Because of this, particularly for those men with more severe curvature, most contemplate surgical interventions at some time. At this point, it is imperative that patients understand that surgery is not a cure for the disease process. Because of this, guidelines exist to determine which patients will achieve the best surgical outcomes.
Surgical options include:
The best possible surgical outcome requires both careful patient selection and sometimes, combination of procedures. For instance, to minimize penile shortening some men choose a grafting procedure in spite of a risk of erectile dysfunction. On the other hand, those who wish to minimize the risk of erectile dysfunction mist likely choose a Nesbit-like procedure.
Penile prosthesis implantation is typically reserved for the treatment of patients who have erectile dysfunction (ED) associated with Peyronie’s disease. As medical treatments for ED advance, fewer patients require implantation as their best treatment option. Fortunately, the corporal tissue underlying Peyronie’s plaque is “uniformly uninvolved”. Because of this, most patients with mild-to-moderate curvature can expect an excellent outcome simply by cylinder insertion. On the other hand, for cases of severe deformity, intra-operative “remodeling” of the penis over inflated cylinders has been quite effective. When remodeling alone is ineffective, however, a judiciously placed incision or graft may further enhance the surgical outcome.
In 1965, Nesbit was the first to describe removal of tunical ellipses opposite an inelastic corporal segment to treat congenital penile curvature. Fourteen years later, this technique finally translated into a successful treatment option for Peyronie’s disease. Modifications that have simplified, and thereby also reduced morbidity, include the transverse closure of longitudinal corporotomies, and an incision-free-suture-based imbrication. Overall, success rates have improved with better selection and the addition of non-absorbable suture to each plication site. This reduces long-term distraction failures.
The best candidate for tunical shortening should have adequate erections, a mature plaque without concomitant hourglass deformity, a curvature of less that 60 degrees, and adequate penile length. The most common “complication” of this procedure is loss of penile length, which fortunately, rarely affects sexual relations. In fact, overall success rates for the original Nesbit and Nesbit-modifications reports in the literature are around 79-95%. Other adverse events include phimosis, penile narrowing, ED, suture granuloma, and palpable suture lumps.
Plication techniques will remain an important treatment option for Peyronie’s disease. From a surgeon’s point of view, it is a relatively straightforward surgical procedure that lends itself to enhancing, or “touching-up”, other operative approaches. From a patient’s perspective, it carries the lowest risk (5%) of post-operative ED.
Inclusion criteria for tunical lengthening contrast with those just mentioned for plication. Surgeons should consider grafting men with a shorter penis, more proximal plaque, and a curvature greater than 60-degrees. Additionally, those patients with an hourglass deformity or a lateral curvature bend seen to do better with grafting procedures.
Replacement of diseased tunica was largely unsuccessful until Devine and Horton introduced dermal grafting in 1974. Since then, an array of grafting materials have been studied and include autologous tissue such a temporalis fascia, dura mater, tunica vaginales, bucal mucosa vascularized preputial and dorsal/saphenous veins; cadaveric tissues such as dermis, fascia and pericardium; and lastly, synthetic materials such as Dacron, Gore-Tex and silastic. Unfortunately, no material has been found perfectly replaces diseased tunica albuginea. Also, in addition to not having optimal grafting material, another problem with this type of management rest with concept of “complete plaque excision”. First, it appears that the deleterious histological effects of Peyronie’s extends well beyond “visibly” altered tunica vaginalis, making the goal of complete surgical excision a difficult, if not impossible, task. Second, grafting large areas seems to have a negative effect on erectile function, resulting in ED rates as high as 25%. Lastly, although initial surgical results were excellent, graft contracture and long-term failures resulted in a disappointing 17% re-operation rate.
In an effort to improve complications rates associated with plaque excision. Gelbard and Hayden (1991) introduced the concept of plaque “incision” with grafting. Apparently, less disruption of the tunica and its underlying tissue resulted is improved rates of postoperative erectile function.
Of all the grafting materials available, the optimal replacement for diseased tunica albuginea has yet to be determined.
Peyronie's disease is a common condition associated with penile vascular disease. Patients should be counselled so that they understand the pitfalls of surgery to enable them to provide truly informed consent. The Nesbit operation is the procedure of choice for most patients, but plaque incision and grafting will give good results in those with more advanced disease. More patients should be offered a penile prosthesis insertion to optimise results but cost limitations will continue to prevent this from happening.
QUESTIONS
Question 1
What is the best candidate for tunical plication?
Correct answer: D
The best candidate for tunical shortening should have adequate erections, a mature plaque without concomitant hourglass deformity, a curvature of less that 60 degrees, and adequate penile length.
Question 2
What it’s the overall success rate foe Nesbit and Nesbit-like procedures in the literature?
Correct answer: B
The most common “complication” of this procedure is loss of penile length, which fortunately, rarely affects sexual relations. In fact, overall success rates for the original Nesbit and Nesbit-modifications reports in the literature are around 79-95%.
Question 3
What it’s the best candidate for tunical lengthening?
Correct answer: D
Inclusion criteria for tunical lengthening contrast with those just mentioned for plication. Surgeons should consider grafting men with a shorter penis, more proximal plaque, and a curvature greater than 60-degrees
Question 4
Which of following material are not consider autologous?
Correct answer: BCadaveric pericardium (Tutoplast) offers good results by coupling excellent tensile strength and multi-directional elasticity/expansion by 30%, while avoiding secondary, tissue-harvesting incision(s). The drawback, similar to dermal grafting, however, in contraction with recurrent penile curvature. In a retrospective telephone interview, 44% of patients with pericardium grafting reported recurrent curvature, although most continued to have successful coitus and were pleased with their outcomes.
Question 5
What kind of material means SIS?
Correct answer: B
Small intestinal submucosa (SIS) is a collagen-based xenogenic graft derived from the submucosal layer of the porcine small intestine. It has been shown to promote tissue-specific regeneration, and supports the growth of endothelial cells. SIS acts as a scaffold to promote angiogenesis, host cell migration and differentiation-resulting in tissue that is structurally and functionally similar to the original. In small numbers, SIS has been used successfully to repair severe chordee and Peyronie´s without significant contraction or histological alterations. SIS holds promise as a tunical substitute, but needs more clinical and long-term study before widespread Peyronie´s use can be suggested.