madman
Super Moderator
ABSTRACT
Objectives: To report our initial experience with the extra-tunical grafting (ETG) procedure. This procedure was recently introduced by UCSF investigators as a tunica-sparing technique for the management of penile concavity deformities.
Methods: We retrospectively reviewed records of patients who underwent ETG at our tertiary-care referral center between 2017-2020. A collagen graft made from bovine pericardium (Lyoplant®) was placed overlying the defect without violating the tunica albuginea or mobilizing the neurovascular bundle. The stretched penile length (SPL) and circumference at the location of deformity were measured intraoperatively. Patient-reported outcomes were evaluated by an anonymous ten-question online survey.
Results: Nineteen men underwent ETG with a median follow-up of 59 (IQR: 24 - 708) days. ETG was performed via either a window (15/19, 78%) or a de-gloving (4/19, 21%) incision with concomitant penile plication performed in 16/19 (84%) patients. Penile circumference increased by an average of 1.4 cm + 0.5 (p = 0.03) at the location of deformity, while pre-and post-operative SPL were similar (14.0 + 1.4 vs. 14.0 + 1.3 cm, p = 0.95). Overall patient satisfaction was reported by 13/15 (86%) patients. Twelve out of 15 (80%) patients reported concavity deformity to be “improved”, with 73% reporting “much better”. Among 8 patients with follow-up greater than six months, graft palpability was reported in 4/8 (50%) patients but was not bothersome.
Conclusions: The ETG procedure appears to be safe and effective for the treatment of penile concavity deformities. Patient outcomes and satisfaction are favorable at intermediate follow-up.
INTRODUCTION
Peyronie’s disease (PD) is an acquired idiopathic connective tissue disorder involving the formation of a fibrotic plaque within the tunica albuginea of the corpus cavernosum. 1, 2 The prevalence of PD is estimated to be 0.5-20% depending on the study and patient population.1 PD has been shown to negatively impact self-perception of physical and sexual attractiveness.3-5
Penile concavity deformities (notching and hourglass) are particularly troubling for patients and are estimated to be present in 10% of PD cases. 6 Notching results from a volume-loss deformity that may destabilize the axial rigidity of the erect penis.6 Hourglass deformity results from bilateral notching and causes circumferential narrowing of the tunica albuginea.7 Traditionally, plaque incision/excision and grafting (PIG/PEG) has been the surgical procedure of choice for men with penile concavity deformities.8 However, PIG/PEG requires violation of the tunica albuginea and mobilization of the neurovascular bundle potentially leading to postoperative erectile dysfunction (ED) or altered penile sensation.
The extra-tunical grafting (ETG) technique was first described in 2017 by UCSF investigators as a tunica-sparing surgical procedure to be utilized in the treatment of PD concavity deformities.9 ETG was designed to reinforce the tunica albuginea with a graft that improves penile stability and cosmesis. The neurovascular bundle is not mobilized, and integrity of the tunica albuginea is maintained, which mitigates the risk of postoperative hypoesthesia and de novo ED. 9 Here we examine our experience with the ETG procedure to evaluate patient-reported outcomes of this promising new technique.
Operative Technique for Concavity Deformities
Extratunical grafting is performed in the outpatient surgery center (OSC) under general anesthesia most commonly with a laryngeal mask airway (LMA). Patients are positioned on the operating room table in the supine position and 20 mcg alprostadil (Edex©) is administered intracorporally to induce a pharmacologic erection. Injectable saline is utilized as needed for patients with minimal response to alprostadil to create a fully rigid erection. SPL and girth are measured prior to starting the procedure.
The choice of surgical incision is determined based on the location and extent of deformities. For patients with unilateral plaques, we prefer a 'window' technique with a 3-4 cm longitudinal incision over the defect. This incision gives adequate exposure to the tunica albuginea for placing the graft material and can be moved along the penile shaft as needed for plication sutures. For bilateral and extensive deformities (especially those without curvature), we perform a circumcising incision to fully expose the tunica albuginea to allow for the placement of multiple grafts into the defects. We prefer to perform a 'window' technique whenever possible to decrease the risk of penile skin lymphedema and hasten patient recovery.
The chosen incision is made sharply and dissection is performed through dartos and Buck’s fascia to expose the tunica albuginea. The defect is measured for both length and width. If patients have concomitant curvature, this is corrected using a series of braided permanent (2-0 Ethibond ®) sutures. On the back table, an appropriately sized collagen graft (bovine pericardium, Lyoplant ®) is prepared in a single layer or “postage stamp” fashion (Figure 1). This graft is then inserted into the deformity and secured with monofilament absorbable suture (4-0 Monocryl ®). Multiple layers of graft can be fashioned and stacked to completely fill in the defect until it is symmetric with the contralateral side.
