3rd Annual Jefferson Urology Symposium: Men’s Health Forum

© The Canadian Journal of Urology TM : International Supplement, August 2020 new use of erectile aids (p = 0.06), pain on erection (p = 0.12), or subjective penile shortening (p = 0.41). However, pa t i ent s who underwent pl aque incision with grafting had longer operative times (p = 0.0001) and were more likely to experience loss of rigidity (p=0.03), inability tohave intercourse (p=0.05), and sensation loss (p = 0.0045). On the other hand, patients in the plication group were more likely to experience palpable nodules (p = 0.03). These results suggest that plication may yield similar results while maintaining fewer side effects. Nevertheless, plaque incision or excision with or without grafting provides an effective surgical option for patients with extensive plaque, severe or complex deformities, and/or for those who desire preservation of penile length. Penile prosthesis Penile prosthesis (PP) surgery may be offered to patients with concomitant PD with ED and/or penile deformity sufficient to impair sexual intercourse despite pharmacotherapy and/or vacuum device therapy. This surgery may offer patients a solution to both issues in one surgery as the insertion of PP may correct deformity without the need for other surgical interventions. Importantly, results from the PROPPER (Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration) study demonstrated that inflatable PP (IPP) patients can produce high rates of patient satisfaction (> 80%) and device usage (> 88%), with decreased rates of depression (baseline 19.3% to 10.5% at 1 year [p = 0.02] and 10.9% at 2 years [p = 0.07]). 47 Surgeons need to be prepared for adjunctive maneuvers since Levine et al determined in their single-center study that satisfactory straightening was accomplished in 4% (4/90) of patients with IPP alone while the remaining 79% (71/90) required IPP + modeling. 48 Manual modeling with the device inflation may correct deformities as the penis is bent in the direction opposite the curvature to help disrupt the plaque. Wilson and Delk published their results in a study of 138 patients treated with IPP insertion and manual modeling of the erect penis. 49 Their technique achieved successful straight, rigid erections in 86% (118/138) of patients with 90% (124/138) actually using their IPPwithout penile shorteningor impairedsensation at mean follow up of 32 months. The most worrisome complication during modeling is urethral perforation, which occurred in their study in 4 patients (3%). Combining IPP with penile plication or graft excision/incision have also been reported in the scientific literature, demonstrating safe, efficacious, and durable results in addressing severe curvatures and ED during the same case. Rahman et al reported complete correction in all 5 patients who received combined plicationwith IPPplacementwithno recurrence atmean follow up of 22 months. 50 Cormio et al reported their successful outcome in a patient 8 years after combined plication + IPP surgery (normal voiding function, successful intercourse, straight penis, IIEF-5 score 24). 51 In a retrospective review, Chung et al demonstratedhigh patient satisfaction and effective curvature correction following synchronous IPP placement and plication down from a mean of 39° to a mean < 5° in PD patients presenting with dorsal (n = 11), lateral (n = 2), and biplanar curvatures (n = 5). 52 In a study that evaluated IPPplacement with tunica albuginea-relaxing incisions without grafting, Djordjevic and Kojovic reported complete penile straightening in 95% (59/62) of patients at median follow up of 35 months. 53 Some patients who undergo IPP placement for ED have undiagnosed concomitant PD that is only identified intraoperatively due to prior history of incomplete assessment secondary to poor erection quality. Tausch et al demonstrated in a retrospective study that regardless of whether PD was identified preoperatively, synchronous plication/IPP or Yachia corporoplasty can be safely and effectively performed with satisfactory results. 54 These studies show that IPP alone, withmodeling, or combinedwith other surgical techniques synchronously yield beneficial results. Other potential treatments Vacuum therapy Vacuum therapy has been explored in the scientific literature and aims to treat PD through mechanical straightening of penile curvature. Raheem et al performed a study of 31 PDpatients withmean disease duration of 9.9 months. 55 The treatment regimen involved using the vacuum device (Osbon ErecAid, MediPlus, High Wycombe, UK) for 10 minutes twice daily over a 12-week period. After 12 weeks, there was a clinically and statistically significant improvement in penile length, curvature, and pain. Notably, 21 patients demonstrated improved curvature (5°-25°), 7 had no change, and 3 had worsened curvature. Of the 31 patients, 51% (16/31) were satisfied with the outcome of therapy, with 15 undergoing subsequent surgical correction. These results suggest that vacuum therapy may be safe to use in both active and passive disease phase, may improve or stabilize PD curvature, and may reduce the number of patients requiring surgery. Nevertheless, larger studies need to be performed and current guidelines do not recommend its use as a stand- alone treatment option. 10 17 Peyronie’s disease: what do we know and how do we treat it?