Partial Plaque Excision Research Articles

Collagen fleece grafting for surgical treatment of patients with mild to severe peyronie's curvatures.

Collagen fleece grafting (CFG) is the recommended treatment for severe Peyronie's disease (PD) curvature (> 60°), but its efficacy in mild/moderate curvatures remains uncertain. This study evaluated CFG in patients with mild/moderate curvatures (< 60°) at risk of penile shortening or symptomatic plaque. A retrospective review was conducted on patients who underwent surgical treatment for PD using plaque incision or partial plaque excision and CFG. Clinical parameters and complications were reviewed. Subgroup analysis was performed on patients with curvatures of > 60° and curvatures ≤ 60°. 89 patients with a median age of 59years and a median curvature of 70 (20-90)° were identified. Dorsal curvature was predominant in 66% of cases, followed by lateral (16%), ventral (8%), and complex curvatures (10%). Partial plaque excision was performed in 98% of patients, with an average grafting area of 2.1cm2; 71% had a singular penile plaque, while 29% presented two or more plaques. The comparison between patients with curvatures ≤ 60° and > 60° revealed no significant differences in mean operation time (86.3 vs. 94.4min, p = 0.13) or in the incidence of postoperative complications, including glans necrosis, hypoesthesia, ecchymosis, bleeding, hematoma, infection, residual curvature, revision surgery, or pain. Early postoperative outcomes and complication rates following plaque incision or partial plaque excision and grafting with CFG were comparable in patients with mild/moderate and severe PD deformities. The technique may be a viable option with a similar risk profile for achieving penile straightening in selected PD cases, particularly when plication is not feasible.

Current concepts of Peyronie’s disease (clinical lecture)

The article is presented in the format of a lecture. Peyronie’s disease (induratio penis plastica) is a progressive fibrotic disorder of the penile tunica albuginea that results in fibrotic penile plaques and can cause penile deformity. The issues of etiology, pathogenesis, clinical picture and diagnosis of Peyronie’s disease (PD) are reviewed in the lecture from the modern points of view. PD is frequently associated with penile pain, erectile dysfunction, and a secondary anxiety-depressive state. Despite the existence of this problem for several centuries, no unified concept of the Peyronie’s disease pathogenesis can be found in literature. A growing amount of research has shown that PD is a chronical disorder of local wound healing process within the tunica albuginea and the Smith’s space. Over the past 40 years, multiple lines of evidence have pointed to a genetic factor that predisposes some men to the development of Peyronie’s disease. Treating men with PD remains a challenging problem for clinicians working in urology. Given the high prevalence of PD and its significant impact on affected men, its better understanding is essential. Treatment methods for PD are varied and include oral, local, intralesional and traction therapy, and surgical treatment. Current clinical care standards for PD are aimed at the symptom suppression, as there are currently no treatment for PD that can eliminate its causes or progression. Clostridium histolyticum collagenase has shown its effectiveness in treating PD, but its efficacy and safety remain controversial. Surgery remains the most effective method for PD treatment and is considered to be “gold standard”. The choice of the surgical technique depends on the length of the penis, degree of deformity, erectile function, patients’ expectations and surgeon’s preferences. Various surgical techniques and grafting materials (autologous and non-autologous) can be used for the coverage of the tunica albuginea defect after partial plaque excision or incision.