In the case of complex defects, various sizes of grafts may need to be stacked in order to optimally fill out the indentation. For bilateral defects, a circumferential graft can be utilized in an omega shape to spare covering the corpus spongiosum as previously described.9 Once completed, the penis is examined closely for symmetry and cosmesis and fine alterations can be made if needed. We err on the side of slightly larger grafts to compensate for graft resorption during the perioperative period.
For patients with penile curvature undergoing concomitant penile plication, this was performed by placing a series of plication sutures along the opposing side of the curvature to straighten the penis. For patients with dorsal penile curvature, we made a ventral incision and dissected along either side of the spongiosum and the ventrolateral tunica albuginea. There we place multiple parallel sutures along the ventrolateral penile shaft, beginning proximally and continuing distally to correct dorsal curvature.
The incision is irrigated, and meticulous hemostasis is achieved. Buck’s fascia is reapproximated with absorbable suture (4-0 Monocryl ®) ensuring that there is no entrapment of the shaft skin. For window incisions, the skin is closed in a subcuticula fashion with surgical glue (Dermabond®) to minimize scar formation. In the case of circumcising incisions, the mucosal collar is trimmed to prevent lymphedema and the skin closed with simple interrupted sutures. Finally, SPL and penile girth are remeasured and compared to preoperative values (Figure 2).
A non-adherent dressing is placed and the penis is gently wrapped in Coban™ dressing to prevent swelling. The entire procedure typically takes less than 1 hour and patients are discharged to home the same day without specific work restrictions. Patients are instructed to exchange their dressing daily for 1-2 weeks and abstain from sexual activity for 5 weeks. Clinic follow-up is arranged at 5 weeks postoperatively and patients are assessed for satisfaction with erections, curvature, and penile girth. Assuming adequate wound healing, patients are cleared to return to sexual activity and follow up as needed.
CONCLUSIONS
The ETG procedure appears to be a straightforward, safe, and effective procedure for the treatment of penile concavity deformities. Patient-reported outcomes and satisfaction are favorable at intermediate follow-up. ETG should be an important component in the armamentarium of urologists treating Peyronie’s disease.
Objectives: To report our initial experience with the extra-tunical grafting (ETG) procedure. This procedure was recently introduced by UCSF investigators as a tunica-sparing technique for the management of penile concavity deformities.
Methods: We retrospectively reviewed records of patients who underwent ETG at our tertiary-care referral center between 2017-2020. A collagen graft made from bovine pericardium (Lyoplant®) was placed overlying the defect without violating the tunica albuginea or mobilizing the neurovascular bundle. The stretched penile length (SPL) and circumference at the location of deformity were measured intraoperatively. Patient-reported outcomes were evaluated by an anonymous ten-question online survey.
Results: Nineteen men underwent ETG with a median follow-up of 59 (IQR: 24 - 708) days. ETG was performed via either a window (15/19, 78%) or a de-gloving (4/19, 21%) incision with concomitant penile plication performed in 16/19 (84%) patients. Penile circumference increased by an average of 1.4 cm + 0.5 (p = 0.03) at the location of deformity, while pre-and post-operative SPL were similar (14.0 + 1.4 vs. 14.0 + 1.3 cm, p = 0.95). Overall patient satisfaction was reported by 13/15 (86%) patients. Twelve out of 15 (80%) patients reported concavity deformity to be “improved”, with 73% reporting “much better”. Among 8 patients with follow-up greater than six months, graft palpability was reported in 4/8 (50%) patients but was not bothersome.
Conclusions: The ETG procedure appears to be safe and effective for the treatment of penile concavity deformities. Patient outcomes and satisfaction are favorable at intermediate follow-up.
INTRODUCTION
Peyronie’s disease (PD) is an acquired idiopathic connective tissue disorder involving the formation of a fibrotic plaque within the tunica albuginea of the corpus cavernosum. 1, 2 The prevalence of PD is estimated to be 0.5-20% depending on the study and patient population.1 PD has been shown to negatively impact self-perception of physical and sexual attractiveness.3-5
Penile concavity deformities (notching and hourglass) are particularly troubling for patients and are estimated to be present in 10% of PD cases. 6 Notching results from a volume-loss deformity that may destabilize the axial rigidity of the erect penis.6 Hourglass deformity results from bilateral notching and causes circumferential narrowing of the tunica albuginea.7 Traditionally, plaque incision/excision and grafting (PIG/PEG) has been the surgical procedure of choice for men with penile concavity deformities.8 However, PIG/PEG requires violation of the tunica albuginea and mobilization of the neurovascular bundle potentially leading to postoperative erectile dysfunction (ED) or altered penile sensation.
