BackTable / Urology / Podcast / Transcript #72

Podcast Transcript: Peyronie's Disease Challenges and Solutions

with Dr. Jonathan Clavell

In this episode of BackTable Urology, Dr. Jose Silva interviews Dr. Jonathan Clavell, a men’s health specialist, about workup and treatment options for Peyronie’s disease. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Initial Patient Presentation for Peyronie’s Disease

(2) Patient Management for Acute Phase Disease

(3) Patient Treatment Options and Counseling

(4) XIAFLEX Utilization and Treatment Recommendation

(5) Additional Patient Factors Indicating Treatment

(6) Indications for Surgical Management

(7) Surgical Treatment Options and Considerations

(8) The Plaque Incision Approach

(9) TachoSil and Penile Implant Technique

(10) Post Operative Recovery & Pain Management

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[Dr. Jose Silva]
Me, Jose Silva, your host this week and I'm very excited to have back Dr. Jonathan Clavell, you guys know is a men's health specialist and assistant professor of urology for UT Houston, and currently he's also the section editor for Peyronie's disease for the AUA core curriculum. Congratulations with that. Welcome to BackTable, Jonathan. How are you doing?

[Dr. Jonathan Clavell]
I'm doing very well, Jose, and thank you for having me back. It's been a while, but it's always great to be a part of the BackTable Urology Podcast. I want to congratulate you and the entire team for the amazing content you guys are bringing to the urology community. It's been pretty cool to listen.

[Dr. Jose Silva]
Thank you again for your contribution. Definitely, one of your things in urology that you're very passionate about is Peyronie's disease and I wanted to do this podcast about Peyronie's, so prior to talking about the topic, I wanted to ask you about that. I see you on social media, you always post about the Tiger Maker. Can you explain that a little bit?

[Dr. Jonathan Clavell]
That's actually pretty cool. Tiger maker, this is something that started when I was in fellowship. As you remember, my fellowship was in sexual medicine and my mentor and fellowship director, Dr. Ron Wong, when we were evaluating and counseling patients prior to penile implant surgery or even Peyronie's, usually the fellow, which it was me at the time, would be the one explaining everything to the patient. Then, Dr. Wong, he would come into the room and be there for literally 30 seconds and tell the patients, "Do not worry, we'll make you a tiger."

Then when Dr. Wong's second fellow came along, which was Dr. Saavedra from Puerto Rico, we used to joke about being Tiger Makers. He came up with t-shirts, scrub hats, and the full merchandise for Tiger Makers. Now, everybody who graduates from our fellowship program is considered a Tiger Maker. That's why the name. I didn't start it, it's with my mentor.

[Dr. Jose Silva]
Wow. I didn't know that. That sounds like a cool story. I have seen that your scrub hat from the pictures is also of tigers, right?

[Dr. Jonathan Clavell]
That's right. One of the things that when we graduate from the fellowship, they gave us a scrub hat that says Tiger Maker. Everybody who's graduated from that fellowship has the same scrub hat.

[Dr. Jose Silva]
Awesome. It is pretty cool
.
[Dr. Jonathan Clavell]
I'm just exploiting the social media posts. That's it.

[Dr. Jose Silva]
No, no, that's great. Do patients ask you about it or do they know about it or is something for social media only?

[Dr. Jonathan Clavell]
Sometimes they do, and I'm not going to lie, sometimes it can be a little bit awkward when they're like, "Hey, doctor, why are you a Tiger Maker?" Then I'm like-- We are proud of the hashtag and it's a pretty cool thing to have actually.

(1) Initial Patient Presentation for Peyronie’s Disease

[Dr. Jose Silva]
It is. Jonathan, I'm sure you get a lot of referrals for patients with angled penis, but let's talk about the usual presentation. When they come to your practice, you usually see them in the acute phase, stable phase, pain, no pain.

[Dr. Jonathan Clavell]
True. Well, you're correct. The most common referral that I get from other urologists is to help treatment with Peyronie's disease. Peyronie's like many other conditions of extremely variable and there are so many different ways in which a patient can present. There are many types of deformities, distal curvatures, proximal curvatures, hourglass deformity, corporeal wasting, penile shortening, pain, no pain. The same way we do not treat every stone case or BPH case is the same way. With Peyronie's disease, the treatments should be individualized.

