Stephen Larsen

Combination of Penile Traction, Intralesional Verapamil, and Oral Therapies for Peyronie's Disease

Introduction. There is no current consensus as to the most effective non-surgical therapy for Peyronies disease (PD).Aim. To assess the benefit of penile traction therapy (PTT) when added to intralesional verapamil injections (IVI) combined with oral L-arginine 1g bid and pentoxifylline 400 mg tid in men with PD.Methods. 74 men with PD completed 12 IVI. Patients electing to add PTT were advised to wear the device for 2-8 hours daily, and no longer than 2 hours per session. Subjective responses were measured using patient questionnaires. Stretched penile length (SPL) and erect penile curvature (EPC) using penile duplex ultrasound (DU) were measured. Response to therapy was defined as at least a 10 degree reduction in EPC.Main Outcome Measures. Change in SPL (cm), change in EPC (degrees).Results. 39 patients in the PTT group (I) vs. 35 patients in group (II) completed the protocol. 54% of men in group I responded to therapy vs. 46% in group II (p = 0.75). Responders had a mean EPC improvement of 26.9 degrees in group I vs. 20.9 in group II (p = 0.22). Mean PTT use was 3.3 hours per day, and men with >3 hours per day use gained 0.6 cm in SPL vs 0.07 cm using less than or equal to 3 hours per day (p= 0.09), while men in group I on lost 0.74 cm of SPL on average. Multivariate analysis revealed that duration of PTT use significantly predicts length gain (0.38 cm gain for every additional hour per day of PTT use, p = 0.007).Conclusion. There was a trend toward measured curvature improvement, and a significant gain in SPL in men using the combination therapy protocol. Length improvement is related to duration of use of the traction device [corrected].

Surgery for Peyronie's disease

Peyronies disease (PD) is most simply referred to as a fibrotic wound-healing disorder of the tunica albuginea. It is both a physically and psychologically devastating disorder that causes penile deformity, curvature, hinging, narrowing and shortening, which may compromise sexual function. Although a variety of non-surgical treatments have been suggested, none to date offer a reliable and effective correction of the penile deformity. As a result, surgery remains the gold standard treatment option, offering the most rapid and reliable treatment which will be the focus of this article. We review the preoperative evaluation, surgical algorithm, graft materials and postoperative management of PD. Outcomes for tunical shortening, tunical lengthening and penile prosthesis placement for penile straightening are reviewed. Tunica albuginea plication is the preferred method of straightening for men with adequate rigidity and less severe disease defined as curvature less than 70° without narrowing/hinging. Men who have more severe, complex deformity, but maintain strong preoperative erectile function should be considered candidates for straightening with plaque incision or partial excision and grafting. Finally, for those men who have inadequate rigidity and PD, penile prosthesis placement with straightening is the best approach to address both problems.

Review of non-surgical treatment options for Peyronie's Disease

Non-surgical treatment of Peyronies disease (PD) has come a long way since it was first described in 1743. A myriad of treatment options are currently available, including oral, intralesional and external energy therapies. The purpose of this article is to review the contemporary literature on non-surgical therapies for PD, and where possible, focus on randomized, placebo-controlled trials, as well as review the latest guidelines for the management of PD from the International Committee on Sexual Medicine, which conveyed its findings in July 2009. At this time, it appears that a combination of oral agents and/or intralesional injection with traction therapy may provide a synergy between the chemical effects of the drugs and the mechanical effects of traction. Until a reliable treatment emerges, it does appear that some of the non-surgical treatments discussed can be used to stabilize the scarring process and may result in some reduction of deformity with improved sexual function.

Peyronie’s Disease: Review of Nonsurgical Treatment Options

The purpose of this article is to review the contemporary literature on nonsurgical therapies for Peyronies disease (PD); focus on randomized, placebo-controlled trials; and review the latest guidelines for the management of PD from the International Consultation on Sexual Medicine. A combination of oral agents or intralesional injection with traction therapy may provide a synergy between the chemical effects of the drugs and the mechanical effects of traction. Until a reliable treatment emerges, some of the nonsurgical treatments discussed can be used to stabilize the scarring process and may result in some reduction of deformity with improved sexual function.