The extra-tunical grafting (ETG) technique was first described in 2017 by UCSF investigators as a tunica-sparing surgical procedure to be utilized in the treatment of PD concavity deformities.9 ETG was designed to reinforce the tunica albuginea with a graft that improves penile stability and cosmesis. The neurovascular bundle is not mobilized, and integrity of the tunica albuginea is maintained, which mitigates the risk of postoperative hypoesthesia and de novo ED. 9 Here we examine our experience with the ETG procedure to evaluate patient-reported outcomes of this promising new technique.
Operative Technique for Concavity Deformities
Extratunical grafting is performed in the outpatient surgery center (OSC) under general anesthesia most commonly with a laryngeal mask airway (LMA). Patients are positioned on the operating room table in the supine position and 20 mcg alprostadil (Edex©) is administered intracorporally to induce a pharmacologic erection. Injectable saline is utilized as needed for patients with minimal response to alprostadil to create a fully rigid erection. SPL and girth are measured prior to starting the procedure.
The choice of surgical incision is determined based on the location and extent of deformities. For patients with unilateral plaques, we prefer a 'window' technique with a 3-4 cm longitudinal incision over the defect. This incision gives adequate exposure to the tunica albuginea for placing the graft material and can be moved along the penile shaft as needed for plication sutures. For bilateral and extensive deformities (especially those without curvature), we perform a circumcising incision to fully expose the tunica albuginea to allow for the placement of multiple grafts into the defects. We prefer to perform a 'window' technique whenever possible to decrease the risk of penile skin lymphedema and hasten patient recovery.
The chosen incision is made sharply and dissection is performed through dartos and Buck’s fascia to expose the tunica albuginea. The defect is measured for both length and width. If patients have concomitant curvature, this is corrected using a series of braided permanent (2-0 Ethibond ®) sutures. On the back table, an appropriately sized collagen graft (bovine pericardium, Lyoplant ®) is prepared in a single layer or “postage stamp” fashion (Figure 1). This graft is then inserted into the deformity and secured with monofilament absorbable suture (4-0 Monocryl ®). Multiple layers of graft can be fashioned and stacked to completely fill in the defect until it is symmetric with the contralateral side.
In the case of complex defects, various sizes of grafts may need to be stacked in order to optimally fill out the indentation. For bilateral defects, a circumferential graft can be utilized in an omega shape to spare covering the corpus spongiosum as previously described.9 Once completed, the penis is examined closely for symmetry and cosmesis and fine alterations can be made if needed. We err on the side of slightly larger grafts to compensate for graft resorption during the perioperative period.
For patients with penile curvature undergoing concomitant penile plication, this was performed by placing a series of plication sutures along the opposing side of the curvature to straighten the penis. For patients with dorsal penile curvature, we made a ventral incision and dissected along either side of the spongiosum and the ventrolateral tunica albuginea. There we place multiple parallel sutures along the ventrolateral penile shaft, beginning proximally and continuing distally to correct dorsal curvature.
The incision is irrigated, and meticulous hemostasis is achieved. Buck’s fascia is reapproximated with absorbable suture (4-0 Monocryl ®) ensuring that there is no entrapment of the shaft skin. For window incisions, the skin is closed in a subcuticula fashion with surgical glue (Dermabond®) to minimize scar formation. In the case of circumcising incisions, the mucosal collar is trimmed to prevent lymphedema and the skin closed with simple interrupted sutures. Finally, SPL and penile girth are remeasured and compared to preoperative values (Figure 2).
A non-adherent dressing is placed and the penis is gently wrapped in Coban™ dressing to prevent swelling. The entire procedure typically takes less than 1 hour and patients are discharged to home the same day without specific work restrictions. Patients are instructed to exchange their dressing daily for 1-2 weeks and abstain from sexual activity for 5 weeks. Clinic follow-up is arranged at 5 weeks postoperatively and patients are assessed for satisfaction with erections, curvature, and penile girth. Assuming adequate wound healing, patients are cleared to return to sexual activity and follow up as needed.
CONCLUSIONS
The ETG procedure appears to be a straightforward, safe, and effective procedure for the treatment of penile concavity deformities. Patient-reported outcomes and satisfaction are favorable at intermediate follow-up. ETG should be an important component in the armamentarium of urologists treating Peyronie’s disease.
