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Surgery for Peyronie’s Disease: Weighing the Options

Author Devante Delbrune covers Surgery for Peyronie’s Disease: Weighing the Options on BackTable Urology

Devante Delbrune • May 22, 2023 • 214 hits

Deciding if surgery for Peyronie's Disease is the best course of action can be a daunting task once it is diagnosed, especially for clinicians who infrequently deal with the condition. Peyronie’s Disease (PD) frequently goes unnoticed because of patient hesitancy and vague diagnostic standards. In this article, we distill a discussion between Dr. Jonathan Clavell and Dr. Jose Silva about Peyronie’s Disease, identifying when patients might need immediate surgery and providing insights into procedure types and selection. Dr. Clavell categorizes surgery for Peyronie's Disease into three types: plication surgery, grafting procedures, and penile implants.

This article features excerpts from 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 a condition when fibrous scar tissue is formed inside the penis with a variable presentation and is diagnosed based on history and physical exam.

• Certain physical characteristics, such as severe calcification, extreme curvature (e.g., 120 degrees), corporeal wasting, or dual points of angulation, often mean surgery for Peyronie's Disease is the best intervention.

• Dr. Clavell categorizes surgery for Peyronie’s disease into three types: plication surgery, grafting procedures, and penile implants.

• Successful surgery for Peyronie's Disease necessitates matching the procedure's major risks with patient preferences and maintaining a patient-centric approach. If a case is too complex, surgeons should feel comfortable referring the patient to a specialist.

Surgeons performing penile surgery

Table of Contents

(1) Diagnosing Peyronie’s Disease

(2) Surgery For Peyronie's Disease Candidacy & Factors

(3) Surgical Management of Peyronie’s Disease

Diagnosing Peyronie’s Disease

Peyronie’s Disease, a condition where fibrous scar tissue develops in the penis, can cause various curvature presentations, some of which may be painful. While penile pain often accompanies the diagnosis, it is not a determinant; angulation is. The selection of treatment should be tailored to the patient's history and physical examination. Management options range from penile traction and medication to the most definitive option, surgery.

[Dr. Jonathan Clavell]
Seeing a patient with Peyronie's, it was the greatest thing because, at that time, when I was a resident, I still remember we had to wait one year without any changes before considering treatment. Whenever the patient presented, I always ask them, so how long have you had the curvature, or when was the last time you noticed a change? If they told me, "Doc, it was three months ago," I'm like, "Okay, well, great, I'll see you in nine months." Then we go on to the next patient. Those conversations tended to be very quick. Now, it's very different.

Now, we considered the stable phase when they have had no changes within three months. I always ask them, "When was the last time you noticed a change?" If they have a picture, I ask them, "How long has your penis been like this? Has it changed?" We need to know these things as it may change our treatment algorithm a little bit. Right now, it's very important that we remember that it's only three months before a change for us to consider it to be within the stable condition.

[Dr. Jose Silva]
Pain is no longer a determinant in that sense? It's just the change in angulation.

[Dr. Jonathan Clavell]
That's very interesting because, again, patient who presents with penile pain, first of all, penile pain alone is not considered Peyronie's disease. Pain in the penis can be secondary to infection. It can be potential nerve entrapment, it can be pelvic floor dysfunction. There are so many things that can be causing penile pain. However, when you have pain in combination with an acquired deformity, it can be considered Peyronie's. Another thing we need to remember is that, just like you're saying, pain is a subjective complaint.

There recently was a debate on Twitter regarding a review article published by the Mayo Clinic, in which they were discussing the inconsistencies in the literature when it comes to differentiated acute versus chronic disease. Pain is one of the things that is considered inconsistent. Why? Because pain is objective. Many men can have stable curvature or deformities for months or even years but if they also have a good, strong erection, that scar tissue will start tethering on that erection, that tunic albuginea, and the patient can complain of pain. The other thing that I also take into consideration is, are we talking about pain or are we talking about them having discomfort? Again, with Peyronie's disease, the scar tissue is not allowing the penis to stretch out to its full capacity, therefore, if you have a patient who has a strong erection and that scarred tissue is holding the penis back, it will at least be uncomfortable. Not a reliable indicator at least for me.

[Dr. Jose Silva]
In terms of pain with erection versus, really it's a matter of the curvature. Will that symptom of erection of pain with erection versus will push you toward thinking something else?

Listen to the Full Podcast

Peyronie's Disease Challenges and Solutions with Dr. Jonathan Clavell on the BackTable Urology Podcast)
Ep 72 Peyronie's Disease Challenges and Solutions with Dr. Jonathan Clavell
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Surgery For Peyronie's Disease Candidacy & Factors

Deciding on surgery for Peyronie's Disease versus medical management is often challenging. Potential surgical candidates must fully understand their options and the associated risks. Dr. Clavell considers patients with severe calcified plaque, pronounced deformity (such as a 120-degree curvature), corporeal wasting, or two points of angulation as prime candidates for surgery. If a patient falls short of these criteria, he usually suggests alternative strategies based on their specific condition. Patients should be aware that despite successful surgery for Peyronie's Disease, plaque reoccurrence is possible, which could necessitate further procedures.

[Dr. Jose Silva]
That's awesome. Jonathan, in terms of surgical procedures, when would you say, "Okay, you need a surgery, we're not going to bother with injections."

