A Surgical Algorithm for Men with Combined Peyronie's Disease and Erectile Dysfunction: Functional and Satisfaction Outcomes

Abstract

Introduction Men with Peyronie's disease who also have erectile dysfunction represent a challenge to the urologist. Historically, penile prosthesis surgery has been the management strategy of choice for this population. This study was undertaken to define the outcomes of a penile reconstructive surgery algorithm in men with Peyronie's disease and concomitant erectile dysfunction (ED). Methods Patients presenting with combined Peyronie's disease and erectile dysfunction were treated with vasoactive therapy initially. All patients underwent dynamic infusion cavernosometry and cavernosography. Nonresponders to erectogenic pharmacotherapy were advised to undergo penile prosthetic surgery. Responders to erectogenic therapy were considered candidates for either corporoplasty or plaque incision and grafting. The International Index of Erectile Function (IIEF) questionnaire was used to compare erectile function and satisfaction profiles serially pre- and postoperatively between the patients in the three groups. Results Sixty-two patients constituted the study population. Eighty-one percent of the patients responded to erectogenic pharmacotherapy. Postoperative IIEF erectile function domain scores were statistically higher for implant patients and lower for plaque incision and grafting patients compared to preoperative scores. Postoperative IIEF satisfaction domain scores were higher for corporoplasty and implant patients and lower for plaque incision and grafting patients compared to preoperative scores. Conclusions The surgical algorithm used in this study leads to excellent IIEF erectile function and satisfaction scores for corporoplasty and implant patients; however, plaque incision and grafting patients had poor functional and satisfaction outcomes. These data support the concept that not all men with combined ED and Peyronie's disease require penile prosthetic surgery, and furthermore, plaque incision and grafting surgery is a poor option for men with combined disease.

Surgery for Peyronie's disease

“…22 SURGICAL ALGORITHM FOR THE MANAGEMENT OF PD Several surgical algorithms have been published and are summarized in Box 2. [23][24][25] In men who have rigidity which is adequate for coital activity with or without pharmacotherapy, tunica plication techniques vs. plaque incision or partial excision and grafting (PEG) techniques may be employed. Tunica plication techniques are recommended for those who have a simple curve of less than 60-70u, absence of hourglass or hinge effect, and when the anticipated loss of length would be less than 20% of the total erect or stretched length.…”

“…23,25,28 This allows for correcting the deformity while addressing the ED as well. If curvature is not satisfactorily corrected after the prosthesis is inflated at the time of placement, additional straightening maneuvers may be performed.…”

“…[23][24][25]28 Manual modeling may then be performed if necessary as only patients with mild curvature or presence of hinging without curvature will be fully corrected with prosthesis placement alone. Incising the tunica albuginea is then indicated if residual curvature is in excess of 30u after modeling attempts.…”

Buccal mucosa is a promising graft in Peyronie’s disease surgery. Our experience and a brief literature review on autologous grafting materials

“…At the moment, no one surgical technique demonstrates superiority. Is it clear that when penis have a severe curvature (> 60°) or deformity or it is affected by marked shortening or narrowing, plaque incision/partial excision and the graft of the resulting albuginea defect is the preferred surgical approach (20).…”

Long-term results of the surgical treatment of Peyronie's disease with plaque incision and grafting

“…4 Larger grafts, men older than 60 years old, and those with ventral grafting also appear to have a higher risk of postoperative ED. 5,6 Following surgery, postoperative rehabilitation is recommended to enhance recovery of erectile function. Massage and stretch therapy, is performed by grasping the glans penis and pulling it gently and repeatedly away from the body while also gently massaging the graft area.…”