside for several seconds and then repeat for a total of 10 to 15 minutes twice daily.

Postprocedural Considerations

Warn the patient that he may experience significant pain for several days after injection and that he may develop bruising over the shaft of his penis, pubis, or scrotum. He may also notice that with modeling procedures or during nocturnal erections that he may feel or hear the plaque stretching. These are all normal occurrences. The patient should avoid intercourse for 2 to 3 weeks after injection. If he is taking aspirin or anticoagulants, recommend placement of a compression dressing for 1 to 2 days after injection to avoid excessive ecchymosis or hematoma. Counsel the patient that if he hears a popping sound or sensation in the erect penis with the sudden loss of the ability to maintain an erection, he should seek immediate medical attention as he may have a penile fracture. The other major complication seen with collagenase injections is herniation of the tunica albuginea. We theorize that this may be due to thinning of the tunica by the collagenase. Anatomically, the lateral aspect of the tunic is thinner and therefore more prone to herniation after Xiaflex injection.

Surgical Interventions

16-Dot Plication

Position the patient supine on the operating room table. Light sedation with local anesthesia is appropriate for this operation. Induce a rigid pharmacologic erection by injecting papaverine or papaverine with phentolamine into the corpus using a 25-gauge needle. Prepare the genital area in the usual sterile fashion. Inject local anesthetic, such as bupivacaine 0.25% into the incision site or perform a penile ring block at the base of the penis. Assess the degree and laterality of deformity.

If pharmacologic erection is not an option or was ineffective, alternatively, create a saline artificial erection after the sterile field has been prepared. Place a 21-gauge scalp needle into one corpus. One hand is used to compress the proximal corpora as proximally as possible, squeezing between the thumb and index finger, while injectable saline is infused through the scalp needle. It is difficult to place a tourniquet proximally enough, and the extent of the curvature may be underestimated. In addition, placing a tourniquet directly over the dorsal nerve may cause numbness of the penis.

Make either a longitudinal or a circumcision incision. If the patient is already circumcised, desires circumcision, or desires to avoid a longitudinal penile scar, make the circumferential incision approximately 1 cm from the corona of the glans; using this incision rather than the previous circumcision incision will decrease postoperative edema in the distal penile skin, which can be prolonged postoperatively because of distorted lymphatic drainage after circumcision. If the patient is not concerned about cosmesis, a longitudinal penile incision is preferable because it allows for direct visualization of the area of concern with minimal dissection and thus minimal postoperative morbidity ( Fig. 126.3 ).

For dorsal curvature, incise Buck fascia longitudinally adjacent to the corpus spongiosum. Extending just lateral to the corpus spongiosum, expose the ventral tunica albuginea along the length of the curvature. Mark the center of the curvature. Mark the entry and exit points of the sutures, measuring approximately 0.5 to 1 cm apart. Place the points 2 to 3 mm lateral to the corpus spongiosum. Every four dots correspond to one suture; most curvatures require two or three sets of sutures on each side of the corpus spongiosum to straighten the deformity (total of 16 or 24 dots). In some cases, you may choose to place only one suture. In rare cases with severe angle of deformity or an extremely long phallus, four pairs of sutures (32 dots) are used. Place a 2-0 braided polyester nonabsorbable suture through the full thickness of the tunica albuginea ( Fig. 126.4 ). With the erection still relatively full, tie the sutures with a single throw of a knot and place a rubber-shod clamp just above each half knot. With manual compression of the base of the penis, induce a rigid erection and assess the straightness of the penis ( Fig. 126.5 ). Make any correction by loosening or tightening the sutures and then reevaluate.