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BackTable / Urology / Article
Peyronie’s Disease Surgery for Penile Implants
Quynh-Chi Dang • Jan 5, 2022 • 923 hits
Peyronie’s disease is caused by fibrous scar tissue in the penis that causes painful, curved erections. Dr. Jonathan Clavell shares his Peyronie's disease surgery tips for penile implants on the BackTable Urology Podcast.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• Peyronie’s disease is caused by fibrous scar tissue in the penis that causes painful, curved erections. In patients wanting a penile implant for Peyronie’s disease, Dr. Clavell always assesses the degree of curvature before formulating his surgical plan.
• For patients with mild curvature (under 45 degrees), he places the penile implant and uses manual remodeling techniques intraoperatively to straighten the penis. For patients with more severe curvature (more than 60 degrees), the most common Peyronie’s disease surgery technique is a plaque incision or excision with grafting (PIEG).
• Dr. Clavell uses a ventral non-degloving incision to avoid the risk of glans ischemia. He also prefers to make multiple smaller incisions around the point of maximal curvature in order to prevent the need for a graft in Peyronie’s disease surgery.
• In severe Peyronie’s disease patients, he will do the PIEG first and then place the implant in order to minimize implant exposure time and infection risk.
Table of Contents
(1) Peyronie's Disease Surgery Options
(2) Using a Ventral Non-Degloving Technique in Peyronie’s Disease Surgery
(3) Incision Techniques and Grafts in Peyronie’s Disease Surgery
Peyronie's Disease Surgery Options
Patients with Peyronie’s disease experience painful, curved erections due to the accumulation of fibrous scar tissue in the penis. Dr. Clavell emphasizes the importance of assessing the degree of penile curvature in order to decide whether to perform penile implant surgery with Peyronie’s disease surgery simultaneously. For patients with normal mild curvature, correction of the curvature may introduce unnecessary surgical risks.
[Dr. Jose Silva]
And so for patients that have Peyronie's, after using Trimix, how do you prepare for those cases? Do you try to do modeling? Do you know beforehand that you're already going to do a graft?
[Dr. Jonathan Clavell]
I mean, I am your Peyronie's man. We could have a full two-hour podcast about Peyronie's disease. When it comes to Peyronie's, it's similar to priapism cases. I make sure to set proper expectations, assess the severity of the curvature, and make sure that I have at least an idea of how bad that curvature is.
I don’t promise patients a really straightforward case because I could go in there and find that the guy has a 120 degree curvature. You want to make sure that you know what you're getting yourself into and make sure that both you and the patient are on the same page when it comes to what the goals of the surgery are. Is the goal to make the penis straight like an arrow, or is he okay to be what we call “functionally straight”?
It's not the same thing for a guy to have a 20 degree curvature, which is normal. Most of us have some degree of curvature. So again, you want to make sure that you set those proper expectations. Is his goal to get back as much length as possible? You need to make sure he understands the risks involved and the expectations to set yourself up for success.
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Using a Ventral Non-Degloving Technique in Peyronie’s Disease Surgery
In patients with mild curvature (< 45 degrees), mild manual modeling or the scratch technique can be used to straighten the penis at the time of penile implant surgery. In patients with severe curvature (> 60 degrees), specific Peyronie’s disease surgery techniques must be used. The most common Peyronie’s disease surgery approach is a plaque incision or excision with grafting (PIEG). Commonly, a dorsal incision is initially made in order to deglove the penis. However, this surgical technique increases the risk of glans ischemia. To avoid this complication, Dr. Clavell uses a ventral incision and a non-degloving approach in Peyronie’s disease surgery instead.
[Dr. Jonathan Clavell]
So in a scenario, for example, if the patient has like a 90 degree curvature–like severe curvature–and he also has erectile dysfunction, I try to fix everything at the time of the implant surgery. There are different ways we can do this.
Just placing the implant is not going to be enough. For example, for a guy who has a mild 45 degree curvature, you can probably get away with just placing the implant and do very mild manual modeling. You can also use a scratch technique in which you, from inside the corpora, can actually get a nasal speculum inside the corporotomy and then use either a 12 blade that has like a little hook or the tip of Metzenbaum scissors. You can just scratch off the plaque from the inside. And sometimes you're able to model later, and the penis will actually be kind of straight. I've used it before I can actually bill for that. You can actually bill for that. Just like if it was an incision of the Peyronie’s plaque. It's just doing it from the inside instead of from the outside.