Intraoperative glanspexy during complex repair of Peyronie’s disease

Abstract Background Men undergoing surgical correction of Peyronie’s disease (PD) have had intraoperative identification of a glans tilt or floppy glans not recognized preoperatively. Aim To describe the outcomes of a novel modified glanspexy performed on a large cohort of men with PD who also underwent a partial plaque excision or incision and grafting, tunica albuginea plication, or inflatable penile prosthesis (IPP) with straightening maneuvers. Methods A retrospective analysis (2016-2021) was performed on all patients who presented to a single surgeon with PD and were treated with a surgical procedure that included a glanspexy. Patients were tracked longitudinally, and interventions and outcomes were collected. All glanspexies were performed with the same surgical technique, where the glans was secured over the tips of the corpora cavernosa with several 4-0 Monocryl sutures between the glans and the tunica albuginea contralateral to the tilt through a subcoronal incision. Outcomes Our novel modified glanspexy technique resulted in excellent postoperative results with a high rate of durable repair. Results A total of 88 glanspexies were performed during surgery for PD with a median follow-up of 9 months (range, 1-77). All patients underwent a glanspexy plus partial plaque excision or incision and grafting (34.1%), tunica albuginea plication (10.2%), or an IPP with straightening maneuvers (55.7%). The most common direction of the glans tilt was dorsal (78.8%). Glanspexies were successful in 97.3% of patients, as only 2 (2.7%) had recurrent glans deformity &amp;gt;20° during the follow-up period. Our glanspexy technique repaired the glans deformity without compromising sensitivity or sexual function. Sensory complaints were noted in 1 patient (1.1%), who complained of hypoesthesia of the glans; however, there was no adverse effect on orgasm or ejaculation. A repeat glanspexy for recurrent glans deformity was performed on 1 patient (1.1%). Clinical Implications While most literature focuses on glanspexy after IPP placement, our article provides evidence for use of our glanspexy technique to repair glans hypermobility in patients with PD. Strengths and Limitations Our data are strengthened by the relatively large sample population and consistent outcomes regardless of straightening maneuver used. Conclusions regarding glanspexy and long-term satisfaction are limited by the lack of a validated questionnaire to illicit satisfaction during the postoperative period. Conclusion Glanspexy with 4-0 Monocryl suture on a TF needle appears to be a safe, easy, minimally invasive, and effective technique for the treatment of a glans tilt or floppy glans identified during the surgical management of PD.

Outcomes of surgical correction of Peyronie's disease with plaque excision and grafting: Comparison of testicular tunica vaginalis graft versus bovine pericardium graft

ObjectivePeyronie's disease (PD) is an abnormal wound healing in the penile tunica albuginea. After fibrotic plaque excision, different graft materials have been used to repair the defects, but the optimal graft remains unknown. This study aimed to compare the functional outcomes of testicular tunica vaginalis grafts and bovine pericardium grafts in patients with severe PD. MethodsA retrospective comparative study was conducted on 33 PD patients undergoing partial plaque excision and grafting from September 2015 to May 2021. The patients were divided into two groups depending on the type of graft used. For 15 patients in Group B, testicular tunica vaginalis grafts were used to repair the defect, while for 18 patients in Group A, bovine pericardium grafts were used. Data of the patient's age, comorbidities, sexual function, penile curvature, postoperative complications, need for further treatment, change in penile length, and satisfaction were gathered and compared between the groups. Sexual function was evaluated using the 5-item version of the International Index of Erectile Function (IIEF-5), and a functional less than 20-degree penile curvature after surgery was considered a successful intervention. ResultsThere was no difference in age, comorbidities, degree of curvature, perioperative IIEF-5, operative time, plaque size, or complication rates. After surgery, a statistically significant improvement in curvature degree (p<0.05) and satisfactory penile appearance (p<0.05) were seen in both groups without any superiority between the two groups (p=0.423 and p=0.840, respectively). With a 30-month follow-up, the IIEF-5 was consistent in both groups, with no statistical significance between the groups (p=0.492). The main change in penile length during the operation was increased and still positive in the last follow-up in both groups without statistical significance (p=0.255 and p=0.101, respectively). ConclusionPartial plaque excision and corporoplasty with both testicular tunica vaginalis or bovine pericardium grafts are equally effective in treating males with clinically significant PD.