When it comes to patient presentation, when a patient presents to my office for a complaint of Peyronie's disease, first of all, I listen. I try not to book more than two new Peyronie's patients in one day because I know they will take a long time to counsel. These patients are extremely distraught, they're frustrated, they're anxious. Think about it, their penis was perfectly fine and most of the time, all of a sudden, without a clear injury or without them even knowing why their penis started changing. Let's be honest, it is not easy to talk about these things to a stranger.

There's actually been research on this and most men take years, again years, before they seek treatment. The least we can do is listen to them. I believe Peyronie's disease is a lot more common than we think. Men with Peyronie's, for me, I always tell people it's like men with Peyronie's are just hiding in caves. They're scared, they're ashamed, they push their partners away, and they do not even know that it can be fixed. I listen, I examine them, and I try to explain everything. My practice is very different from many urologists. Most of the men that I see are already in the stable phase.

They have seen either one or two other doctors, be it their primary care doctor, they refer them to a urologist. Urologists didn't know what to do with them or it was too complex for them to manage and they at least have an idea of what's going on. Regarding the acute versus stable phase, we need to remember that the guidelines have changed from several years ago. I still remember being in residency. When I was in residency, you had to cram down a clinic of 50 patients.

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?

[Dr. Jonathan Clavell]
If they have, again, there are some men that have pain without the erection, although in my practice at least, I don't see that as often. Most men that mention pain, usually it's during the erection. The other thing is, most of the time it happens temporarily. I always ask them, "Are you having pain?" If they say yes, I'm like, "Okay, are we talking about pain or discomfort? Was the pain worse several months ago?" Most of the time, they're able to differentiate.

It's like, "Yes, at the beginning, it was painful that it woke me up in the middle of the night, but now I can still enjoy sex." If they're still able to enjoy sex, then it could probably just be discomfort from the tethering of the tunica rather than actual pain because they're in the acute phase.

(2) Patient Management for Acute Phase Disease

[Dr. Jose Silva]
Those patients in the acute phase, prior to seeing them again in three months, do you do anything to them? Any pills, anything, or just tell them, try to cancel, and say, "Hey, we need to wait"?

[Dr. Jonathan Clavell]
No, it depends on where, how bad the curvature is. It depends on their state of their erection. It depends on their age, their comorbidities. It depends on also the how quickly they really want to get to a solution. If they have pain, I just give them pain control, NSAIDs, Tylenol, there's some studies right now suggesting that low-intensity shockwave therapy, again, not radial wave therapy, but through linear shockwave therapy could help. However, according to guidance, the pain sometimes, most of the time, it actually improves once the plaque stabilizes.

I always wonder if the shockwave really helped or was it just time that helped the pain. Now, they're saying that the shockwaves the one that helped them out. However, who knows what happens? Then if they have erectile dysfunction, I will give them medications for erectile dysfunction. PDE5 inhibitors. There's been some doctors mostly in Europe that say that their patients do well and that the plaque stabilizes better if they are on daily Tadalafil. I don't believe that's true. It was only like one doctor talking about that.

I am one that I believe that a daily Tadalafil should be in water. We call it vitamin C or vitamin Cialis. Again, it's a great medication, low dose, it can help them bring blood flow into the penis. There's actually been some studies suggesting, again, don't take that as scripture, but there are some studies suggesting that it can actually, even that medication Tadalafil has anti-inflammatory properties. It's something that I give during the acute phase and sometimes even after surgery to help them recover quicker.

[Dr. Jose Silva]
Good to know that. The 5 milligrams or you go to 2.5?

[Dr. Jonathan Clavell]
I go five milligrams daily. I think I prescribe that at least 10 to 15 times every day. I should have some stock options.

[Dr. Jose Silva]
Even for stones. No, just kidding, just kidding.

[Dr. Jonathan Clavell]
That's right. I like that.

(3) Patient Treatment Options and Counseling

[Dr. Jose Silva]
Jonathan, when do you start talking about patient or treatment options?

[Dr. Jonathan Clavell]
That's a great question. Just like with a patient who presents with erectile dysfunction, I talked to them about their treatment options during their first visit. When a man comes in with ED, I talk to them about pills, injections, vacuum pumps, the intraurethral therapies. I tell them about the experimental stuff, although I do not offer them my practice, but I tell them like, "Hey, you might counter people who might be offering you these things and these could be considered experimental."

