Editing Peyronie's Disease (section)

==== Surgical ====

===== Indications =====

* '''Indications for surgical intervention in Peyronie’s disease (4):'''
*# '''<span style="color:#ff0000">Stable disease (defined by AUA as disease that is ≥ 1 year from onset and ≥3-6 months of stable deformity)</span>'''
*#* '''CUA considers stable disease after 6-12 months after disease onset and ≥3-6 months of stable deformity'''
*#* The surgical literature focuses almost entirely on patients with stable disease; outcomes for patients with active disease are not known.
*#* Although pain is associated with acute phase, '''surgery may be considered even in the presence of pain''' if persistent penile pain during erection is related to penile deformity.
*# '''<span style="color:#ff0000">Deformity that compromises sexual intercourse</span>'''
*# '''<span style="color:#ff0000">Failure of non-surgical therapy</span>'''
*#* It is not incorrect to bypass medical management and proceed straight to surgery; however, the patient must clearly be aware and have consented to the potential treatment side-effects of surgery.
*# '''<span style="color:#ff0000">Desire for most rapid and reliable result</span>'''

===== Pre-operative counselling (4): =====

# '''<span style="color:#ff0000">Persistent or recurrent curvature</span>'''
#* '''<span style="color:#ff0000">Goal is to make penis “functionally straight”</span>''' (penetration not compromised, usually corresponding to '''<span style="color:#ff0000">residual curvature < 20º)</span>''' vs. completely straight (comparing to pre-PD anatomy))
# '''<span style="color:#ff0000">Reduction of penile erect length</span>'''
#* Result is more likely shorter with plication than with grafting
# '''<span style="color:#ff0000">Diminished rigidity</span>'''
#* ≥5% in all studies—grafting more than plication
#* ≥30% if suboptimal pre-operative rigidity—dependent on pre-operative erectile quality
# '''<span style="color:#ff0000">Decreased sexual sensation</span>'''
#* '''Typically resolves in 1-6 months'''
#* Rarely compromises orgasm or ejaculation

===== Surgical approach =====

* '''<span style="color:#ff0000">Depends on erectile function and severity of deformity</span>'''
* '''<span style="color:#ff0000">Options (3):</span>'''
*# '''<span style="color:#ff0000">Capable of erection (with or without adjunct therapy (oral medications, vacuum pump therapy, or intracavernosal injection) and lack of deformity precluding intercourse</span>'''
*## '''<span style="color:#ff0000">Plication</span>'''
*## '''<span style="color:#ff0000">Plaque incision, partial excision, or excision, with grafting</span>'''
*# '''<span style="color:#ff0000">Refractory erectile dysfunction or severe deformity</span>'''
*## '''<span style="color:#ff0000">Prosthesis</span>'''
*##* Men who are considering penile straightening procedures without a penile prosthesis should be carefully evaluated for the quality of their pre-operative erections
*##** '''CUA Guidelines recommend pre-operative evaluation with combination of colour duplex ultrasonography with intracavernosal injection (CDU-ICI) to delineate both disease extent and intact erectile function; however, CDU-ICI may not be required in cases where normal rigidity is present and digital photographs at full erection delineate disease extent'''
*##** '''Plication may have less risk of new ED compared with grafting procedures. However, grafting more likely to restore penile length compared to plication.'''
*##* '''Post-operative rehabilitation period (e.g. traction)''' is designed to improve postoperative healing and outcomes by (4):
*##*# Preventing shortening
*##*# Encourage straight wound healing
*##*# Preserve vascular integrity
*##*# Encourage partner participation.

