Abstract:Study Type – Diagnostic (non‐consecutive series) Level of Evidence 3b
What’s known on the subject? and What does the study add?
Peyronie’s disease with heterotopic, ossified plaques require surgical removal. While conventional tunical excision techniques risk erectile and sensory compromise, we describe a tunical‐sparing technique which maintains potency with durable results.
OBJECTIVE
Ossified Peyronie’s plaques may require surgical excision because of the palpable problems and penile curvature that result.… Show more
“…The ETG operation was developed originally for indent and HG deformities to reinforce, or thicken, the narrowed portion of the penile shaft to prevent buckling or hinging during sexual intercourse. Over time the operation has been modified to treat other penile pathologies including congenital weakness of the TA, corporeal herniation through the TA after CCH injection, and thinned TA after tunica-sparing excision of ossified Peyronie’s plaque ( 17 ). All of these pathologies are associated with significant negative consequences to erectile function due to the natural history of such a condition.…”
BackgroundTo describe a novel, tunica-sparing surgical technique—extra-tunical grafting (ETG)—for the treatment of penile indent and hourglass (HG) deformities and to describe patient-reported outcomes after the ETG procedure.MethodsAn IRB-approved, retrospective chart review of ETG patients was performed to collect data including pre-operative deformity, operation performed, and post-operative patient-reported perception of deformity, erectile function, penile sensation, and overall satisfaction with the ETG operation. The indications for surgery were difficulty with sexual intercourse due to deformity and/or poor cosmesis of the penis. Pre-operatively all patients had erections adequate for intercourse with or without medications. The ETG procedure is performed through a ventral longitudinal penile skin incision. The dissection is continued to the level between Dartos and Bucks fascia, circumferentially for HG deformity and focally for indent deformity. The neurovascular bundle (NVB) is left undisturbed. A cadaveric fascia graft is applied, singly or in multiple layers, to fill the exposed tunical depressions. Our preferred graft material is Tutoplast Suspend® (Coloplast, Minneapolis, MN, USA). The graft is sutured into position with multiple interrupted, long-lasting absorbable sutures to achieve the desired penile shaft contour. The urethra is excluded from the graft.ResultsFrom October 2013 to June 2017, 36 patients had the ETG procedure for HG and/or indent with or without penile curvature. Results with a minimum of 6 months of follow-up could be extracted for 18 of the patients. One was excluded as he required concurrent excision of a large calcified tunical plaque, which necessitated incision into the tunica albuginea (TA). Follow-up was between 6 and 44 months (average 21 months). All patients reported satisfactory resolution of the HG or indent. No patient reported worsened erectile function. Two patients (11.8%) reported slight penile hypoesthesia, with one of these having had multiple previous penile degloving surgeries for trauma. Ten of the patients reported being “very satisfied” and six reported being “satisfied” with the procedure. One was neutral. All reported that they would recommend the ETG procedure to a friend, and all would repeat the same surgery again.ConclusionsThe ETG procedure is a straightforward approach to HG and indent deformities to correct the penile deformity and to provide structural support to prevent penile buckling during intercourse. The procedure does not violate the TA and does not require dissection of the NVB. Thus, ETG carries a very low risk of de novo impotence or hypoesthesia as highlighted by this patient series. With such low risk and high patient-reported satisfaction rates, the ETG procedure is a valuable surgical technique for the treatment of complex penile deformities.