I also even talk to them about the penile implant. The same way, a man who presents with Peyronie's, I explain to them all the treatment options from pills, which by the way, none of them work to correct deformities. I talk to them about traction therapy, injectable therapy, and also surgical therapies. They could even be in the acute phase. I will let them know that there are treatment options for them. I explain the different surgical therapies, which include, again, plication procedures, plaque incision, and excision with grafting and penile prosthesis placements with or without adjunct procedures.

I explained all of that on the first visit. Some might be overwhelmed, but at the end of their first visit, I basically try to remind them one thing and I tell them like, "Hey, I know we've talked a lot, I already explained to you why we think the Peyronie's happened. What's the disease process? What's the normal process of the actual disease?" Some of them recover, some of them do not recover, some of them get worse. What I tell them is like, "I want you to remember one thing and it's that I can help you. Just remember one thing, I can help you." Most of the time again, they at least know that I got their back and we can actually help them out.

[Dr. Jose Silva]
I'm glad you listen. Yes, definitely.

[Dr. Jonathan Clavell]
I try to.

[Dr. Jose Silva]
Patients complain of that nobody listens to them that they're making it up, but most likely it's just that they didn't offer anything. In terms of penile rehab or penile stretching, is there something unto it?

[Dr. Jonathan Clavell]
When it comes to penile rehabilitation, it depends. Men with good erections and a penis that is losing size, I try to recommend them to use traction therapy with or without the injection therapy, men with poor or weak erections who is also losing size, maybe a combination of the vacuum therapy to help stretch the corporeal tissue along with the tunical tissue so it really depends. If they don't have good erections, I try to get them on the vacuum therapy as soon as possible. If they have good erections, I try to get them in with traction therapy. Usually, the one that I use the most is the RestoreX device.

[Dr. Jose Silva]
Okay. You point them towards the website and have them order?

[Dr. Jonathan Clavell]
We have brochures in our office and I explain to them how it works. I have the actual device in my office. I don't wear it myself and show them but I give them an idea of how it works. The RestoreX instructions that come in with the kit, it's actually pretty self-explanatory and patients are able to follow it. The good thing about this RestoreX device is that as opposed to other traction therapies that were required to be used for many hours, the good thing about the RestoreX device is that most of the time, you can use it within an hour and start noticing some results. That's the pretty cool thing about the RestoreX device. It looks archaic, but in my experience, some patients, they do respond to it.

[Dr. Jose Silva]
Do you recommend it for something else for patients that want the penis to look bigger?

[Dr. Jonathan Clavell]
I've never offered that offer it to them. Again, if they want to mess with it, by all means, it's $500 online, so you can probably get that.

[Dr. Jose Silva]
I had a patient, 20, 22-year-old guy, something like that, he was using a stretching device and then he stretched too much and then he was numb. The penis went numb. He wasn't having any erections. I started him on Cialis daily. At some point, he started working again.

[Dr. Jonathan Clavell]
It's scary. I've had those patients as well. I've had some patients that when they're pulling too hard on their penis, it can damage their nerves. It's minimal. I've also had some guys who their penis retracts a lot and by them doing regular traction, they become from growers, they become shoulders now. Again, you see a little bit of everything. I don't recommend it for that, but if you want to try it.

[Dr. Jose Silva]
People use it.

[Dr. Jonathan Clavell]
I know. People will use it

(4) XIAFLEX Utilization and Treatment Recommendation

[Dr. Jose Silva]
Let's talk about the XIAFLEX and other injections. When do you use them? When you start using them? At what point during the stage of the Peyronie's you use them?

[Dr. Jonathan Clavell]
The limiting factor for using XIAFLEX within the acute phase, there's actually been studies comparing acute phase, using XIAFLEX, acute versus stable. They actually respond during the acute phase but the limiting factor is the insurance company. Insurance companies will find whatever excuse to not approve this medication. I mean this medication is a little bit expensive, at least for a patient who's paying out of pocket. When it comes to offering these injections, I truly believe they can work.

However, when it comes to choosing which treatment to offer, the most important thing to remember is this. As I tell them, I start off to every patient, I tell this sentence, "We only treat Peyronie's depending on two things. Your degree of bother and the degree of erectile function." I will repeat that. Degree of bother, not the degree of curvature, but degree of bother and the degree of erectile function. A man who has good erections and is not bothered, we leave alone.

