madman
Super Moderator
Abstract
Peyronie’s disease (PD) is due to a fibrotic alteration of the tunica albuginea of the penis. It is responsible for penile pain, angulation, and possible erectile dysfunction (ED). Despite almost three centuries have passed since the first description of the disease, etiology still remains uncertain. This fact has led to the lack of a truly effective medical therapy and to date the surgical treatment, although not yet standardized, is the only one that offers acceptable outcomes in terms of function and overall patient satisfaction. Since the beginning of the surgical experience in this field, two different currents of thought have developed: the first, involved the proposal of a number of different plication techniques, applied on the healthy side of the penis, opposite to the sick side, with the sole purpose of correcting the curvature; on the other side, efforts have focused on treating the “focus” of the disease, thus developing the so-called “plaque surgery.” If with the passing of the decades neither of the two “philosophical” currents has prevailed, this probably depends on the fact that is still not clear which is the lesser of evils: the frequent onset of ED which may follow the plaque surgery or rather the penis shortening that inevitably occurs if any technique of plication has been applied. Our contribution aims to offer a historical retrospective of the surgical treatment of this disease as well as to discuss the latest international guidelines on this topic. The reader will also find some notes about our personal experience in this field.
Introduction
Peyronie’s disease (PD) is an idiopathic, acquired alteration of the penis associated with a history of pain and deviation of the penile shaft that occurs during erection due to the presence of a fibrotic degeneration affecting the tunica albuginea of the corpora cavernosa. The nature and extent of this anatomical alteration, and therefore the severity or the complexity of penile deformity varies widely as well as its association with erectile dysfunction (ED).
Although almost three centuries have passed since the first official description of the disease, the countless treatments that have been proposed over the years have often proved to be a failure, to the test of facts. This is probably due to the forced empiricism of the therapeutic solutions proposed a consequence in turn of the not yet fully understood etiology of this disease.
Moreover, the spontaneous improvement of the curvature, that sometimes can occur during the natural history of the disease helped to underestimate its consequences on sexual function.
In this context, the three main studies analyzing the natural history of PD agrees on a spontaneous improvement of the curvature in 12%–13% of cases,1–3 with the pain that marks the initial stages of the disease, self-limiting in a time ranging from 12 to 18months.3 The purpose of our effort has been to analyze the different surgical options that have been proposed over the past decades, their possible drawbacks, risks, and satisfaction rates.
*Historical aspects of surgical management
-First reports
-Development of two currents of thought for the surgical treatment of Peyronie’s disease
-The concept of “radical surgery”
-The evolution of plication techniques versus improvement of grafting strategies
-Current aspects and future perspectives
*Surgical indications
*Current technical options for surgical treatment of Peyronies disease
Since the two currents of thought have survived to date, PD surgical techniques are still grossly divided into two groups:
(1) Shortening procedures, acting on the convex uncontracted side, using excision or a simple plication of the tunica;
(2) Plaque surgery, which works on the concave contracted side, with incisions or excision of the affected tissue, followed or not by a covering graft.
*Shortening techniques
-Nesbit technique
-Fontana’s modification of Nesbit technique
-Yachia’s technique
Other proposals
-Essed-Schroeder procedure
-16-knot technique
*Plaque surgery
-Autologous grafts
-Synthetic grafts
*Allograft or xenograft materials
*Penile prosthesis
-Soft penile prosthesis—Austoni technique
*Personal experience
Conclusion
Peyronie’s disease is a pathology of uncertain etiology. The careful investigation of different domains, such as the preserved ability to have penetrative sexual intercourse, the contemporary presence of ED, the length of the penis, the stability of the disease is of fundamental clinical importance for the right surgical indication.
To date, a unique “gold standard surgical procedure” is still to be found and the right choice among many different techniques should be specifically tailored, based on the pre-operative aspects of any single patient.
The recently updated European Guidelines can help all of us to grossly orientate in the challenging task of suggesting the right surgical treatment to our patients.
The proposed algorithm has now correctly abandoned the previous rigid correlation between the angle of the penile curvature and the surgical technique to be used, and greater importance was recognized to the holistic approach in the evaluation of each individual patient.
*Surgeon experience, kind, and degree of penile acquired deformity, as well as patient preference, will definitely impact the final surgical outcomes.
