Page 104 - Remedial Andrology

The results of tunical shortening and lengthening approaches are presented in Tables 30 and 31. It must be
emphasised that there have been no RCTs comparing surgical outcomes in PD. The risk of ED seems to be
greater for penile lengthening procedures [1002]. Recurrent curvature is likely to be the result of failure to wait
until the disease has stabilised, re-activation of the condition following the development of stable disease,
or the use of early re-absorbable sutures (e.g., Vicryl) that lose their strength before fibrosis has resulted in
acceptable strength of the repair. Accordingly, it is recommended that only non-absorbable sutures or slowly
re-absorbed absorbable sutures (e.g., polydioxanone) should be used. With non-absorbable sutures, the knot
should be buried to avoid troublesome irritation of the penile skin, but this issue may be alleviated by the use
of slowly re-absorbable sutures (e.g., polydioxanone) [1103]. Penile numbness is a potential risk of any surgical
procedure, involving mobilisation of the dorsal neurovascular bundle. This is usually a temporary neuropraxia,
due to bruising of the dorsal sensory nerves. Given that the usual deformity is a dorsal deformity, the procedure
most likely to induce this complication is a lengthening (grafting) procedure, or the association with (albeit rare)
ventral curvatures [1094].

8.2.3.2.3 Penile prosthesis
Penile prosthesis (PP) implantation is typically reserved for the treatment of PD in patients with concomitant
ED not responding to conventional medical therapy (PDE5I or intracavernous injections of vasoactive agents)
[1002]. Although inflatable prostheses (IPPs) have been considered more effective in the general population
with ED, some studies support the use of malleable prostheses in these patients with similar satisfaction rates
[1002, 1222, 1223]. The evidence suggests that there is no real difference between the available IPPs [1224].
Surgeons can and should advise on which type of prosthesis best suits the patient but it is the patient who
should ultimately choose the prosthesis to be implanted [1225].

Most patients with mild-to-moderate curvature can expect an excellent outcome simply by cylinder insertion
[1169, 1226]. If the curvature after placement of the prosthesis is < 30° no further action is indicated, since
the prosthesis itself will act as an internal tissue expander to correct the curvature during the subsequent 6-9
months. If, the curvature is > 30°, the first-line treatment would be modelling with the prosthesis maximally
inflated (manually bent on the opposite side of the curvature for 90 seconds, often accompanied by an
audible crack) [1227, 1228]. If, after performing this manoeuvre, a deviation > 30° persists, subsequent steps
would be incision with collagen fleece coverage or without (if the defect is small, it can be left uncovered) or
plaque incision and grafting [1229-1234]. However, the defect may be covered if it is larger, and this can be
accomplished using grafts commonly used in grafting surgery (described above) which prevent herniation and
recurrent deformity due to the scarring of the defect [1235]. The risk of complications (infection, malformation,
etc.) is not increased compared to that in the general population. However, a small risk of urethral perforation
(3%) has been reported in patients with ‘modelling’ over the inflated prosthesis [1227].

In selected cases of end-stage PD with ED and significant penile shortening, a lengthening procedure, which
involves simultaneous PP implantation and penile length restoration, such as the “sliding” technique has
been considered [1236]. Although the “sliding” technique is not recommended due to reported cases of glans
necrosis because of the concomitant release of the neurovascular bundle and urethra, new approaches for
these patients have been recently described, such as the MoST (Modified Sliding Technique), MUST (Multiple-
Slit Technique) or MIT (Multiple-Incision Technique) techniques, but these should only be used by experienced
high-volume surgeons and after full patient counselling [1237-1240].

While patient satisfaction after IPP placement in the general population is high, satisfaction rates have been
found to be significantly lower in those with PD. Despite this, depression rates decreased after surgery in PD
patients (from 19.3% to 10.9%) [1241]. The main cause of dissatisfaction after PPI in the general population
is a shortened penile length. Therefore, patients with PD undergoing PP surgery must be counselled that the
prostheses are not designed to restore the previous penile length [1241, 1242].

8.2.3.2.4 Summary of evidence for surgical treatment of Peyronie’s disease

Summary of evidence LE
Surgery for PD should only be offered in patients with stable disease with functional impairment. 2b
In patients with concomitant PD and ED without response to medical treatment, penile prosthesis 2a
implantation with or without additional straightening manoeuvres is the technique of choice.
In other cases, factors such as penile length, rigidity of erection, degree of curvature, presence of 3
complex deformities and patient choice must be taken into account to decide on a tunical shortening
or lengthening technique.

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