Long-term results in surgery for Peyronie’s Disease
Saturday, 17 April 2010- At the Meeting of the of the EAU Section of Genitourinary Reconstructive Surgeons (ESGURS) held today in Barcelona on the second day of the 25th Anniversary Congress of the EAU, Prof. Edoardo Austoni lectured on the long-term results in surgery for Peyronie’s Disease (PD).
Austoni said that in the past 30 years therapy for Induratio Penis Plastica (IPP) has undergone continual evolution in terms of both pharmacological and surgical approaches. This is largely due to the fact that no entirely effective and curative etiological therapy has yet been identified. The first approach to the PD surgery (introduced in the 1980s) only focused on prosthetic implants. And some authors noted that it not only favoured coital activity, but also slowed progression of disease.
Later on, surgery of the albuginea came into use all around the world. In milder forms, various authors proposed contralateral albugineal excision/plication to correct the deformity (Nesbit). A recent review on 279 patients (89 months follow-up) showed a success rate of 86.3%, good erectile function in 87.1%, major sensory changes (glans area) in 11%. However, indication could be limited by postoperative penile shortening, 1.5 to 3 cm in 17.4%, and the failure to have intercourse in 2.3%.
In the mid-1980s, both the Milan and Norfolk groups evolved the idea of 'complete excision of the plaque.' Autologous dermal graft appeared to provide satisfactory results. Moreover, in particular cases penile disassembly was carried out and in presence of erectile dysfunction (ED), a prosthetic implant was performed at the same time.
However, REPS was associated with a high rate of complications: graft retraction, formation of a new plaque and ED. A study on 619 patients (1993) showed that 51% of patients with dermal graft suffered from ED or recurrent retraction. The degree of ED depended on the width of the defect and the use of dermis graft because local fibrotic reaction induced.
From the 1990s authors suggested a number of techniques: partial plaque excision and deep dorsal vein patch-work graft ; small multiple plaque electric incisions and synthetic grafting (Schreiter & Olianaz, GER); come back to Nesbit’s procedure; simple prosthetic surgery and manual relaxation.
From 1997 to date the Milan (Italy) group have applied a different approach on more than 250 patients, which is characterised by:
- single relaxing albugineal incision, instead REPS, to reduce ED
- saphenous graft, instead dermal or synthetic, to reduce local fibrotic reaction [21,22]
- minimally invasive implant of soft axial tutors, to offer the best postoperative graft taking.
Recent long-term postoperative follow-up indicates satisfactory erection in 81-94% patients, lengthening between 1.9 and 3.5 cm in 89.9-93% and the most common complication being necrosis and extrusion of the prosthesis which occurred in 0.5-2.5% [7,23,24].
In his closing remarks, Austoni summarised the indications for PD surgery as follows:
. Nesbit's technique in light recurvatum and not retracted penis;
· Albugineal relaxation and single plaque incision in all other cases, with the following procedure (Fig. 1):
- single transversal relaxing incision, ending bilaterally to the paraurethral side with a “Y” shape;
- angle visual assessment of the graft surface: 1.5 cm every 30° (Austoni), or geometric measurement (Egydio);
- saphenous graft, or biological acellular matrix graft;
- in case of optimal erection (normal PSV and normal EDV) “single relaxing incision and saphenous graft;
- in case of ED (insufficient PSV-EDV) “oversized prosthesis implant and single relaxing incision and graft.
· For ossified plaque: excision, grafting and prosthesis implant;
· Postoperative bandages in hyperextension and stretching exercises associated to oral PDE5-in administration and corticosteroids.
Source: E. Austoni, Milan (IT) G. Pini Modena (IT), EAU 25th Anniversary Congress, Barcelona; Saturday, 17 April 2010, Meeting of the EAU Section of Genitourinary Reconstructive Surgeons (ESGURS)