For example, I've had guys who have almost 60-degree ventral curvature and they call me and we've had even virtual visits and they're like, "Hey, doc, I'm not sure, this started happening." I asked, "Are you able to have sex?" "Yes." "Does your wife complain?" "No." "Do you complain?" "Well, I just want to make sure that, I'm not going to develop cancer or something like that." Then I asked him, "Does it bother you?" "No." "Well, just leave it alone if you're able to have sex." He's like, "Oh, well, great, doc, that's what I want to know."

Sometimes you will have a guy who has a 30-degree curvature or sometimes even a 20-degree curvature and you're like, "I think my penis might curve more than yours." He wants it fixed. Again, it all depends on the degree of erectile function and also the degree of bother, not the degree of curvature. That's the most important thing. Then depending on those two things, I start offering treatments. Then the other things that we have to take into consideration is, for example, is the plaque calcified? Does the patient have hourglass deformity? Do they only have a curvature? Do they also have erectile dysfunction? Do they have an unstable penis? Are they in a hurry to fix it? Do they want to be functionally straight or they want to be straight like an arrow? Those are the things that we really need to take into consideration and make sure that we address those questions. Because again, these treatments are not for life or death. We're talking about quality of life. When it comes to a penis, a man who wants their penis to look good, right? We want to make sure that one we set up proper expectations.

Number two, we offer them something to meet those expectations, if we're able to get there. The only injectable therapy right now that I currently use is XIAFLEX. I offer it to patients with a curvature and a plaque that is not calcified, and have good erectile function. There is some data for the use of interferon and verapamil. The only one that I'm using at the moment is XIAFLEX. Again, I use it for those with good erection and a curvature. If they have ED that is not responding to pills, they need an implant.

Then the other thing is regarding calcified, versus noncalcified, a plaque that is calcified in my opinion is unlikely to respond to the medication. Why? Whenever we inject XIAFLEX, we need to inject the scar, not around the scar. The XIAFLEX injection that is injected, we're usually using an insulin needle, which is very unlikely to go into a calcified scar. Whoever's injecting, we should be able to, first of all, identify and feel the plaque, he or she who's injecting, we should probably be struggling when we're injecting.

I tell guys, "If I go in and goes like whoop," super quick, is very unlikely that I injected at the right spot. I try to emphasize this whenever I do trainings for-- I'm a speaker for XIAFLEX. For example, I tell that to practitioners, and the providers who are using these injects, what we need to make sure that we struggle, otherwise, we're not really injecting in the right spot.

[Dr. Jose Silva]
Jonathan, in terms of that calcified plaque, is it based on ultrasound, or just on palpation?

[Dr. Jonathan Clavell]
Most of the time, it's with ultrasound. However, there will be some guys that as soon as you start pulling on that penis and you touch it, you know that's like a rock. For those, I tell, "Hey, man, XIAFLEX is really not going work for you." Again, the other thing that I wanted to mention, now that we're talking about XIAFLEX, is that we need to remember what the research shows. XIAFLEX injections in the pivotal studies, which were the IMPRESS Trials that showed 30% improvement in degree of curvature.

If you have a patient who has a 60- degree curvature, expect to get down to about 45 degrees, 30% improvement. If you have a patient who has a 90-degree curvature, you have to explain to the patient, "Don't expect your penis to be spread like an arrow." Most of the time, the XIAFLEX alone might not do the job, but it can be done with penile traction. To be honest, I am not a huge believer in XIAFLEX alone, I am not a big believer in traction therapy alone, but both together, I've seen men go from an almost 90-degree curvature to almost 30-degree curvature, which many men consider it to be functional.

Again, if there's anybody, any urologist listening to me, when it comes to XIAFLEX injections, we need to make sure that these patients are doing their rehab at home. The XIAFLEX will only soften that scar tissue, but the real homework needs to be done by the patient. They are the ones who has to be doing those regular exercises at home. The good thing about this RestoreX device, and again, just in case I have no stock in RestoreX. Again, it is a device that can actually help men. There's been good research showing that sometimes it can be more than 50% improvement when you combine both RestoreX with the XIAFLEX injection.

(5) Additional Patient Factors Indicating Treatment

[Dr. Jose Silva]
Good, Jonathan. Also, a question, you mentioned the partner. If the patient doesn't have any discomfort, but the partner is the one having the discomfort, you treat it as if he was having a discomfort in that sense, you will correct the deformity?