Peyronie’s disease (PD) is due to a fibrotic alteration of the tunica albuginea of the penis. It is responsible for penile pain, angulation, and possible erectile dysfunction (ED). Despite almost three centuries have passed since the first description of the disease, etiology still remains uncertain. This fact has led to the lack of a truly effective medical therapy and to date the surgical treatment, although not yet standardized, is the only one that offers acceptable outcomes in terms of function and overall patient satisfaction. Since the beginning of the surgical experience in this field, two different currents of thought have developed: the first, involved the proposal of a number of different plication techniques, applied on the healthy side of the penis, opposite to the sick side, with the sole purpose of correcting the curvature; on the other side, efforts have focused on treating the “focus” of the disease, thus developing the so-called “plaque surgery.” If with the passing of the decades neither of the two “philosophical” currents has prevailed, this probably depends on the fact that is still not clear which is the lesser of evils: the frequent onset of ED which may follow the plaque surgery or rather the penis shortening that inevitably occurs if any technique of plication has been applied. Our contribution aims to offer a historical retrospective of the surgical treatment of this disease as well as to discuss the latest international guidelines on this topic. The reader will also find some notes about our personal experience in this field.
Introduction
Peyronie’s disease (PD) is an idiopathic, acquired alteration of the penis associated with a history of pain and deviation of the penile shaft that occurs during erection due to the presence of a fibrotic degeneration affecting the tunica albuginea of the corpora cavernosa. The nature and extent of this anatomical alteration, and therefore the severity or the complexity of penile deformity varies widely as well as its association with erectile dysfunction (ED).
Although almost three centuries have passed since the first official description of the disease, the countless treatments that have been proposed over the years have often proved to be a failure, to the test of facts. This is probably due to the forced empiricism of the therapeutic solutions proposed a consequence in turn of the not yet fully understood etiology of this disease.
Moreover, the spontaneous improvement of the curvature, that sometimes can occur during the natural history of the disease helped to underestimate its consequences on sexual function.
In this context, the three main studies analyzing the natural history of PD agrees on a spontaneous improvement of the curvature in 12%–13% of cases,1–3 with the pain that marks the initial stages of the disease, self-limiting in a time ranging from 12 to 18months.3 The purpose of our effort has been to analyze the different surgical options that have been proposed over the past decades, their possible drawbacks, risks, and satisfaction rates.
*Historical aspects of surgical management
-First reports
-Development of two currents of thought for the surgical treatment of Peyronie’s disease
-The concept of “radical surgery”
-The evolution of plication techniques versus improvement of grafting strategies
-Current aspects and future perspectives
*Surgical indications
*Current technical options for surgical treatment of Peyronies disease
Since the two currents of thought have survived to date, PD surgical techniques are still grossly divided into two groups:
(1) Shortening procedures, acting on the convex uncontracted side, using excision or a simple plication of the tunica;
(2) Plaque surgery, which works on the concave contracted side, with incisions or excision of the affected tissue, followed or not by a covering graft.
*Shortening techniques
-Nesbit technique
-Fontana’s modification of Nesbit technique
-Yachia’s technique
Other proposals
-Essed-Schroeder procedure
-16-knot technique
*Plaque surgery
-Autologous grafts
-Synthetic grafts
*Allograft or xenograft materials
*Penile prosthesis
-Soft penile prosthesis—Austoni technique
*Personal experience
Conclusion
Peyronie’s disease is a pathology of uncertain etiology. The careful investigation of different domains, such as the preserved ability to have penetrative sexual intercourse, the contemporary presence of ED, the length of the penis, the stability of the disease is of fundamental clinical importance for the right surgical indication.
To date, a unique “gold standard surgical procedure” is still to be found and the right choice among many different techniques should be specifically tailored, based on the pre-operative aspects of any single patient.
The recently updated European Guidelines can help all of us to grossly orientate in the challenging task of suggesting the right surgical treatment to our patients.
The proposed algorithm has now correctly abandoned the previous rigid correlation between the angle of the penile curvature and the surgical technique to be used, and greater importance was recognized to the holistic approach in the evaluation of each individual patient.
*Surgeon experience, kind, and degree of penile acquired deformity, as well as patient preference, will definitely impact the final surgical outcomes.