(487) Long-term Outcomes Following Partial Plaque Excision and Grafting (PEG) for Peyronie’s Disease and Subanalysis of Patients Who Undergo PEG Despite Pre-operative Counseling Against PEG

Abstract Introduction Peyronie’s Disease (PD) is a debilitating condition characterized by progressive scarring of the tunica albuginea. The resulting deformities are often emotionally devastating to patients, and include erectile dysfunction, painful erections, penile curvature, indentation, hourglass, and hinge deformities. According to previously published surgical algorithm for PD in 1997, partial plaque excision and grafting (PEG) is recommended for patients with &amp;gt;60 degree curvature +/− hinge and strong pre-operative erections while placement of an inflatable penile prosthesis (IPP) is recommended when rigidity is sub-optimal.* Nevertheless, many patients counseled to undergo an IPP refuse and insist on proceeding with PEG due to personal preference. We hypothesize that men counseled to undergo IPP but choose to undergo PEG will report lower satisfaction rates and reduced ability to engage in sexual intercourse post-operatively. Objective Our objective was to evaluate and compare long-term patient-reported outcomes in men who underwent PEG at a single institution between 2007 and 2021. Methods A retrospective chart review was conducted from 2007 to 2021 on PEG surgeries performed at a single, tertiary-care institution in patients ≥18 years old who had &amp;gt;3 months of follow up. Results 251 patients underwent PEG with a mean follow up was 35.5 months. 54 patients (22%) were initially advised to undergo IPP but elected for PEG. Of these 54 patients, 17 (32%) had pre-operative 9-10 subjective erectile rigidity, relative to 110 of 197 (56%) patients who were initially counseled to undergo PEG (p=0.002). On duplex penile ultrasound, patients counseled to undergo IPP had a mean objective erectile rigidity of 7.8, compared to a mean objective rigidity of 8.6 in patients initially counseled to undergo PEG (p 15 units for pre-operative duplex ultrasound evaluation were less likely to be able to engage in post-operative intercourse following PEG surgery (48.6%) relative to those who needed &amp;lt;15 units (71.1%) (p=0.02). Conclusions Patients who were initially counseled to undergo IPP due to sub-optimal erectile rigidity but elected for PEG procedure had worse post-operative ability to engage in penetrative intercourse. Significantly more of these patients also eventually underwent IPP. Pre-operative trimix dosing &amp;lt;15U is a predictor of post-operative erectile function as it may be reflective of better pre-operative erectile quality. Subjective and objective measures of erectile function appear to be critical predictors of post-operative erectile function in patients who had underwent PEG, confirming the previously published 1997 algorithm on the surgical management of PD.* *J Urol 1997; 158: 2149-52. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific (Consultant)

(483) Predictors of Hinge Effect in Patients with Peyronie’s Disease

Abstract Introduction Patients with Peyronie’s disease (PD) suffer from a variety of penile deformities including curvature, indentation, hourglass, penile shortening, as well as erectile dysfunction. The presence of a hinge effect can be appreciated at time of penile duplex evaluation as buckling or folding of the shaft when axial pressure is placed on the glans. Patients with hinge effect can experience bothersome buckling of the erection and instability during penetrative sex. The actual characteristics that cause this hinge effect and its clinical implications are not fully understood. Objective We aim to determine the PD factors that cause hinge effect. Furthermore, we seek to assess the role of hinge effect on subsequent surgical intervention. Methods Retrospective chart review was conducted on 1483 patients presenting with PD from 2016 to 2021. 1223 patients who had a complete penile duplex evaluation and hinge assessment were included for analysis. Baseline demographics, penile duplex assessment, and clinical outcomes were recorded. Univariate and multivariate analyses were performed to assess for predictors of hinge effect. Results Hinge effect was observed at the time of penile duplex evaluation in 33% of PD patients. The degree of indentation (1.82 OR, p &amp;lt; 0.001), rigidity of erections (0.82 OR, p=0.002), and degree of primary curvature (1.03 OR, p &amp;lt; 0.001) predicted presence of hinge effect. Furthermore, hinge effect greatly affected the type of surgical intervention required to correct PD deformity. Patients with presence of hinge effect were more likely to require plaque incision/excision and grafting as opposed to tunica albuginea plication in PD patients with good quality erections. When controlling for erectile rigidity, patients who underwent partial plaque excision and grafting were more likely to have hinge when measured girth discrepancy was &amp;gt;1 cm (p &amp;lt; 0.001). In patients requiring penile prosthesis, incision and grafting was more commonly required when hinge effect was present. Conclusions The presence of hinge effect can be extremely bothersome and cause instability of erections during penetrative sex. Multiple factors may predispose to a hinge effect, including quality of erection, severity of curvature. But when controlling for rigidity, a girth discrepancy of &amp;gt;1 cm did appear to pre-dispose to a hinge. Additionally, assessment of hinge effect pre-operatively was important in terms of determining the optimal surgical intervention to correct PD deformities. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific

(139) Intraoperative Glanspexy During Complex Repair of Peyronie’s Disease

Abstract Introduction Peyronie’s disease (PD) is a disorder marked by the formation of a fibrous plaque in the tunica albuginea often causing a penile deformity. Surgical correction remains the gold standard of treatment for PD. The choice of procedure depends on various factors including erectile function, degree of penile curvature, hinge effect, and patient preference. We have found that men undergoing surgical correction of PD had intraoperative identification of a glans tilt or floppy glans, which was not recognized preoperatively. Objective Our aim was to analyze a large PD database to review the results after a glanspexy was performed in men undergoing partial plaque excision and grafting (PEG), tunica albuginea plication (TAP) or inflatable penile prosthesis (IPP) with straightening maneuvers. Methods A retrospective analysis was performed on all patients who presented with PD and were subsequently treated with a surgical procedure that included a glanspexy from 2016-2021. Demographics, comorbidities, erectile function (ED), PD characteristics, physical exam, penile duplex ultrasound findings, and surgical outcomes were obtained. Patients were tracked longitudinally, and subsequent interventions and outcomes were collected. All glanspexies were performed using the same surgical technique, where the glans was secured over the tips of the corpora cavernosa using several 4-0 Monocryl sutures between the glans and the tunica albuginea contralateral to the tilt through a subcoronal incision. Results A total of 97 glanspexies were performed in conjunction with an operation for PD. IPP with glanspexy (49.5%) was the most common procedure performed followed by PEG with glanspexy (36.1%) and TAP with glanspexy (14.4%). Post-operatively, there were no patient complaints or physician identification of irregularities pertaining to glans position or sensitivity. 6 patients required a reoperation after their initial PD procedure, however, none of the indications were related to the glanspexy portion of the procedure. There was one patient who sustained partial glans necrosis following complex reconstruction including extensive plaque incision with grafting, IPP and glanspexy. Conclusions Glanspexy using 4-0 Monocryl suture on a TF needle appears to be a safe, easy and effective technique for the treatment of a glans tilt or floppy glans identified during the surgical management of PD. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

MP36-09 EXPERIENCE WITH EXTRATUNICAL GRAFTING (ETG) FOR CORRECTION OF INDENTATION DEFORMITY WITHOUT BUCKLING IN MEN WITH PEYRONIE’S DISEASE

