***Trost Commentary and Key Take-Home Points***
This manuscript represents a nice review of outcomes of patients who undergo surgery post Xiaflex treatment. The key finding from the study is that surgery remains a viable option for men who do not experience a sufficient improvement with Xiaflex. I think it’s important to recognize that the key finding from the study should NOT be interpreted that men with hourglass, hinge, or severe curvatures should not consider Xiaflex but should only undergo surgery. Rather, the key take home is that surgery remains a viable option in these cases. The reason for this important distinction is because this group only included men who went to a physician with persistent bother after Xiaflex. It did not include men who initially had these conditions (hourglass, indentation, severe curvatures) but were satisfactorily treated with Xiaflex. Because of this, it is a biased group towards further intervention. It is interesting to note that even in this group who was motivated for further treatment and who were offered surgery, only ~50% of them ultimately ended up choosing surgery. This has also been my experience, where the far majority of men who present with Peyronie’s Disease are seeking non-surgical therapies to treat their condition. This also highlights a key debatable topic with Peyronie’s Disease management in 2020: whether Xiaflex or surgery should be considered 1st line management. It has been my personal preference to utilize Xiaflex as a first line, as our studies at Mayo had shown that the majority of men (~60%) felt that they no longer needed surgery after Xiaflex and experienced improvements that would allow penetrative intercourse. Also, since it is a more conservative option, the possibility of erectile dysfunction, sensation loss, length loss, and other things associated with surgery occur much less frequently (if ever). It also does not rule out the possible use of surgery as a later, backup step. In contrast, surgery results in permanent changes and cannot be undone. Also, our data at Mayo showed that only about 5% of men with PD will ever end up seeking surgical therapy for the condition. However, whether surgery or Xiaflex should be used as a first-line treatment remains a debatable point at the present time. Because of this, the recommendations that a patient with PD will receive largely depends on which provider they end up seeing!
Outcomes of Peyronie’s disease, a tunica albuginea fibrotic condition, often include decreased sexual function, physical deformity and psychological distress. Symptoms and treatments often change between the acute or “active” phase and the chronic “stable” phase. For the chronic phase, the gold standard treatment has typically been surgery, though other less invasive treatment options exist such as penile traction therapy (PTT), oral or topical medications or intralesional injections. Injections have particularly become a popular option with the FDA approval of collagenase clostridium histolyticum (CCH), or Xiaflex.
CCH has been found to be safe and effective for men with stable Peyronie’s disease, 30-90 degree curvature and good erectile function. These injections degrade collagen fibers to break down the plaques caused by Peyronie’s disease. Despite its high effective rate, there will be some men who do not respond as readily or at all. With various studies indicating possible predictors with more or less favorable results. In the current study, the authors sought to characterize patients with negative responses to CCH therapy and the outcome of subsequent surgical intervention.
Materials and Methods
A retrospective analysis of patients seen from October 2014 to October 2019 was done to reveal those who had been treated with CCH elsewhere prior to being seen at the author’s institution. CCH treatment failure was defined as seeking further treatment after prior CCH injections, persistent compromised sexual function, deformity or dissatisfaction with appearance of curvature.
After thorough patient examination and history, patients were recommended further treatment consisting of conservative therapies or surgical intervention, with surgical type being determined using a previously published surgical algorithm. Possible surgical procedures included tunica albuginea plication (TAP), plaque incision and grafting (PIG) or partial plaque excision and grafting (PEG) with or without TAP, and inflatable penile prosthesis (IPP) implantation with or without PIG. Some possible conservative therapies included PTT, pentoxifylline and I-citrulline, tadalafil and verapamil injection therapy.
67 out of 573 men were identified as having prior CCH treatments but retained persistent bother. Previous CCH injection treatments were a median of 6 (possible 2-24) and reported side effects such as bruising, pain, swelling, and corporal rupture requiring surgery.
Of the 67 men in the study, 33 chose surgical intervention in the form of PEG, TAP or IPP/PIG. The remaining 34 patients were treated with PTT or other medical treatments. Those who underwent surgery had great mean composite curvature than those who did not choose surgical intervention, 82.6 degrees vs 55.4, respectively.
This cohort of 67 men with continual bother following CCH therapy had a mean composite curvature of 69 degrees and a high rate (77%) of indentation, narrowing or hourglass deformities, as well as 38% with hinge/instability. Some studies show that having curvature between 30-60 degrees is a good predictor of success, as well as PD duration and good baseline IIEF-5.
CCH is an effective treatment option for many men, and those who failed to see improvement had more severe curvature (70 degrees) and high rates of narrowing or indentation deformities and calcification. Surgical treatment has proven safe and effective for this population, particularly in men with hinge deformity.
Characteristics of Men With Peyronie’s Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes
Bajic, Petar et al. The Journal of Sexual Medicine, Volume 17, Issue 5, 1005 – 1011 https://www.jsm.jsexmed.org/article/S1743-6095(20)30067-9/fulltext