Surgical Technique for Complex Cases of Peyronie’s Disease With Implantation of Penile Prosthesis, Multiple Corporeal Incisions, and Grafting With Collagen Fleece

Abstract

Introduction Patients with Peyronie’s disease (PD) and erectile dysfunction (ED) concomitant with shortening or other malformations benefit from prosthesis implantation and penile lengthening procedures. Aim To evaluate the safety and efficacy of a multi-incisional technique with penile prosthesis implantation with multiple corporeal incisions and collagen grafting for the surgical management of complex cases of PD with ED and severe penile shortening. Methods From February 2015–May 2018, 43 consecutive patients with complex PD were treated using this technique. Implantation of a penile prosthesis (malleable or inflatable [IPP]) together with multiple relaxing tunica albuginea incisions and grafting with a self-adhesive collagen-fibrin fleece (TachoSil, Baxter Healthcare) was performed in all patients by a single surgeon (J.I.M.S.). Main Outcome Measure Penile length and curvature correction, operative time, and incidence of postoperative complications were recorded as outcome measures. Functional outcomes were measured with questionnaires (International Index of Erectile Function-5, Erection Hardness Score, modified Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire, PD Questionnaire) before and 3 and 6 months after surgery. Results With a median follow-up of 21 months (range 10–31), mean postsurgical penile lengthening was 2.5 (range 1–5) cm, with an improvement in the Bother domain of the PD Questionnaire of 4.4 (range 2–5) points. The average operative time was 86.7 and 71.6 minutes for the IPP and malleable penile prosthesis procedure, respectively. No glans ischemia was recorded; however, 1 IPP infection and 1 delayed distal corporeal erosion were recorded. Hematoma or bruising was observed in 23.2% of patients. The modified Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire was completed by 39 (90.7%) patients. Overall, 89.7% would recommend this surgery. Patient satisfaction with straightness and length was 94.9% and 82.1%, respectively. Clinical Implications The described technique helps restoration of penile length and erectile function in patients with complex PD. Strengths & Limitations The strength of the study is that it offers a simple, easy-to-apply technique for surgeons to correct shortening and other malformations in patients with ED and complex PD. The study is limited by the small number of patients, the short follow-up period and the performance of the technique by a single high-volume implanter. Conclusion The implantation of a penile prosthesis (malleable or inflatable) together with multiple incisions of the plaque/tunica albuginea and grafting with a collagen fleece is a safe and efficient treatment for patients with complex PD in addition to ED and significant shortening.

A comprehensive narrative review of residual curvature correction during penile prosthesis implantation in patients with severe erectile dysfunction and concomitant Peyronie’s disease

“…Only 11 articles were published until 2010 (14,16,(24)(25)(26)(27)(31)(32)(33)(34)(35). Most of the articles were published during the last decade (17)(18)(19)(20)(21)(22)(23)(28)(29)(30)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47). Most studies had a retrospective design and only five studies were prospective (21,24,27,41,43).…”

“…Nineteen studies investigated the results of PPI with additional tunical/plaque incision/excision and grafting of the defect for the correction of severe residual penile curvature (Table 4) (14,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47). They included a total of 1,072 patients with a pooled mean age of 59.8 years (ranged from 51.2 to 67.2) and a pooled mean follow-up of 27 months (ranged from 6.6 to 45 months) (14,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47). Most studies assessed the use of inflatable 3-piece penile prosthesis (14,20,31,38,(42)(43)(44)(45)47)...…”

“…They included a total of 1,072 patients with a pooled mean age of 59.8 years (ranged from 51.2 to 67.2) and a pooled mean follow-up of 27 months (ranged from 6.6 to 45 months) (14,20,(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47). Most studies assessed the use of inflatable 3-piece penile prosthesis (14,20,31,38,(42)(43)(44)(45)47), while many of them included patients with both inflatable and malleable penile prosthesis (33,34,36,37,39,41,46). Two studies evaluated the use of only malleable penile prosthesis (32,40).…”

“…Most trials performed a penoscrotal incision for the PPI and a separate subcoronal circular incision with degloving for the plaque incision/excision and grafting (14,31,38,41,(43)(44)(45)(46). S o m e s t u d i e s , e s p e c i a l l y t h o s e t h a t p r e f e r r e d a malleable prosthesis, performed only the subcoronal incision with degloving for both the PPI and grafting (32)(33)(34)36,39,40,45,46). Two authors proposed a ventral longitudinal non-degloving incision from the frenulum to the scrotum (20,42) and one an infrapubic approach (35).…”

“…Most surgeons performed a single incision at the point of maximal curvature on the concave side or multiple relaxing incisions (14,(31)(32)(33)(34)(35)40,43,45,46). Some authors performed a circular incision of the tunica (36,38,39), while others selected the sliding technique (20,37,41,42).…”