You have accessJournal of UrologyCME1 Apr 2023MP36-09 EXPERIENCE WITH EXTRATUNICAL GRAFTING (ETG) FOR CORRECTION OF INDENTATION DEFORMITY WITHOUT BUCKLING IN MEN WITH PEYRONIE’S DISEASE Jose Quesada-Olarte, Spencer Mosack, Daniel Roadman, and Laurence Levine Jose Quesada-OlarteJose Quesada-Olarte More articles by this author , Spencer MosackSpencer Mosack More articles by this author , Daniel RoadmanDaniel Roadman More articles by this author , and Laurence LevineLaurence Levine More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003270.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Peyronie's Disease (PD) can be surgically challenging, especially in men with indentation deformity. Extratunical grafting (ETG) is a relatively new surgical option that be employed to treat corporal indentation in those without buckling or hinge effect. Objective: To report our experience with the ETG procedure, including different grafts or graft location (under or over Buck’s fascia) pre and post-operative patient characteristics, and patient satisfaction. METHODS: We performed a retrospective chart review of patients following ETG, collecting data including baseline demographics, prior treatments, pre-operative deformity, erectile function, type of graft, grafting location (under or over Buck’s), patient satisfaction, and clinical outcomes at our tertiary-care referral center. RESULTS: From December 2018 to July 2022, 33 patients presenting with PD underwent an ETG and TAP and/or PEG (partial plaque excision and grafting) for indentation deformity with a mean follow-up of 14.6 months. Overall, patient satisfaction, specifically for the correction of indentation was 94%. Grafting location under or over Buck's fascia showed no statistical difference in patient satisfaction with penile appearance (54.5% and 72.7%, respectively, p>=0.05). Patients undergoing ETG, with PEG had significantly lower satisfaction with their erect appearance than TAP and ETG (0% and 71.4%, respectively, p=0.003). Several different grafts were used, there was no difference in satisfaction between the grafts used. Palpable graft was reported in 30 patients (91%), but only two were bothered by the graft (6%). Statistical analysis showed no difference in patient satisfaction according to the size of the graft or degree of curve correction. CONCLUSIONS: ETG has emerged as a less invasive and less risky surgical option than PEG to correct indentation deformities which are not associated with buckling or axial instability. Our initial results demonstrate a high rate of satisfaction with correction of indentation, but multiple factors contributed to lower overall satisfaction with appearance of the penis including loss of length (9%), residual curvature (6%), sensory changes (9%), and erectile dysfunction (15.1%). Further studies are needed to determine the optimum approach. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e482 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jose Quesada-Olarte More articles by this author Spencer Mosack More articles by this author Daniel Roadman More articles by this author Laurence Levine More articles by this author Expand All Advertisement PDF downloadLoading ...

MP36-15 PERCEPTION AND REALITY OF POSTOPERATIVE PENILE LENGTH IN MEN UNDERGOING GRAFTING PROCEDURE FOR PEYRONIE’S DISEASE

You have accessJournal of UrologyCME1 Apr 2023MP36-15 PERCEPTION AND REALITY OF POSTOPERATIVE PENILE LENGTH IN MEN UNDERGOING GRAFTING PROCEDURE FOR PEYRONIE’S DISEASE William Langbo, Morgan Sturgis, Jose Quesada Olarte, and Laurence Levine William LangboWilliam Langbo More articles by this author , Morgan SturgisMorgan Sturgis More articles by this author , Jose Quesada OlarteJose Quesada Olarte More articles by this author , and Laurence LevineLaurence Levine More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003270.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Peyronie’s disease presents as penile deformity, oftentimes with curvature and shortening, secondary to scarring of the tunica albuginea. Surgical reconstruction using partial plaque excision and grafting (PEG) is recommended for men with excellent erectile function and severe curvature refractory to conservative management. PEG can correct penile curvature while preserving length, however subjective patient satisfaction rates are highly variable. Our study sought to explore perceived penile shortening in the pre- and post-operative period in one of the largest sample sizes to date. METHODS: A retrospective chart review and phone survey was conducted to analyze patients ≥18 years old who had >3 months of in-office follow up after PEG surgery at a single, tertiary-care institution from February 2007 - November 2022. Erect length was approximated by in-office measurement of flaccid stretched penile length (SPL). Data was collected to assess subjective and objective penile length, patient satisfaction, and other variables. RESULTS: A total of 137 patients met inclusion criteria. 76% of all patients reported perceived preoperative shortening, while fewer (46%) reported perceived postoperative shortening. Perceived postoperative shortening was significantly associated with perceived preoperative shortening (p=0.05). (Table 1) There was no significant association between perceived postoperative shortening and measured change in SPL (p=0.16). In fact, on average, patients who underwent PEG gained 0.51 cm in SPL. Of patients who reported perceived postoperative shortening, only 25% objectively lost SPL; this group had an average increase of 0.33 cm in SPL. Subjective post-operative shortening was associated with both reduced patient satisfaction (p=0.006) and shorter time to follow up (p=0.001). CONCLUSIONS: Overall, patients were less likely to report perceived shortening after PEG. Perceived preoperative shortening was predictive of perceived postoperative shortening, in spite of measurements not indicating length loss, suggesting that pre-existing factors, such as erectile function or psychogenic components, might play a role. This is further supported by no difference in measured change in SPL between groups, with an overall average gain in SPL after PEG. The association between reported postoperative shortening and shorter follow up times may be due to an immediate adjustment period to the appearance of the penis after PEG, which resolves over time. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e485 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information William Langbo More articles by this author Morgan Sturgis More articles by this author Jose Quesada Olarte More articles by this author Laurence Levine More articles by this author Expand All Advertisement PDF downloadLoading ...