Surgical Correction of Persistent Peyronie's Disease Following Collagenase Clostridium Histolyticum Treatment

INTRODUCTION Collagenase clostridium histolyticum (CCH) is an Food and Drug Administration-approved intralesional injection for treatment of Peyronies disease (PD) that has been shown to reduce penile curvature deformity and PD symptom bother in phase 2b and phase 3 placebo-controlled clinical trials. For some patients, nonsurgical treatment with CCH may not sufficiently improve penile curvature, and surgical correction may be pursued following CCH therapy. AIM This study aims to examine intraoperative and postsurgical outcomes of surgical correction of persistent penile curvature in patients with PD who had previously received CCH. METHODS Retrospective chart review was used to identify patients with PD who had received CCH intralesional injection within either the phase 2b or phase 3 CCH clinical trials and then underwent surgical correction due to remaining penile curvature. Surgical techniques used were partial plaque excision and grafting (PEG) and/or tunica albuginea plication (TAP). MAIN OUTCOME MEASURES Primary assessments included pre- and postsurgery penile curvature, erectile rigidity, stretched penile length, intraoperative time, and occurrence of adverse events. RESULTS Seven men were identified who underwent surgical straightening with TAP or PEG following CCH treatment. Mean number of days from the final CCH injection to surgery was 182 (standard deviation 118; median 127 days). Average penile curvature prior to surgical straightening was 58°. No anatomical difficulties or complications secondary to the effects of prior CCH treatment occurred during surgery. Intraoperative time was representative of standard TAP and PEG surgeries (range 88-146 minutes). All men reported penile curvature <20° postsurgery. One patient experienced a postsurgery subgraft hematoma that required aspiration. There were no postsurgery reports of decreased penile sexual sensation and no occurrence of vascular compromise or decreased penile rigidity. CONCLUSION This initial case series supports the hypothesis that prior CCH treatment is not a contraindication to PEG or TAP surgery in the treatment of penile curvature in patients with PD.

Microdenervation of the Spermatic Cord for Chronic Scrotal Content Pain: Single Institution Review Analyzing Success Rate After Prior Attempts at Surgical Correction

PURPOSE Microdenervation of the spermatic cord is an effective treatment for men with intractable scrotal content pain. We evaluated a single center experience, analyzing patients in whom prior surgical attempts had failed to correct pain who subsequently underwent microdenervation of the spermatic cord. MATERIALS AND METHODS A retrospective chart review of 68 patients who underwent microdenervation of the spermatic cord from 2006 to 2010 was performed. Prior ipsilateral surgical procedures with the intent to correct scrotal content pain were selected, identifying 31 testicular units. RESULTS Chart review was performed on 68 men with mean age of 42 years at presentation and a mean followup of 10 months. Patients in whom prior surgical correction had failed and who subsequently had microdenervation of the spermatic cord had a mean postoperative pain score of 3 (range 0 to 10) with an average decrease in pain of 67%. Those who had not undergone a prior attempt at surgical correction had a mean post-microdenervation of the spermatic cord pain score of 2 (range 0 to 10) and an average pain decrease of 79% which did not differ statistically from those in whom prior surgery failed. In addition, 50% of men who had undergone surgery before microdenervation of the spermatic cord had complete relief of pain after microdenervation of the spermatic cord vs 64% of those who had not undergone previous surgery. CONCLUSIONS Men with chronic scrotal content pain in whom prior attempts to correct pain have failed have similar, albeit lower, success rates as those without prior surgical intervention. Therefore, men with chronic scrotal content pain in whom prior surgical management has failed and who have a positive spermatic cord block should be considered candidates for microdenervation of the spermatic cord.