So again, you know, however, if there is a patient who has severe curvature, if it's 60 degrees or more, I personally prefer to do a plaque incision with, or without grafting. There's two approaches you can use to do this. Most people use a circumcision incision, they deglove the penis in order to access the tunica.
If you need to elevate the neurovascular bundle for dorsal plaques, you can do so. If you need to elevate the urethra for ventral plaques, you can definitely do it. Personally, I prefer to use a ventral incision. So instead of degloving the penis, I actually make an incision right along that ventral raphae, and I'm able to expose everything. There's also a video on YouTube about that. And you can actually elevate both the skin dartos and to the neurovascular bundle. Altogether this way, we can keep the skin attached to the glans at all times. And theoretically we could avoid the risk of glans ischemia.
I mean, there was a study back in 2017, for example, that looked at the risk factors for cases with glans ischemia and they had 17 patients who had glans ischemia with penile prosthesis placement. Out of those 17 patients, 86% had a circumcision with the gloving. So for this reason, when I was in my fellowship, my mentor Dr. Wong and I published approaching these cases with the use of a ventral non-degloving incision.
Incision Techniques and Grafts in Peyronie’s Disease Surgery
Although many surgeons make one large incision at the point of maximal curvature, Dr. Clavell prefers to make multiple smaller incisions around the point of maximal curvature. He has found that making smaller incisions can prevent the need for a graft in Peyronie’s disease surgery. When he has to use a graft, he uses a tight seal graft.
Finally, he prefers to place the penile implant after Peyronie’s disease surgery to minimize the infection risk due to prolonged implant exposure time.
[Dr. Jonathan Clavell]
Another thing that I personally do for these severe curvature cases without calcified plaque and hourglass deformity is doing multiple incisions instead of doing one incision at the point of maximal curvature. Instead of going at the point of maximal curvature, I should go around it. Making multiple incisions allows the incisions to be smaller. And most of the time I don't even have to place a graft.
I actually plan to present my findings. I've done more than 35 cases, I believe now, using this approach and I'm actually presenting it next month.
[Dr. Jose Silva]
So you're not doing sutures, you're just doing the incisions.
[Dr. Jonathan Clavell]
Yeah, that is correct. Whenever we do Peyronie’s cases and we're doing a plaque incision with grafting, the biggest risk with that is erectile dysfunction. The good thing about these guys who also need a penile prosthesis is that you don't have to worry about that.
So sometimes if the defect is less than two centimeters in size, you can get away without having to place a graft. However, if you have a guy who has severe curvatures, like a 75/90/100 degree curvature, and you have to make an incision to the point of maximum curvature.
When you get that penis straight, you will have a very large defect. Now you're probably going to have to graft. In order for me to avoid that, what I started doing was making multiple smaller incisions and all of those incisions are probably a centimeter or a centimeter and a half. Again, you have to close the neurovascular bundle.
You have to close the dartos. They will serve as a scaffold to be able to cover those defects. And you don't have to worry about placing a graft. That being said nowadays, we have different types of grafts. There are these hemostatic patches. And the good thing about it is you don't have to worry about sewing a graft. Cause we all know that whenever we do these Peyronie’s cases and used to have to sew a graft that's 30 minutes that you have to add into your surgery in order for you to get that water tight. So I am one that uses a seal graft. I use that graft for Peyronie's and erectile dysfunction patients who are getting penile implant surgery.
[Dr. Jose Silva]
So when do you place the implant?
[Dr. Jonathan Clavell]
So again, it really depends on what your approach is. Many surgeons, what they do is they place the implant first and then they do the reconstruction. I don't do it that way. I do my reconstruction first, and then I place the implant at the end because I don't want the implant to be exposed for a long time because that can increase the risk of infection.
So I would place the implant afterwards and test it. And if the defect is not that big, I just close them. And again, I haven't had erosions, herniations, or aneurysm. And they've done very well.
Podcast Contributors
Dr. Jonathan Clavell
Dr. Jonathan Clavell is a high-volume prosthetic urology surgeon and assistant professor of urology at UT Health Science Center Houston.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2021, November 24). Ep. 23 – Complex Penile Implants [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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