[Dr. Jonathan Clavell]
It depends on both. Just like with a patient who has erectile dysfunction, try to bring in the partner, because again, just like you're saying, this is something that affects both. If the partner is complaining of discomfort, and it is truly because of the curvature, then you can consider treatment. I've also had couples coming in, and the partner is saying, "Yes, his penis is curving, and that's what's causing pain." Then you induce an erection in the office, and they really don't have a curvature, or he could have a 10-degree curvature. I'm sorry, anybody who's listening to me, a 10-degree curvature is very, very, very unlikely to cause any problems. Most penises curve. I always, whenever I speak for XIAFLEX, one of the things I tell the audience is, that it's like, "Hey, I'm pretty sure one or two of us here in the audience have some degree of curvature, and we're still able to be functional." Again, it's all a matter of discomfort, either for the patient or for the partner. Again, we really have to make sure that we are setting proper expectations because sometimes you might get a partner who just doesn't want to have sex with the patient and they're using that as an excuse.

[Dr. Jose Silva]
Also, you mentioned that the patient also doesn't have any issues in terms of pain or anything, have good erections, but if they want something more, to look better for aesthetic purposes, is that someone you will correct, if it's just purely aesthetic?

[Dr. Jonathan Clavell]
Yes, it depends. I don't see that as much for Peyronie's, I see that more for patients who have congenital curvatures. Sometimes they can be-- They're very self-conscious about their penis and they want to correct it, then we can try to correct it. If it's congenital curvature, there is no scar tissue. Of course, I'm not going to offer them XIAFLEX injections. I've had patients who come in with a penile fracture because somebody injected XIAFLEX on a non-scar tissue, and then they end up breaking the tunica. Patients who want corrections for their deformities, if there's something that we can do about it, I will offer it to them.

[Dr. Jose Silva]
In terms of XIAFLEX only for angulation, if he has an hourglass deformity, do you still use XIAFLEX in those cases?

[Dr. Jonathan Clavell]
It depends. If they have mild hourglass deformity, I still explained to them that it is very unlikely that they will see any correction on the hourglass deformity. If their main complaint is a curvature, I would offer them the XIAFLEX injection.

[Dr. Jose Silva]
Based not on the plaque, but mainly in the angulation.

[Dr. Jonathan Clavell]
Yes, mainly on the angulation and patient, whatever is bothering the patient. Again, sometimes you can do XIAFLEX injections and then you can do extra-tunical grafting for the hourglass, if they have a good strong erection. Sometimes you can combine XIAFLEX injection to correct the angulation and then you can use even a sub-dermal filler. Sometimes those fillers can help give some uniformity and girth to that wasting area. Again, it all depends on the degree of bother and the degree of erectile function.

[Dr. Jose Silva]
You're doing fillers also?

[Dr. Jonathan Clavell]
I'm going to start doing them next month. I still haven't done it, I just going to start doing it soon. I was not a believer until I saw a clinic that was doing a really good job with them. They have a pretty cool protocol. When I saw it and I felt it, I even went to the clinic with my wife. She's a dermatologist, she knows a lot more about fillers than I do. We were there and it looked legit. There was no way I could tell that there was anything there. We're going to start offering to men soon.

(6) Indications for Surgical Management

[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."

[Dr. Jose Silva]
The patient that you mentioned that has a good erection up to the mid-shaft and then soft, what do you do with that patient?

[Dr. Jonathan Clavell]
For those are a little bit complex. I've only seen it maybe about three or four times. All patients they presented wanting an implant. They've already seen other urologist, some of them have had already XIAFLEX injections. I'm not sure what they were doing it for because these are guys who do not have curvature, they just have severe narrowing across a distal shaft. They will tell you, "Doc, past the midway of my penis, my penis is completely unstable, and I'm not able to penetrate."

For those, I tend to offer penile implants. Again, it's a very complex option, or a little bit of an invasive option. Most of the time, these can be your happiest patients because, again, this is from somebody who cannot penetrate at all, and now he's able to penetrate. However, if you have a guy who has good, stable-- They have stability in their erections, but they have this more or less the same thing, and they have narrowing, but the distal penis is still strong enough for them to be able to penetrate. For them, we can offer either filler injections.

I haven't done it yet, but it's something that I will probably consider doing because, again, it's non-surgical, and the goal is to make the penis cosmetically better, it's a cosmetic procedure and you can offer that to them. The other thing that you can do is a procedure called extra-tunical grafting which is a very easy surgery in which you have to use have to dissect the Dartos and just right underneath the Dartos, you can place a graft. Most of time, we used cadaveric pericardium to the plaque and you can use that mostly on the size of the penis and it will give some uniformity to the penis. I wish I could show you pictures. I'm probably going to bombard your cell phone tonight with a bunch of penis picture.