MP36-11 PREDICTORS OF HINGE EFFECT IN PATIENTS WITH PEYRONIE'S DISEASE

You have accessJournal of UrologyCME1 Apr 2023MP36-11 PREDICTORS OF HINGE EFFECT IN PATIENTS WITH PEYRONIE'S DISEASE Daniel Roadman, Vinson Wang, William Langbo, David Paddock, and Laurence Levine Daniel RoadmanDaniel Roadman More articles by this author , Vinson WangVinson Wang More articles by this author , William LangboWilliam Langbo More articles by this author , David PaddockDavid Paddock More articles by this author , and Laurence LevineLaurence Levine More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003270.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with Peyronie’s disease (PD) suffer from a variety of penile deformities including curvature, indentation, hourglass, shortening, and erectile dysfunction (ED). The presence of a hinge effect can be appreciated during penile duplex assessment (PDDU) as buckling or folding of the shaft when axial pressure is placed on the glans. Patients with hinge effect can experience bothersome buckling of the erection and instability during penetrative sex. The characteristics that cause hinge effect and its clinical implications are not fully understood. We aim to determine the PD factors that cause hinge effect and to assess the role of hinge effect on subsequent surgical intervention. METHODS: Retrospective review was conducted on 1,483 patients presenting with PD from 2016-2021. Complete PDDU and hinge assessment were obtained in 1,223 included for analysis. Baseline demographics, PDDU findings, and clinical outcomes were obtained. Univariate and multivariate analyses were performed to assess for predictors of hinge effect. RESULTS: Hinge effect was observed at the time of PDDU in 33% of PD patients. The degree of indentation (1.82 OR, p<0.001), rigidity of erections (0.82 OR, p=0.002), and degree of primary curvature (1.03 OR, p<0.001) predicted presence of hinge effect. Furthermore, hinge effect greatly affected the type of surgical intervention required to correct PD deformity. Patients with hinge effect were more likely to require plaque incision/excision and grafting as opposed to tunica albuginea plication in PD patients with good quality erections. When controlling for erectile rigidity, patients who underwent partial plaque excision and grafting were more likely to have hinge when measured girth discrepancy was >1 cm (p<0.001). In those requiring penile prosthesis, incision and grafting was more commonly required when hinge effect was present. CONCLUSIONS: The presence of hinge effect can be extremely bothersome and cause instability of erections during penetrative sex. Multiple factors may predispose to a hinge effect, including quality of erection and severity of curvature. When controlling for rigidity, a girth discrepancy of >1 cm did appear to pre-dispose to a hinge. Additionally, assessment of hinge effect pre-operatively was important in determining the optimal surgical intervention to correct PD deformities. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e483 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Roadman More articles by this author Vinson Wang More articles by this author William Langbo More articles by this author David Paddock More articles by this author Laurence Levine More articles by this author Expand All Advertisement PDF downloadLoading ...