Single Center Outcomes after Reconstructive Surgical Correction of Adult Acquired Buried Penis: Measurements of Erectile Function, Depression, and Quality of Life

INTRODUCTION Management of adult acquired buried penis is a troublesome situation for both patient and surgeon. The buried penis has been associated with significant erectile and voiding dysfunction, depression, and overall poor quality of life (QOL). AIM To identify outcomes following reconstructive surgery with release of buried penis, escutcheonectomy, and circumcision with or without skin grafting. METHODS We retrospectively identified 11 patients treated by a single surgeon between 2007 and 2011, patient ages were 44-69; complete data review was available on all 11. OUTCOME MEASURES Validated European Organisation for Research and Treatment of Cancer 15 QOL, Center for Epidemiologic Studies Depression Scale (CES-D), and International Index of Erectile Function (IIEF) surveys assessed patient QOL, depression, and erectile function pre- and postoperatively. RESULTS Mean body mass index (BMI) was 48.8 (42.4-64.6). Mean operative time was 191 minutes (139-272). Mean length of stay was 2.1 days. Ten of 11 patients required phallic skin grafting. There was one perioperative complication resulting in respiratory failure and overnight stay in the intensive care unit. Wound complications were seen in 2/11 patients, and 1 needed surgical debridement for superficial wound infection. Skin graft take was seen in 100% of the patients. Ninety-one percent of patients noted significant improvement in voiding postoperatively. Ninety-one percent of patients reported significant erectile dysfunction preoperatively. Subsequently, IIEF scores improved post surgery by an average of 7.7 points. Clinical depression was noted to be present in 7/11 patients preoperatively and 2/11 postoperatively based on CES-D surveys. QOL improved significantly in 10/11 compared with preoperative baseline; however, many patients noted significant difficulties based on their weight and other comorbidities. CONCLUSIONS Management of adult acquired buried penis is a challenging, yet correctable problem. In our series it appears that by using established surgical techniques we were able to achieve significant improvements in erectile function, QOL, and measures of depression.

Does a Positive Response to Spermatic Cord Block Predict Response to Microdenervation of the Spermatic Cord for Chronic Scrotal Content Pain

INTRODUCTION Microdenervation of the spermatic cord (MDSC) has been demonstrated to be an effective treatment for men with intractable scrotal content pain. AIM This study evaluates the correlation between a positive response to a spermatic cord block with local anesthetic and the subsequent surgical outcome following MDSC. MAIN OUTCOME MEASURES Pre- and post-cord block pain and pre- and post-MDSC pain. METHODS A retrospective review of 74 patients (77 testicular units) who underwent MDSC from 2006 to 2010 was performed. Pre- and post-spermatic cord block pain scores based on a 0-10 visual analog scale (VAS) were compared with pre- and post-MDSC pain scores. A positive response to the block was defined as greater than or equal to 50% temporary reduction of pain based on VAS. RESULTS The average patient age was 42 years with a mean follow-up of 10 months. The mean duration of symptoms before surgery was 69 months. Mean pre-cord block pain score was 8 with an 89% average decrease in pain following the block. Mean post-MDSC pain score was 2 with an average decrease of 73%. The level of temporary improvement from the cord block appeared to be a useful predictor of sustained improvement with MDSC (P = 0.05). Positive response to spermatic cord block was an independent predictor of MDSC response (P = 0.03). CONCLUSIONS Men with chronic orchialgia who have a positive response to a spermatic cord block are likely to have durable and complete resolution of symptoms after undergoing MDSC. The amount of pain relief obtained after the cord block correlates with pain relief after undergoing a MDSC. Men with chronic orchialgia who desire surgical correction should undergo a preoperative spermatic cord block as part of their complete evaluation. The result of the cord block can help guide the practitioner and the patient toward definitive surgical management via MDSC.

Peyronie’s Disease Reconstruction: Simple and Complex

Peyronie’s disease (PD) is often a physically and psychologically devastating condition for the affected man. Though conservative treatments have come a long way since PD was first described, surgical correction remains the most reliable and durable treatment for this condition. This chapter describes the surgical management of PD from start to finish including indications, patient selection, patient counseling, surgical approaches, instruments, graft materials, postoperative management, and rehabilitation strategies. Both simple and complex reconstructive techniques are detailed with step-by-step intraoperative photography and expert instruction.