(7) Surgical Treatment Options and Considerations

[Dr. Jose Silva]
We'll go ahead and put them on our website. Talk to us about what surgical options patients have with Peyronie's.

[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, 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. At the end of the day, in order to keep your patient happy, which again is the main goal, they need to be at peace with that specific 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.

If you have a guy that their main concern is like, "Doc, my penis is definitely getting smaller and I cannot spare anymore," then we have to take that into consideration. 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." Again, we have to take into consideration. Are we incising the plaque or are we excising the plaque? 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? Does the patient know the risk, again, of graft contraction, sub-graft hematoma? I've had guys who develop a small hematoma right underneath the graft that we have to be pulling out blood from. Recurrence of the curvature. We have to really discuss these things to patients and you've asked, like, "Hey, are you willing to take that risk?"

Because some men will tell you, he's like, "Doc, that seems a little bit complicated," or sometimes the partner, their wife is there in the room and they're like, "Doc--" He's not going to pay attention to that. I was the one who pulled him over to the office. He's definitely not going to be doing that at home. We have to take those things into consideration. When it comes to a penile implant, how bad is there ED? Were you able to induce an erection to fully assess how bad that curvature is? I have guys-- now, I get many men who travel from outside of Houston and they travel for these specific surgeries.

Just today, we were scheduling a guy who's coming in from Colorado. The guy is like, "Yes, I have 45-degree curvature." When he sends me a picture, it's like a 50% erection. It's very likely that when you induce a full erection, that curvature is going to get a little bit worse. Whenever that guy comes in, he also needs an implant but I posted him for a penile implant, possible plication, possible plaque incision grafting, possible extra-tunical grafting, possible everything. We have to be ready for all these things.

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.

Now, fortunately, I've seen it all when it comes to these surgeries, so now I'm the one taking care of all these really, really complex cases. It's just a matter of what you feel comfortable doing as well. Don't get yourself into a pickle. Damaging a guy's penis can be extremely detrimental. I will never forget when I was in training, I met a resident from Brazil. He was telling me like, "I will never do a Peyronie's case in my life." I'm like, "Why not? I mean, this is a pretty cool surgery." He's like, "Because in Brazil, those urologist get shot."

[Dr. Jose Silva]
Very important, very important.

(8) The Plaque Incision Approach

[Dr. Jonathan Clavell]
Again, it's very important that we remember these things. Again, I offer all surgical procedures. Just today, Jose, just today, I did two complex Peyronie's cases. One of them was a 90-degree dorsal curvature with a penile implant. I do a slightly different way of incisions. I presented my abstract of almost 35 patients two years ago at the SMSNA. Actually, a year ago in the SMSNA but I still am working on writing the article about it. Check this out. Most of time, whenever we do these plaque incisions for men, we incise-- everybody was taught to make the incision right at the point of maximal curvature.

The reason I don't do that is because whenever-- I'm not sure if you can see me in the screen but I cut through the point of maximal curvature. Whenever I do that, there's going to expand the tissues a lot. Then you have to place this huge old graft in order for you to correct the curvature. What I do is instead of putting one incision across the point of maximal curvature, I actually go around the point of maximal curvature. I put in one incision below, one incision above, and sometimes I would add one depending on how much the penis allows me to do.

I do one incision above or one incision below each of the other two incisions. Most men get about three or four incision. For example,we did this for a guy who had severe calcified plaque, hourglass deformity, unstable penis with erectile dysfunction. The guy's young and we were able to correct this deformity. I'm hoping that the guy does very well.

The other surgery was the guy who also had severe vascular path, smoker, diabetic. We did implant with a plication. Because without when I didn't want to risk him having problems with his penis so I didn’t elevate his neurovascular bundle. I just wanted to correct the curvature as much as I could the easiest way possible. I did a plication, corrected the curvature, and then we just got it an implant. Again, this is something that we do on a regular basis and it's fun. For me, it's fun.

[Dr. Jose Silva]
For this first patient, the one you did the incision. You did a multiple incision then you put a patch all over?

