Page 9 - 2018 Canadian Urological Association guideline for Peyronie’s disease and congenital penile curvature

guideline: Peyronie’s disease

lateral to inelastic plaque segments), ED, pain and change fibrosis, graft contractures, and possibility of allergic reac-
of penile shape (worsening curvature 2–28%), and sensation tions (Level 3 evidence, Grade C recommendation). 76,87
(wide range across studies, 24% reported with elevation of Grafting follows incision, partial excision, or excision of
neurovascular bundle with Nesbit and Yachia). 1,3,78,83-85 plaque. There are three broad categories of TA plaque inci-
Regarding penile length loss, Hudak reported 84% of men sion (double-Y, H-shaped, and Egydio geometric) that are
had no measureable decrease in stretched flaccid length made at the point/relative to the maximum curvature on the
(SPL), but 78% reported perceived length reduction, while convex side of the penis, followed by placement of a graft
Taylor and Levine reported post-surgery length loss vs. objec- material (autologous, allografts, xenografts, and synthetic) to
tive length loss documented in 18% of these patients. 83,85 repair the defect and potentially lengthen the shorter side of
Following plication, penile length should be similar to pre- the penis. 1,3,69-72,76,78,86-102 There is a strong trend towards mini-
operative SPL; preoperatively, it is often useful to illustrate mal TA disruption, therefore, favouring incision or partial
the estimated length loss on the long side of the penis to excision techniques; partial plaque excision vs. total plaque
the patient, as measured during erection at CDU/ICI test- excision offers the advantage of decreasing risk of irrevers-
ing by measuring the difference in length between the long ible erectile tissue damage with resultant veno-occlusive
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and short side of the penis. There has been widening use permanent postoperative ED. 76-78,103 Curvature correction
of penile traction physiotherapy device in the postoperative reliably occurs and is the most commonly reported endpoint;
period; given the low risk of adverse events balanced against in a review of 88 observational study arms, improvement
3
limited supportive literature for therapeutic benefits, it may rates were >80% in 64 and >90% in 57. Complete deformity
be reasonable to consider adding traction to these patients’ correction rates range from 50–98% and the satisfaction rates
postoperative routines while awaiting definitive studies. 86 are highly variable from 35–51%. Penile shortening was
78
PD plication procedures are minimally invasive, tend to observed in seven of 11 studies, ranging from 15.4–63% of
preserve potency, and offer satisfactory rates of curvature subjects; grafting does not guarantee length return or length
3
correction. Drawbacks include length loss, and plication preservation. Postoperative care pathways are not uniform.
does not address and, in fact, may worsen existing hinge or Early return to erection is thought to be of benefit and some
hourglass deformities; complications may include persistent experts advocate for application of external penile traction
pain, persistence or recurrence of penile curvature (>30º, therapy to minimize loss of length once the skin incision is
8–11%), penile hematoma (0–9%), urethral injury(0–1.4%), healed and patient can tolerate the modality. A retrospec-
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palpable suture knots, and sensation loss (neurovascular tive study determined perception of length loss is minimal
78
bundle injury during dorsal plication). The type of plica- when traction therapy was used, although dissatisfaction
tion used is dependent on surgeon and patient factors, as with penile length postoperatively remained high at almost
no procedure has proven superior to its counterparts (Level half of surveyed patients. 88
3 evidence, Grade C recommendation). There is no universally accepted optimal graft material;
the search remains for an inexpensive, readily available
Grafting procedures graft that mimics the TAs strength and elastic characteris-
tics, has minimal morbidity (including harvest) and tissue
Grafting technique are appropriate for the surgeon facile reaction, is pliable and easy to suture, resists infection, and
with the techniques and treating the PD patient with severe preserves erectile capacity. 76,78 Tissue-engineered grafts may
penile length loss, significant/severe or complex curvatures, represent the future, but in the meantime, currently avail-
simple curvature >60º, large plaques, and/or hourglass defor- able grafts are associated with potential complications com-
mities in the setting of maintained erectile function (Level monly linked to significant patient dissatisfaction, the most
3 evidence, Grade C recommendation). Although classi- important of which is ED, which can occur in upwards of
cally regarded as “lengthening procedures,” grafting does 25% of patients. 104 Determinants of ED risk include age,
not ensure length preservation or return of lost length due site and severity of curvature, type of incision used, medical
to PD plaque inelasticity. Similar to plication studies, there comorbidities, and pre-existing erectile function. 105,106 When
is a vast experience of observational data encompassing choosing autologous graft material (saphenous vein, tempo-
more than 2500 patients in total, yet comparisons across ralis fascia, fascia lata, tunica vaginalis), complications at
grafting techniques and materials cannot be made to deter- the donor tissue site and extra surgical times to harvest the
2,3
mine a superior approach. Surgeon experience, patient grafts should be discussed with patients prior to the surgery. 78
preference, and type of penile deformity affect the choice of Penile sensation changes are related to freeing of the
graft and surgical approach used. The Committee strongly dorsal neurovascular bundle (NVB), extent of dissection
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recommends against the use of synthetic grafts, including required to completely dissect the area of the plaque, and
polyester and polytetrafluoroethylene, due to increased risks postoperative inflammation and fibrosis at the graft sites;
of infection, secondary graft inflammation causing tissue although the majority of surgeons approach the NVD later-

CUAJ • May 2018 • Volume 12, Issue 5 E205