====== Tunical plication (tunical shortening procedures) ======

* '''<span style="color:#ff0000">Aims to shorten the longer (or convex) side of the tunica albuginea to match the length to the shorter side</span>'''
* '''<span style="color:#ff0000">Recommended for (3):</span>'''
*# '''<span style="color:#ff0000">Simple curvature <70°</span>'''
*# '''<span style="color:#ff0000">Minimal/absent hourglass or hinge effects</span>'''
*# '''<span style="color:#ff0000">Adequate penile length;</span>''' those in whom the anticipated loss of length would be < 20% of total erect length
* '''Advantages (4):'''
*# '''Shorter surgical time'''
*# '''Good cosmetic outcomes'''
*# '''Minimal effect on rigidity'''
*# '''Simple and safe surgery'''
*# '''Effective straightening'''
* '''Disadvantages (2):'''
*# '''Penile shortening'''
*#* Predictors of shortening include direction and degree of curvature
*#** Ventral curvature >60° has greatest potential for loss of penile length
*# '''Failure to correct an hourglass or hinge'''
* '''Complications (7):'''
*# '''Persistent pain'''
*# '''Persistence or recurrence of penile curvature''' (>30º, ≈10%)
*# '''Penile hematoma''' (≈5%)
*# '''Urethral injury''' (≈1%)
*# '''Palpable suture knots'''
*# '''Loss of penile length by default, but tend to preserve potency'''
* '''<span style="color:#ff0000">Types of plication surgery (3):</span>'''
** '''<span style="color:#ff0000">Nesbit</span>''': '''excision of an elliptical segment''' of the tunica on the contralateral side of the curvature
** '''<span style="color:#ff0000">Yachia</span>''': full-thickness '''vertical incision''' is made on the vertical shaft tunica, which is '''then closed transversely''' to shorten the ventral aspect and correct the curvature
** '''<span style="color:#ff0000">16-dot</span>'''
** '''Imbrication procedures''' are used to avoid making a full-thickness tunical incision and fold the tunica to correct curvature
** '''No head-to-head studies of the primary types of plication surgery'''
* During a dorsal penile plication, the deep dorsal vein is occasionally ligated, dissected, and excised and the plication sutures are then placed in the venous bed.

====== Plaque incision or partial excision and grafting (tunical lengthening procedures) ======

* '''<span style="color:#ff0000">Aims to lengthen the shorter (or concave) side of the tunica albuginea to match the length of the longer side</span>'''
** '''<span style="color:#ff0000">Grafting follows incision, partial excision, or excision of plaque</span>'''
* '''<span style="color:#ff0000">Recommended for:</span>'''
*# '''<span style="color:#ff0000">More complex curves >70°</span>''' (CUA suggests >60°)
*# '''<span style="color:#ff0000">Large plaques</span>'''
*# '''<span style="color:#ff0000">Hourglass or complex deformities</span>'''
*# '''<span style="color:#ff0000">Concern or functional compromise attributable to further length loss with plication approaches</span>'''
** '''Ventral deformity does not do well with grafting procedures'''
* '''<span style="color:#ff0000">Grafting does not ensure length preservation, but offers the advantage of decreasing risk of irreversible erectile tissue damage'''
** '''Grafting associated with increased risk of reduced rigidity compared to plication'''
* '''Must have strong pre-operative erections for grafting''' (either with plaque incision and grafting (PIG) or partial plaque excision and grafting (PEG)) and no evidence of venous insufficiency on duplex ultrasound
* '''Graft material'''
** '''Two most commonly used grafts are Tutoplast (processed human and bovine pericardium), and porcine small intestinal submucosa grafts'''
** Multiple '''autologous grafts have''' been used historically, including fat, dermis, tunica vaginalis, dura mater, temporalis fascia, saphenous vein, crura or albuginea, and buccal mucosa. These have '''fallen out of favor''' because of a need for extended surgery to harvest the graft as well as a second surgical site, which has its own potential complications of healing, scarring, and possible lymphedema
** '''Synthetic grafts,''' including polyester and polytetrafluoroethylene, '''should not be used''' due to increased risks of infection, secondary graft inflammation causing tissue fibrosis, graft contractures, and possibility of allergic reactions

====== Penile prosthesis for men with Peyronie Disease ======

* '''<span style="color:#ff0000">Gold standard treatment for PD requiring surgery occurring concurrently with refractory ED</span>'''
* '''<span style="color:#ff0000">Indications (2):</span>'''
*# '''<span style="color:#ff0000">Severe deformity refractory to non-surgical management or failed plication/grafting</span>'''
*# '''<span style="color:#ff0000">Profound penile instability (buckling or hinge).</span>'''
* '''<span style="color:#ff0000">If significant (> 30°) deformity persists after insertion of the penile prosthesis, additional straightening maneuvers may be necessary including (2):'''
*#'''<span style="color:#ff0000">Manual modeling of the phallus over the inflated device'''
*#*'''Critical steps of modeling'''
*#**Marking the point of maximum curvature
*#**Applying force apposite the point of maximum curvature for 90 seconds
*#**Completely inflating the IPP before modeling
*#**Cycling the device and repeating as necessary
*#**Assuring no injury to the urethra or corpora
*#***'''Most common adverse event occurring after manual modeling during placement of a penile prosthesis is urethral injury'''
*#'''<span style="color:#ff0000">Incising the tunica albuginea with or without grafting''' 
* '''Inflatable penile prosthesis is the preferred surgical implant'''.
** See [[Penile Prosthesis|Penile Prosthesis Chapter Notes]]
** '''Most common postoperative complaint with prosthesis is length loss'''
** Complications may include prosthesis infection, persistent penile shortening or curvature, diminished sensitivity, and mechanical device failure or difficulties.