[Dr. Jonathan Clavell]
Depends. Most of the time, given that I'm making smaller slits, this is a modification of a technique that was popularized by Paulo Egydio. He's a Brazilian urologist. We were talking about Brazil earlier. He still hasn't got shot. Anyway, he had some variations of a very unpopular technique called the sliding technique. I'm not sure if you've heard about this procedure. The sliding technique is basically a procedure in which you incise a penis longitudinally.

[Dr. Jose Silva]
I have seen the patients, yes.

[Dr. Jonathan Clavell]
You kind of like extend the penis. We published a series of about seven patients when I was in fellowship. Patients tend to do well but it's a risky procedure. You're stretching out that neurovascular bundle, you're stretching out that skin. Sometimes that can devascularize the glands. Fortunately, for us, we've never seen that in any of our patients undergoing those complex procedures. I have seen glands ischemia before. Fortunately, it was superficial and the patient didn't lose his penis and the patient didn't even lose his implants.

I'm actually presenting that under the Puerto Rico Urology Association this next week. Yes, I want to see everybody's faces when I post those pictures. Going back to your question. Paulo Egydio, he started doing modifications to this. One of them being that he called the MUST. The Multiple Slits Technique or the modified sliding. The MUST is just making a bunch of different incisions across a dorsal part of the penis for a dorsal curvature. Well, what I did was I modified that. I didn't want to make so many incisions. What I did was I just wanted to focus around the point of maximal curvature that will create very small slits. Most the time, those openings are about one centimeter or one and a half centimeters. In theory, you don't even have to graft those. Sometimes I will only graft them if I see that the implant is exposed. If the implant exposed, I will graft them. Most of the time, whenever I start doing these, I don't have to place a graft that I have to sow, I use TachoSil or Evarrest, which is just a hemostatic patch that some say that it could help regenerate the tissues of the tunica.

There's actually an abstract that will be presented next week, not from us, but I saw it in the program for the SMSNA coming in the next week and they did TachoSil on rats. They showed that there wasn't any regeneration of the tunical tissue. Sometimes it can help trap the blood. Believe it or not. Jose, again, have you ever heard about the TachoSil?

[Dr. Jose Silva]
Yes, I've seen it.

(9) TachoSil and Penile Implant Technique

(10) Post Operative Recovery & Pain Management

[Dr. Jose Silva]
Jonathan, in terms of post-op pain management, what do you do in terms of meds?

[Dr. Jonathan Clavell]
One of the things that I do is at the beginning of every surgery, I induce a dorsal penile block and also I do a ring block with a combination of Exparel and either Marcaine or ropivacaine, and depending on what is available. I also induce an erection with a diluted form of the same solution. Again, I stick a needle at the beginning of the surgery and I will fill it up with a combination of Exparel and Marcaine. Most of the time, believe it or not, this keeps the patients pain-free for the first two or three days. It is wonderful to see patients when they wake up and they do not complain about pain at all.

Post-op, I don't use any narcotics, I use a combination of Tylenol and I also combined it with gabapentin and Ketorolac. My pain regimen is I tell patients, I give gabapentin 300 milligrams twice a day. Again, these guys specifically when you're elevating the neurovascular bundle, they're going to complain of neuropathic pain, like shooting pains or severe burning all of a sudden. The gabapentin can help with those. I give them that for 30 days. I also give them, and then I tell them to alternate Tylenol with Ketorolac. With Ketorolac, I usually give them about 20 pills just to protect the kidneys.

I don't want them to go to kidney failure with it. If they run out of that, they can just take ibuprofen. Most of the time, believe it or not, that can keep their pain controlled and they do well. It's very, very rare that I prescribe narcotics to these patients. Also, for guys who do not have implants, you either did plication surgery or a grafting procedure. I explained that the nights will be tougher than during the day. Why? They're going to have those nocturnal erections. Sometimes they're like, "Doc, can you give me something to prevent these?"

What I told them is like, "Man, it's like just lift your hands up to God and say thank you. You're not going to have your erectile dysfunction." Then the other thing as I discussed before is I always prescribe daily tadalafil to all my Peyronie's disease cases. Again, I mean there are some research studies that demonstrate that it can actually have some anti-inflammatory properties and it can help speed up the healing. Most importantly, it also keeps bringing blood flow to the cavernous tissue and it also brings blood flow to the glance during the recovery.

Again, that's something that we always have to be paying attention to. The one thing that you don't want is these guys to show up with a black penis.