“…The ETG operation was developed originally for indent and HG deformities to reinforce, or thicken, the narrowed portion of the penile shaft to prevent buckling or hinging during sexual intercourse. Over time the operation has been modified to treat other penile pathologies including congenital weakness of the TA, corporeal herniation through the TA after CCH injection, and thinned TA after tunica-sparing excision of ossified Peyronie’s plaque ( 17 ). All of these pathologies are associated with significant negative consequences to erectile function due to the natural history of such a condition.…”
BackgroundTo describe a novel, tunica-sparing surgical technique—extra-tunical grafting (ETG)—for the treatment of penile indent and hourglass (HG) deformities and to describe patient-reported outcomes after the ETG procedure.MethodsAn IRB-approved, retrospective chart review of ETG patients was performed to collect data including pre-operative deformity, operation performed, and post-operative patient-reported perception of deformity, erectile function, penile sensation, and overall satisfaction with the ETG operation. The indications for surgery were difficulty with sexual intercourse due to deformity and/or poor cosmesis of the penis. Pre-operatively all patients had erections adequate for intercourse with or without medications. The ETG procedure is performed through a ventral longitudinal penile skin incision. The dissection is continued to the level between Dartos and Bucks fascia, circumferentially for HG deformity and focally for indent deformity. The neurovascular bundle (NVB) is left undisturbed. A cadaveric fascia graft is applied, singly or in multiple layers, to fill the exposed tunical depressions. Our preferred graft material is Tutoplast Suspend® (Coloplast, Minneapolis, MN, USA). The graft is sutured into position with multiple interrupted, long-lasting absorbable sutures to achieve the desired penile shaft contour. The urethra is excluded from the graft.ResultsFrom October 2013 to June 2017, 36 patients had the ETG procedure for HG and/or indent with or without penile curvature. Results with a minimum of 6 months of follow-up could be extracted for 18 of the patients. One was excluded as he required concurrent excision of a large calcified tunical plaque, which necessitated incision into the tunica albuginea (TA). Follow-up was between 6 and 44 months (average 21 months). All patients reported satisfactory resolution of the HG or indent. No patient reported worsened erectile function. Two patients (11.8%) reported slight penile hypoesthesia, with one of these having had multiple previous penile degloving surgeries for trauma. Ten of the patients reported being “very satisfied” and six reported being “satisfied” with the procedure. One was neutral. All reported that they would recommend the ETG procedure to a friend, and all would repeat the same surgery again.ConclusionsThe ETG procedure is a straightforward approach to HG and indent deformities to correct the penile deformity and to provide structural support to prevent penile buckling during intercourse. The procedure does not violate the TA and does not require dissection of the NVB. Thus, ETG carries a very low risk of de novo impotence or hypoesthesia as highlighted by this patient series. With such low risk and high patient-reported satisfaction rates, the ETG procedure is a valuable surgical technique for the treatment of complex penile deformities.
“…At this stage, the main treatment strategy involves the removal of the ossified plaque with or without grafting. In patients with erectile dysfunction (ED), preference should be given to penile prosthesis implantation after the removal or incision of the calcified plaque with or without grafting [ 18 , 19 ]. Fig.…”
Section: Complex Deformitiesmentioning
confidence: 99%
“…In appropriate patients, tunica-sparing bone excision has been described. In a study involving 12 patients with dorsal penile curvature between 10 and 90°, tunica albuginea was freed and the calcified plaque was removed [ 19 ]. At a seven-month follow-up, successful erections were detected in 80% of patients.…”
Section: Management Of Patients With Complex Curvature In Peyronie’s ...mentioning
Purpose
About 10% of Peyronie's patients are complex cases with severe curvature (>60 degrees), ventral plaque, multiplanar curvature, hour-glass/hinge deformity, notching deformity, and ossified plaque. In patients with complex Peyronie’s disease (PD), different techniques (shortening procedures, lengthening procedures, and penile prosthesis implantation (IPP)) may be necessary to achieve successful result. This review aims to analyze the various surgical techniques employed in the management of Peyronie's disease, with a specific focus on patients with complex deformity.
Methods
Articles focusing on the surgical management of complex curvature in Peyronie’s disease were searched in MEDLINE and PubMed published between 1990 and 2023.
Results
Shortening procedures are linked to penile shortening and are not recommended for complex cases such as notching, hour-glass deformity, or ossified plaque. Lengthening procedures are suitable for addressing complex curvatures without erectile dysfunction (ED) and are a more appropriate method for multiplanar curvatures. Penile prosthesis implantation (IPP), with or without additional procedures, is the gold standard for patients with ED and Peyronie's disease. IPP should also be the preferred option for cases of penile instability (hinge deformity) and has shown high satisfaction rates in all complex cases.
Conclusion
While surgical interventions for complex curvature in Peyronie's disease carry inherent risks, careful patient selection, meticulous surgical techniques, and post-operative care can help minimize complications and maximize positive outcome.
“…In those with narrowing and complicated deformity, a grafting procedure is needed although grafting surgery is associated with higher incidence of ED, recurrence and altered penile sensation. To decrease these complications in men with large calcified/ossified plaque, instead of total excision, a tunicapreserving procedure was reported by Eisenberg et al 7 with satisfactory results.…”
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