Plaque incision and grafting represents the best surgical approach to the Peyronie’s disease patient: Con

Surgical treatment options for Peyronie’s disease include tunica shortening (Nesbit and plication) and grafting procedures. Tunica shortening procedures are associated with penile shortening. However, the amount of penile shortening is rarely significant for the patient. Although grafting procedures aim to prevent penile shortening, this may still be an issue due to the pathologic extent of Peyronie’s disease. Long-term postoperative erectile dysfunction is the major drawback. Many types of grafting material have been used, but only saphenous vein has gained certain acceptance. Grafting procedures must be restricted to patients with normal preoperative erectile status and excessive curvature. Nesbit or plication procedures may be associated with significant penile shortening. Grafting procedures are also indicated in cases of hourglass deformities, because they cannot be corrected by the Nesbit procedure. Nesbit wedge resection is still the gold standard for treating Peyronie’s disease.     

Surgical management of Peyronie’s disease: Which operation?

Multiple treatment options are currently available for Peyronie’s disease (PD) and include minimally invasive interventions. Surgical treatments are considered the best option when the plaque proves refractory to these treatments, when penile curvature is severe, or when erectile dysfunction is vascular or mechanical. Most surgeons experienced in surgical management of PD use a wide range of procedures including plication procedures, plaque incision/excision with grafting, or implantation of a penile prosthesis. This article assesses the indications for surgery, the various surgical procedures available, when and to whom surgery should be offered, and the expected results and complications.     

Surgical decisions in Peyronie’s disease

In this review, we examine recent advances assisting surgical decision in Peyronie’s disease. Surgical treatment is indicated in penile deformities that have persisted for at least 6 months and functionally impair or preclude intercourse. Procedures shortening the longer side of the penis are invariably associated with length reduction, which may displease patients, despite penile straightening. Procedures lengthening the shorter side by means of grafting provide the best possible gain from a reconstruction procedure, although they may not restore the penis to its original length. Penile rectification and rigidity are required to achieve complete functional restoration of the penis. Most patients experience associated erectile dysfunction, and penile straightening alone may not be enough to restore complete function. Therefore, in some cases, phosphodiesterase inhibitors, self-injection, or a penile prosthesis may need to be added. Issues concerning surgical indication, patient selection, surgical techniques, and grafting are discussed.     

Addressing residual penile deformity in the Peyronie’s disease patient during penile implant surgery

Peyronie’s disease frequently presents as a painful curvature of the erect penis. Once stabilized, a proportion of patients will require a surgical intervention to correct the curvature. Reconstructive surgery should be considered separately in each patient as those with significant erectile dysfunction may be better suited to the implantation of a penile prosthesis, which will correct both the curvature and impaired erection. The erect penis usually is straightened after the prosthesis insertion, but in a minority of patients, some curvature remains. When this occurs, additional procedures will be necessary to straighten the penis by plaque incision (with or without grafting) or by the modeling technique. These additional techniques are necessary to improve patient satisfaction.     

Local therapy for Peyronie’s disease

The natural history of Peyronie’s disease is extremely variable. There are no clear, efficacious medical treatments. Local therapy includes pharmacotherapy and mechanical therapy. Degree of penile curvature is the critical end point for studies, although plaque size, erectile function, and pain are also important. Intralesional treatment with verapamil is the most commonly used therapy and has shown positive results, mostly in nonrandomized, noncontrolled trials. Interferon has shown efficacy in a large, multicenter, placebo-controlled trial but has significant flu-like symptoms. New data with collagenase show promise, and large, multicenter clinical trials are due to begin in 2008. Mechanical therapy with penis extenders has been introduced in the past year in an attempt to straighten and lengthen the penis in patients with Peyronie’s disease. More double-blind, randomized, controlled studies are necessary to better analyze these minimally invasive modalities in the treatment of Peyronie’s disease.     

Plaque incision and grafting represents the best surgical approach to the Peyronie’s disease patient: Pro

Various surgical modalities have been utilized for the treatment of penile tortuosity caused by Peyronie’s disease. However, the ideal surgical procedure has not yet been developed. Because plaque incision and grafting does not cause penile shortening, it is the best approach, particularly in cases of severe and complex penile curvature. Additionally, if the graft is nonsynthetic, neither inflammatory nor anomalous scarring will develop over time. This review suggests crural corpora cavernosa as the graft of choice, because it more closely resembles the incised area both anatomically and functionally.     

Advances in the Surgical Treatment of Peyronie’s Disease

Surgical treatment is the gold standard for correction of penile deviation in patients with Peyronie’s disease. Generally, plication techniques are applied when deviation is less than 60°, the patient has decreased erectile function, and penile length is satisfactory. Grafting techniques are indicated when deviation exceeds 60°, there is a short penis or an hourglass deformity, and the patient has good erectile capacity. In patients with erectile dysfunction refractory to medical treatment, penile prosthesis implantation with simultaneous correction of deviation is the optimal approach. This article summarizes some of the novel advances for each of these procedures, which have been reported in recent years. Surgical technique and outcomes of these techniques are described, and limitations set. Adequate preoperative counseling, including all options available today, is crucial before planning surgical treatment in Peyronie’s disease. Surgeon experience and careful patient selection for each procedure will remain the most determining factors for success.     

Transdermal therapies for Peyronie’s disease

Topical treatment of Peyronie’s disease has recently emerged as a noninvasive option to decrease the deformity and pain associated with this disorder. This article reviews the literature on this subject with attention to topical verapamil gel, which has been used extensively in the United States. However, no published independent placebo-controlled trials exist to confirm its beneficial effect. This article also reviews iontophoresis, a form of topical energy therapy also known as electromotive drug administration (EMDA). Topical energy therapy without drug administration has been shown to enhance wound healing as a result of the energy transfer. Recent studies have also examined EMDA therapy with verapamil and other agents to encourage scar remodeling with subsequent reduction in penile deformity for the man with Peyronie’s disease.