Postoperative progress of modified grid incision and sealing with collagen fleece for treatment of Peyronie's disease

ABSTRACT Introduction Recently, there have been reports on partial plaque excision and grafting with collagen fleece technique regarding long term efficacy. However, there is still concern regarding complete regeneration of tunical defect from collagen fleece graft in terms of regenerative medicine. Previously, we introduced a less invasive modified technique by multiple grid incisions of Peyronie's plaque to minimize weakness of regenerated tunica from the collagen fleece graft and consequent veno-occlusive erectile dysfunction. Objective To assess the efficacy of Modified Grid Incision of plaque and sealing with Collagen Fleece through post-operative progress of 31 patients with prospective follow-up study. Methods From Aug 2018, 31 patients with stable Peyronie's disease (PD) were included. Surgical technique was composed 3 major steps; 1) dissection of the neurovascular bundle or urethra according to the location of plaque, 2) multiple deep grid plaque incisions for complete correction of curvature and deformity and 3) sealing with collagen fleece (TachoSil®) without suturing. Prospectively, we assessed the stretched penile length (SPL), totally straightness, penile sono, erectile function preoperatively and 6, 12, 24, 36 months postoperatively. This study was approved by the Institutional Review Board of the Korea University Hospital. Results Mean patient age was 58.5 years (range: 46–75). The mean curvature was 45.95 (15-90) degrees, 8 with hinge and 7with hourglass deformity. Inflatable penile prosthesis(IPP) was inserted in 4 patients and postoperative 30 months in a patient for poor erectile function. Mean follow-up was 15 months (6-36). Daily massage softened the hard thickening of penis gradually from 3 months until 2 year. On follow-up sonography, subcutaneous thickening gradually decreased to near normal at 1 year and the breakage of tunica by grid incision reunited at postoperative 10-12 months. All patients achieved totally straightness. All patients gained preoperative length after 1.6 year. 96% of patients satisfied in GAQ at 1 year. Minor skin problem was occurred in three patients of IPP. Subcutaneous bulging hematoma was occurred in 2 patients but subsided within 3 months. In postoperative erectile function of 27 patients without IPP, spontaneous hard erection was recovered in 10 and the rest are satisfied with PED5 inhibitors. Conclusions Our prospective progress reports with technical modification of various plaque incisions shows that one can achieve a sufficient surgical effect without making defect of tunica albuginea. Precise understanding of the postoperative progressions are necessary for physician's confidence and encouraging the patients for successful clinical outcomes. Disclosure Work supported by industry: no.

Postoperative Progress of Modified Grid Incision and Sealing with Collagen Fleece for Treatment of Peyronie's Disease