[Dr. Jose Silva]
I guess the final question or what they always want to know, when can they try it?

[Dr. Jonathan Clavell]
It depends. Most of the time, I tell them to follow up at six weeks with me, no sexual activity of any kind during those six weeks. Whenever we talk about sex, again, they're all thinking about penetration, especially if they have an implant and I did a complex Peyronie's case, I tell them like, "Hold up for the six weeks." My motto is six weeks of abstinence, lifetime of happiness. I tell them that, and no sexual activity of any kind. You don't want them to be penetrating anally. You don't want them to be penetrating or even like masturbating.

Again, you want those stitches to heal. Well, sometimes they don't. Patients do whatever they want and they start having sex at four or five weeks but I tried to discourage them about that.

[Dr. Jose Silva]
Six weeks.

[Dr. Jonathan Clavell]
Yes, six weeks.

[Dr. Jose Silva]
Yes, and it doesn't matter. Let's say if it was just a simple plication, still six weeks?

[Dr. Jonathan Clavell]
If it was a simple plication, as soon as that incision heals up, you can go ahead and do it.

[Dr. Jose Silva]
Jonathan, anything else we missed? You can continue talking about this for hours, but anything else important to those people listening to us?

[Dr. Jonathan Clavell]
The important thing is again, whenever we talk about Peyronie's disease, we discussed before, first of all, listen to the patient, listen to their complaints. Remember, again, these guys now they're coming out of the cave because, fortunately, we finally have a commercial, the famous carrot commercial from XIAFLEX. We finally have something that's putting the word out there. You can listen to it on Siri's exam or the radio. The carrot commercials start coming up and it's pretty cool because, again, now these guys are finding, they're looking at these commercials, they're like, "You know what? I have that. Let me actually seek some help." I believe that the incidence is actually, and the prevalence of Peyronie's is actually a lot more common than what we think. Again, just listen to these guys, and if you don't feel equipped to treat them, at least guide them. Again, in the United States, there's multiple experts across the entire United States, and doctors that feel very comfortable treating these conditions. The important thing is that we at least are able to guide these guys. I know we talk about the Tiger Makers, but one of my other social media mottos is, gatekeepers of men.

As urologists, we are the gatekeepers of men. We are the ones who should be able to help these guys because if they show up to your office for a complaint of penile curvature, and you just blow them off, it's like, "Oh, I don't know what to do." It's like, "There's nothing we can do about that." Then they're just going to go back to their cave. Again, we can guide them to seek an expert, and that way, they can actually get the treatment that they deserve.

[Dr. Jose Silva]
Jonathan, as a urologist, if I want to refer you a case, a patient, how do we go about that?

[Dr. Jonathan Clavell]
I get many patients who travel from all over the US most of the time. Most doctors, if you have my cell phone, you can just text me. I have even from big institutions that they refer me patients. I talk a lot with Dr. Ziegelmann and Dr. Bajic, who are in Cleveland Clinic and Mayo Clinic. They're really good friends, Peyronie's experts so shout out to them. Thank you for helping with the AUA Core Curriculum, and also Dr. Bernie.

For, Matt Ziegelmann, we text each other all the time, and sometimes he's like, "Hey, man, I have this guy who wants to consider a length restoration procedure that I do not offer. Can I send him to you?" I tell him, "Yes, just send me the patient's name and phone number, we'll give them a call." If you don't have my cell phone number, and you want to send me patients, I have Facebook page, I have a website, I have Instagram, I have Twitter. You can direct message me, and I'll be more than happy to once share my information with you.

Just don't share it with the patient. I'm more than happy to at least let you know who you can go to because, again, I know many experts across the US. Probably I'm too far for the patient, but again, there are experts across the entire United States that might be closer to your patient.

[Dr. Jose Silva]
Jonathan, thank you. Thanks again for being part of BackTable. Definitely, congratulations with all your success, and you're going to continue getting bigger.

[Dr. Jonathan Clavell]
No pun intended.

[Dr. Jose Silva]
Exactly.

[Dr. Jonathan Clavell]
Anyway, thank you, Jose. Thank you to the BackTable, all of your team. Again, it's always an honor to be here. You guys are doing great things, the podcast that I've been listening to, they're all have been very helpful. Again, continue doing what you're doing, and I'll be more than happy to come back to discuss any other topics that you guys want to discuss.

[Dr. Jose Silva]
Let's do that.

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). (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.