Surgical Treatment of Peyronie’s Disease

BROOKE EDWARDS

RAMÓN VIRASORO

Peyronie’s disease (PD) is a scarring disorder of the tunica albuginea leading to penile deformity (Fig. 67.1). PD is a completely clinically established entity; still, its etiology is uncertain. Several theories have been proposed since its first description in the mid-18th century, but none has been confirmed yet (1,2,3). To the authors’ knowledge, the development of PD is related to the unique anatomy of the tunica albuginea and its relationship to the septal fibers. The most accepted etiology seems to be the occurrence, in genetically susceptible individuals, of repetitive minimal trauma during sexual life. Unidentified buckling injuries of the penis will eventually lead to scarring and penile deformity (4). Only a few patients relate the onset of symptoms to a specific penile injury during sexual intercourse.

The incidence of PD has recently been estimated at up to 3% or as high as 7% to 9% of the general male population (5,6).

FIGURE 67.1 Cross-sectional penile anatomy with dorsal Peyronie’s plaque.

CLINICAL PRESENTATION

The most frequent presentation is the development of penile curvature, but decrease in penile length, indentation, hinge deformity, and erectile dysfunction are very common complaints (Fig. 67.2).

Clinically, PD has two phases. The first, an active phase, is commonly associated with painful erections and changing deformity of the penis. It is followed by a quiescent secondary phase, characterized by deformity stabilization, disappearance of painful erections, if they were present, and, in general, stability of the process. Up to a third of patients, however, present with what appears to be sudden “overnight” development of painless deformity.

DIAGNOSIS

The diagnosis of PD is mainly clinical, based on a detailed history and physical examination. Recollection of onset, duration, and progression of penile deformity is crucial as well as any degree of sexual dysfunction. Erectile dysfunction, if present, is multifactorial because many of these patients have preexistence comorbidities. The psychological impact of the disease plays an important role.

The physical examination should be focused on delineating plaque location, size, and penile sensitivity because many patients complain of hypoesthesia. Decrease in penile sensitivity needs to be established for this is a common postoperative complaint, and basal sensitivity needs to be established. In an attempt to elicit known disease associations such as Dupuytren’s contracture or other elastic tissue fibromatosis,
an examination of hands and feet should be made. Objective evaluation of penile curvature with home-taken photographs of the erect penis, we find, is extremely helpful, but other authors have found it most useful to perform an artificial erection with vasoactive substances at the time of office visit. Curvature is then measured using a goniometer or protractor. Plain radiographs are effective in demonstrating plaque calcification (Fig. 67.3). The presence of calcifications, once believed to be a sign of plaque maturity, is now debatable, for recent reports have shown it to be more prevalent and present early in the onset of symptoms (7). Plaque calcification is also easily demonstrated with ultrasonography (8). The plaque can be imaged by both computerized tomography (CT) and magnetic resonance imaging (MRI), both being unnecessary except for the possibility of using MRI to “stage” the phase of disease for research or study protocol purposes, or in a rare patient where the diagnosis is not certain and a concern for a possible malignancy arises (9).

FIGURE 67.2 A: Lateral curvatures at the midshaft. B: Hourglass deformity.

FIGURE 67.3 Prominent calcification of a dorsal plaque.

It is important to evaluate and define the surgical candidate’s preoperative erectile function. Prospective surgical patients, at our center, are evaluated with color duplex ultrasound in the presence of pharmacologically induced erection. Abnormalities in the resistive index and end-diastolic velocity, at our institution, prompt further testing with dynamic infusion cavernosometry/cavernosography. In addition, one must determine if acceptable intercourse can be accomplished by enhancement of erectile rigidity alone. In this scenario, patients may be best served with a pharmacologic erection program as an alternative to surgery.

INDICATIONS FOR SURGERY

A frank discussion of treatment goals with the couple is imperative. The patient should be assured that the process is not malignant or life-threatening. The goal of surgery is to straighten the penis and maintain erectile function so that satisfactory intercourse can be achieved.

Couples must be aware that preexisting penile shortening and erectile dysfunction will not be improved by straightening procedures. Rigidity may be improved by straightening the penis, but truly improved erectile function does not occur. Evaluation with a sex therapist can help patients and partners adjust to these new sexual expectations.

Surgical candidates must have stable and mature disease, which includes resolution of pain and stabilization of curvature or other deformity. Fortunately, only a small proportion
of patients with PD have deformity requiring surgical intervention. Surgical intervention should be regarded as palliation of the deformity only and not as cure.

In essence, one can correct the penile curvature by “shortening” the long aspect of the curve or by “lengthening” the short aspect of the curve. Additionally, in those patients with PD and associated severe erectile dysfunction, the option of a penile implant with plaque modeling or incision with or without grafting is valid.

Several surgical techniques have been described to correct penile curvature associated with PD, including plication of the opposite aspect of the lesion and incision/excision of the plaque and grafting. The tissues and materials applied to graft the corporal defect include dermis, tunica vaginalis, cadaveric dura mater, temporalis fascia, veins, cadaveric pericardium, and porcine small intestine submucosa (SIS) (10,11,12,13,14,15,16).

SURGICAL TECHNIQUE

Skin Incision

At our institution, we perform all Peyronie’s corrective procedures in supine position and use either a circumcising incision and penile degloving or an optional ventral midline incision for ventral plications. If the patient has been previously circumcised, then the incision should be performed through the circumcision scar. Once the incision has been made, an artificial erection is created with a pressure infuser device or butterfly needle and syringe with injectable 0.9% normal saline. We tend not to employ the use of a tourniquet to control bleeding or maintain an artificial erection because it is unneeded and tends to distort the presence of a proximal curvature. Some authors use vasoactive substances, such as papaverine or PGE, for this purpose.

Corporoplasty or Corporoplication Procedures

Several techniques and modifications have been published that describe methods of plication, or shortening of the convex side of the curvature. The techniques fall into (a) nonincisional plication, (b) incisional plication, or (c) excisional plication categories.

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