[Dr. Jonathan Clavell]
The only times that I will do that, it's a guy who has a severe calcified plaque, or they have very severe deformity, either 120 degrees, or it's something very complex. They have two points of angulation of their penis, or they have corporeal wasting, sometimes you will have these guys that will present with a scar tissue that they have girth and the base of the penis, and then all of a sudden, midway through the penis, everything narrows down and the penis is unstable. You do a doppler, they have good blood flow going into their penis, but they tell you, "Doc, I cannot maintain an erection, I cannot penetrate." Sometimes these guys can present in their 30s. Again, we have to be very open to all the different surgical procedures because this is not a one-size-fits-all. There's multiple things that we can try for different reasons. Most of the time, Jose, the patient decides what is the treatment they want. However, with those specific scenarios, a guy who has a very severe curvature, or a severe calcified plaque that I know the XIAFLEX injection is not going to do anything to it, then for those, I tell them, "Hey, you need surgery."

Surgical Management of Peyronie’s Disease

The key to deciding the most suitable treatment for Peyronie’s Disease lies in understanding the patient's desired outcome and their willingness to accept risk. When surgery is deemed appropriate, Dr. Clavell typically recommends one of three procedures: plication surgery, grafting procedures, or penile implants. Each category carries its own set of risks, with penile shortening a significant risk in plication surgery, erectile dysfunction in grafting, and functionality problems in penile implants. Surgeons may choose from a variety of graft types in grafting procedures, including Tutoplast, TachoSil, and EVARREST.
In most cases, surgeons opt for an incisional approach rather than excision to reduce erectile dysfunction risk linked to the veno-occlusive mechanism. Importantly, surgeons must acknowledge their comfort level with complex cases and refer these to other providers when necessary.

[Dr. Jonathan Clavell]
I offer all surgical procedures depending on what they're willing to risk. I'm going to repeat that. I offer all surgical procedures and it depends on what they are willing to risk. I explained there are three categories. Number one, Peyronie's Disease plication surgery; number two, grafting procedures; and number three, penile implant. The cool thing about this is that we can even combine these to give a better result for men. Whenever we are offering treatment options to these men, remember, again, this is a quality-of-life issue, not a matter of life and death. We already discussed that.

The patient, the individual patient should be the one deciding what they want. We can orient them and we can inform them about the risks and benefits of each option. We need to always explain the risks of each procedure. For example, men with plication. What's the biggest risk? Penile shortening. You could also have problems with sensation, recurrence of curvature, small risk of worsening erectile dysfunction, but the main risk is penile shortening.

Men undergoing grafting procedures, what's the biggest risk? Erectile dysfunction. Usually, there's about a 20% to 30% chance of having worsening ED. Even though smaller risk, there could also be risk of shortening. These require more attention post op as well. Specifically, if they have a big plaque.

Whenever I talk about grafting procedures without placing an implant, we have to explain to the patients that, "Hey, you have to massage your penis post-op. You have to do some traction therapy post op. If you have some contraction of that graft, you might need a vacuum pump." In general, we try to incise rather than excise because with excision, the risk of erectile dysfunction is worse because the veno-occlusive mechanism within the penis can actually get worse whenever you excise a plaque versus whenever you incise a plaque.

Then the other thing we have to take into consideration is what graft material will we be using? Are we going to be using Tutoplast or are we using one of these newer hemostatic patches like TachoSil, EVARREST?

Then the other things that we need to take into consideration, the risk factors when it comes to penile implant. Is the patient diabetic? Is a patient a smoker? Does he have peripheral vascular disease? Are we risking ischemia of his penis? Most importantly, what are the patient's goals? Does he want to be functionally straight or does he want to be straight like an arrow? Does he want to restore length? Does he not want to risk losing sensation? Because as a surgeon again, we need to be equipped to tackle these complex cases.

If you're not comfortable doing these complex cases, you should probably refer them out. Are you as a surgeon equipped to tackle these complex cases? Adjunct procedures, elevated neurovascular bundle. Is it better to refer out? I remember even when I graduated from fellowship and I started out, I had two very complex cases that presented to my office. I'm like, "You know what? You should go see this other doctor because I don't feel comfortable taking care of you right now." Again, I did a fellowship in this.

Podcast Contributors

Dr. Jonathan Clavell discusses Peyronie's Disease Challenges and Solutions on the BackTable 72 Podcast

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 discusses Peyronie's Disease Challenges and Solutions on the BackTable 72 Podcast

Dr. Jose Silva

Dr. Jose Silva is a board certified urologist practicing in Central Florida.

Cite This Podcast

BackTable, LLC (Producer). (2022, December 28). Ep. 72 – Peyronie's Disease Challenges and Solutions [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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Podcasts

Peyronie's Disease Challenges and Solutions with Dr. Jonathan Clavell on the BackTable Urology Podcast)
Peyronie's Disease (en Español) con Dr. Jose Saaveedra on the BackTable Urology Podcast)

Articles

XIAFLEX injection being loaded for treatment of peyronie’s disease

Utilizing XIAFLEX for Peyronie’s Disease

Peyronie's disease surgery for penile implant

Peyronie’s Disease Surgery for Penile Implants

Topics

Penile Implant Procedure Prep

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