***Trost Commentary and Key Take-Home Points***
The current manuscript is a review article (summarizes research publications performed by other teams) which discusses the role of penile prosthetics in men with Peyronie’s Disease. Penile prosthetics have a clear role for the treatment of PD men who have erectile dysfunction which does not respond to PDE5 inhibitors (i.e. Viagra, Levitra, Cialis, Stendra). Men who require injection therapies (Trimix, Biximix, alprostadil) may also be appropriate candidates (depends on how satisfied the men are with injections). In general, satisfaction rates are high with these devices, although insurance coverage is an increasingly difficult issue for many men (surgery typically runs in the $20-40,000 range). Complication rates are generally fairly low, although once you have the device placed, you are no longer able to achieve a natural, spontaneous erection. Because of this, typically these are reserved as a last-line treatment, when men are no longer able to achieve spontaneous erections with or without pills or injections.
Introduction
Peyronie’s disease is a penile condition thought to be caused by local trauma and causes inflammation, fibrosis, curvature or indentation deformity, penile pain, sexual dysfunction and psychological concerns. There is an acute phase of Peyronie’s disease with penile pain and the curvature is progressive. The chronic phase brings an improvement in penile pain and curvature stabilization.
There are noninvasive treatment options and surgical options, depending on the severity and duration of the disease. Noninvasive options include oral therapies, penile traction therapy and intralesional injections and surgical procedures include penile plication, plaque incision or excision with grafting and penile prosthesis placement.
Penile prosthesis placement is the top treatment for men who desire a reliable erection without negative side effects including loss of penile sensation, issues with urination, ejaculation or orgasm. The device options include inflatable penile prosthesis (IPP) and malleable models, though IPP is preferred due to the decreased risk of side effects when compared to malleable.
Methods
In addition to the penile prosthesis placement, adjunctive straightening maneuvers may be necessary in the form of manual modeling, corporal plication and tunical incision with or without graft placement.
Manual modeling is performed during surgery after the prosthesis is placed and the cylinders are maximally inflated. The surgeon will grasp the penis and forcefully bend the shaft in the direction opposite of the curvature and held, then repeated. The goal of this method is to stretch the fibrotic bands and cause ruptures in the plaque. Risks of this procedure include urethral perforation.
Corporal plication is used for patients whose curvature is severe and manual modeling is not thought to be sufficient. This procedure includes placing sutures on the shaft opposite the curvature, which are tightened enough to correct the curve. The risks of this procedure include penile shortening and can exacerbate severe indentation deformities.
Tunical incision with or without grafting is recommended in men whose curvature remained severe after manual modeling or continued indentation deformity. This procedure includes incising the tunica at the point of maximum curvature to allow expansion.
Discussion
Patients with Peyronie’s disease are often concerned about penile length loss, which can be worsened by surgical treatments, with at least 30-40% of patients reporting a significant loss of length after IPP placement. Several treatments have been developed to restore penile length, both pre- and post-operatively or intraoperatively. Data on penile traction therapy and vacuum therapy has resulted in increased penile length pre- and post-operatively. Many intraoperative methods have been attempted to increase penile length, with varying degrees of success. This includes techniques that only improve the appearance of length and methods for appropriate cylinder sizing. There are also plication and incision techniques that have been used to try and increase length, such as the sliding technique where hemicircular incisions are made in the tunica albuginea to allow the penis to stretch. There are several risks involved with these options including glans necrosis and glanular ischemia.
Penile prosthesis devices have a 10-year survival rate of 65-90% and infection occurs in 1-3% of patients. Men who undergo penile prosthesis placement have reported an 80-90% satisfaction rate and resultant 50% decline in depressive symptoms. Additionally, partner satisfaction rates often exceed 90%.
Conclusion
Penile prosthesis placement is a reliable treatment for men with Peyronie’s disease who wish to correct curvature and restore penetrative ability. Additional treatments can further correct curvature, both during and after surgery.
References
Ziegelmann MJ, Farrell M R, Levine LA. Modern treatment strategies for penile prosthetics in Peyronie’s disease: a contemporary clinical review. Asian J Androl 2020;22:51-9