Jason M. Greenfield

EXPERIENCE WITH INTRAPLAQUE INJECTION OF VERAPAMIL FOR PEYRONIE'S DISEASE

PURPOSE We examined the use of intraplaque injection of verapamil for the treatment of Peyronies disease through its effects on pain, curvature, indentation, sexual function and erectile capacity. MATERIALS AND METHODS A total of 156 men underwent treatment with intraplaque verapamil injection. Patients were assessed objectively, during dynamic penile duplex ultrasound, as well as subjectively using a questionnaire before and after initiation of the treatment protocol. Patients were also stratified by duration of disease before therapy and into 1 of 3 Kelami classification groups based on pretreatment plaque size and severity of curvature. Differences before and after treatment and among the Kelami classification groups were assessed. RESULTS Of the 140 patients who completed treatment 73 (60%) had an objectively measured decrease in curvature while 79 (62%) reported a subjective decrease in curvature during the followup interview. After treatment 111 (83%) men reported an increase in girth, 107 (80%) an increase in rigidity distal to the plaque and 92 (71%) an improvement in sexual function. Among each Kelami class curvature was objectively measured to decrease in 41%, 68% and 62% of patients in classes I, II and III, respectively. There was no significant difference in response based on duration of disease (60% improvement versus 61% improvement for disease duration of less or greater than 1 year in duration, respectively). Mean followup was 30.4 months (range 10 to 81) and there was no reported recurrence of penile deformity in those men with an initial posttreatment positive response. CONCLUSIONS Verapamil injection of Peyronies plaques appears to be a clinically effective treatment option for pain and curvature and can contribute to subjective improvement in sexual function and erectile capacity. The low incidence of complications indicates that this therapy is also clinically safe.

Factors Affecting the Loss of Length Associated With Tunica Albuginea Plication for Correction of Penile Curvature

PURPOSE Loss of length is a common postoperative complaint of the patient who undergoes surgical correction of penile curvature. We investigate the factors influencing complications in patients who have undergone TAP for PD and chordee. MATERIALS AND METHODS A total of 102 patients underwent TAP for PD (68) or chordee (34) between 1997 and 2004. Data were gathered on each patients preoperative complaints, physical examination, Doppler ultrasound, operative data and postoperative complaints. For the purposes of this study penile length was measured from pubis to corona along the dorsal surface of the stretched phallus. RESULTS Mean ages at surgery for men with PD and chordee were 53 and 24, respectively. A range of 1 to 6 plications were performed on each patient (mean 3) with an acceptably straight penis (curve less than 20 degrees) being achieved in 99% of patients. Mean followup for our patient population was 29 months and revealed only 1 patient with residual curvature. The mean loss in length after TAP was 0.36 +/- 0.5 cm with a range of 0 to 2.5 cm. When calculated as a percent of length lost from preoperative length, the postoperative percent length lost was 2.4%. When stratified into groups based on direction of curvature, the patients with ventral or ventrolateral curve had the highest percent loss of length. A 1-way ANOVA of these groups proved the differences between each group to be statistically significant (p = 0.04). Length change also significantly correlated with preoperative stretched penile length and the severity of curvature as measured in degrees in the operating room at time of surgery. Parameters that did not demonstrate a statistically significant impact on penile shortening included patient age, number of plications performed, plaque size, and hinge/narrowing effect due to a PD plaque. CONCLUSIONS The TAP procedure is a safe and effective means of correcting penile curvature, with similar overall outcomes between patients with PD and chordee. Shortening of the penis does commonly occur but is dependent on direction and degree of curvature, as well as the length of the phallus.

Increasing the number of biopsy cores improves the concordance of biopsy Gleason score to prostatectomy Gleason score.

To evaluate taking more biopsy cores for predicting the radical prostatectomy (RP) Gleason score compared with the biopsy Gleason score, as although random sextant biopsies are the standard for a tissue diagnosis of prostate cancer, and taking more biopsies increases the detection rate, it is uncertain whether taking more cores improves the prediction of the RP Gleason score.

Evaluation of the Man With Peyronie’s Disease

The proper evaluation of the male patient with Peyronie’s disease (PD) involves a focused medical history as well as a detailed sexual history. Coupled with an extensive history of the disease, these components are crucial to the subjective assessment. The two main components of the objective assessment include the physical exam focusing on the penis, and evaluation of the patient at maximum erection with (preferred) or without duplex ultrasound. The most important component of the physical exam is assessment of the penis for length, deformity, and plaque. Erectile capacity is one of the most important parameters in the assessment of the man with PD. Duplex ultrasonography after injection with a vasoactive agent is the recommended means for evaluation of vascular flow parameters and erectile response, and it allows objective measurement of deformity in the erect state. The association between PD and erectile dysfunction has been firmly established. The patient’s response to pharmacological agents both before and after development of PD may factor into decisions regarding the direction of future therapy for both problems. Evaluation of the male with PD varies across clinical studies, and no standard currently exists. This chapter provides a framework for obtaining the subjective and objective information for the man presenting with PD.