Germany: A recent study in the journal Sexual Medicine reports the European Society for Sexual Medicine (ESSM) position statement on the surgical treatment of Peyronie's disease.
Peyronie's disease patients may experience significant distress. The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity, and direction of the curvature, penile length, and the quality of erectile function. Daniar Osmonov, University Hospital Schleswig-Holstein, Kiel, Germany, and colleagues aimed to review the evidence associated with surgical treatment of Peyronie`s Disease and provide clinical recommendations on behalf of the EESM. The study included 131 peer-reviewed studies and systematic reviews, which were published from 2009 to 2019 in the English language.
The panel provided statements on clinically relevant questions including patient involvement in the decision process, indications for surgery, choice of the approach, and the management of patient expectations.
"These recommendations aim both to ensure patients and partners have accurate and realistic expectations of their treatment options, as well as to formulate algorithms to guide clinician management pathways," wrote the authors.
Patient Expectations
The treating clinician should adequately counsel patients before surgery. Benefits as well as side effects and complications of each surgical treatment should be discussed in detail with the patient to set realistic expectations towards surgical outcomes.
The treating clinician should thoroughly address psychological, emotional and relationship issues attributable to PD.
Indications for Surgical Treatment
Surgical treatment should only be performed in PD patients when the curvature and/or penile deformity and/or inadequate quality of erections do not allow satisfactory sexual intercourse, or when the deformity causes severe bother.
Surgery should only be performed in patients with stable disease for at least six to twelve months.
In penile surgery for PD, when adopting a subcoronal approach, circumcision is not necessary in selected patients with a normal, elastic prepuce.
Tunical plication can be offered to reduce penile curvature in patients with PD.
Grafting techniques can be offered to improve penile curvature and correct penile deformity in selected patients with PD including those with preservation of erectile quality, curvature of more than 60 degrees, ossified plaque, significant waist deformity, or when plication surgery may potentially cause loss of more than 20% of overall penile length.
The use of DacronTM and Gore-TexTM for grafting in penile surgery for PD should be strongly discouraged.
Penile prosthesis implantation is reserved for PD patients with refractory ED or distal flaccidity not responding to pharmacologic treatment or those with complex deformities that would otherwise require PIG/PEG procedures.
Additional procedures including modeling, tunical plication, plaque incision/excision and/or grafting are performed when penile deformity and/or penile curvature persist following penile prosthesis implantation.
Inflatable prostheses are associated with superior results in terms curvature correction, rigidity, girth restoration and concealability than their semirigid counterpart in patients with PD.
Postoperative Complications
In select cases, complications may be managed successfully with revision surgery, including delayed PP implantation in patients who have developed de novo refractory ED.
Difficult Salvage Cases: Management of Recurrent Deviation Following Plication, Grafting, Or Intralesional Injection Treatments
None of the straightening procedures currently available has proven superior with regards to preventing curvature recurrence.
Surgical curvature correction after Collagenase Clostridium Histolyticum (CCH) injection is possible without significant increase in postoperative complications.
Postoperative rehabilitation programs may reduce the risk of penile curvature recurrence and shortening.
When necessary, revision surgery should be carried out at least 6 months after the initial procedure to allow for complete healing and stabilization of the deformity and for adequate assessment of postoperative erectile function.
Penile prosthesis implantation alone or in combination with straightening maneuvers can be considered during revision surgery, in order to minimize further penile length loss or to avoid worsening of erectile function.
The use of collagen fleece as a graft material following plaque incision can be contemplated in revision surgery.
Reference:
"ESSM Position Statement on Surgical Treatment of Peyronie's Disease," is published in the journal Sexual Medicine.
DOI: https://doi.org/10.1016/j.esxm.2021.100459