ABSTRACT Introduction Recently, there have been reports on partial plaque excision and grafting with collagen fleece technique regarding long term efficacy. However, there is still concern regarding complete regeneration of tunical defect from collagen fleece graft in terms of regenerative medicine. Previously, we introduced a less invasive modified technique by multiple grid incisions of Peyronie's plaque to minimize weakness of regenerated tunica from the collagen fleece graft and consequent veno-occlusive erectile dysfunction. Objective To assess the efficacy of Modified Grid Incision of plaque and sealing with Collagen Fleece through post-operative progress of 31 patients with prospective follow-up study. Methods From Aug 2018, 31 patients with stable Peyronie's disease (PD) were included. Surgical technique was composed 3 major steps; 1) dissection of the neurovascular bundle or urethra according to the location of plaque, 2) multiple deep grid plaque incisions for complete correction of curvature and deformity and 3) sealing with collagen fleece (TachoSil®) without suturing. Prospectively, we assessed the stretched penile length (SPL), totally straightness, penile sono, erectile function preoperatively and 6, 12, 24, 36 months postoperatively. This study was approved by the Institutional Review Board of the Korea University Hospital. Results Mean patient age was 58.5 years (range: 46–75). The mean curvature was 45.95 (15-90) degrees, 8 with hinge and 7with hourglass deformity. Inflatable penile prosthesis (IPP) was inserted in 4 patients and postoperative 30 months in a patient for poor erectile function. Mean follow-up was 15 months (6-36). Daily massage softened the hard thickening of penis gradually from 3 months until 2 year. On follow-up sonography, subcutaneous thickening gradually decreased to near normal at 1 year and the breakage of tunica by grid incision reunited at postoperative 10-12 months. All patients achieved totally straightness. All patients gained preoperative length after 1.6 year. 96% of patients satisfied in GAQ at 1 year. Minor skin problem was occurred in three patients of IPP. Subcutaneous bulging hematoma was occurred in 2 patients but subsided within 3 months. In postoperative erectile function of 27 patients without IPP, spontaneous hard erection was recovered in 10 and the rest are satisfied with PED5 inhibitors. Conclusions Our prospective progress reports with technical modification of various plaque incisions shows that one can achieve a sufficient surgical effect without making defect of tunica albuginea. Precise understanding of the postoperative progressions are necessary for physician's confidence and encouraging the patients for successful clinical outcomes. Disclosure No

Suture-Free Sealing of Tunical Defect with Collagen Fleece after Partial Plaque Excision in 319 Consecutive Patients with Peyronie's Disease: The Sealing Technique.

We describe the sealing technique with collagen fleece in patients with advanced Peyronie's disease (PD) and provide the prospective long-term outcomes. We performed a multicenter cohort study in patients with preserved erectile function and stable PD that precluded sexual intercourse. All patients underwent partial plaque excision with collagen fleece grafting. The applied technique is explained through a high-quality video accompanied by relevant animations. After hospital discharge, all patients were assessed at 1, 4 and 24 weeks after treatment. Subsequently, they presented for an additional long-term evaluation. From December 2004 to June 2015, 367 patients underwent surgery. Of these, 319 (86.9%) presented for the long-term evaluation and were included in the present study. At a median operative time of 79.8 minutes (range 50-130), total straightness of the penis was achieved in 299 cases (93.7%) and mean±SD penile length increased by 1.1±0.6 cm (p=0.017). After a median followup of 47.2 months (range 12-100), 291 patients (91.2%) presented with complete penile straightness. The penile glans sensation returned to the preoperative levels in 300 cases (94%). Only 11 cases of treatment-related grade 1 Clavien-Dindo complications were reported. Erectile function improved in 78 participants (24.5%) and remained unchanged in 191 (59.8%), whereas it was worsened in 50 (15.7%). Overall, the patient satisfaction rate was 87.8% and the partner satisfaction rate was 84.3%. Grafting with collagen fleece in patients with advanced PD is a safe and effective procedure that reduces operative time, provides an additional hemostatic effect and represents a cost-effective technique.

The use of collagen fleece (TachoSil) as grafting material in the surgical treatment of Peyronie's disease. A comprehensive narrative review.

Grafting for the treatment of Peyronie's disease (PD) can be performed with autologous grafts, allografts, xenografts and synthetic grafts, with all available materials presenting their own characteristics. Still, there is a current arising interest in the use of collagen fleece (TachoSil) as grafting material. We generated an extensive literature review, aiming to assess the use of TachoSil in the treatment of PD. TachoSil is currently indicated in men with PD and preserved erectile function for defect closure after partial plaque excision or incision. In addition, it is indicated for residual curvature correction during penile prosthesis implantation (PPI) in patients with PD and severe erectile dysfunction. Our literature search identified 12 studies evaluating the role of TachoSil for PD surgical treatment. We presented the surgical procedure of TachoSil grafting for the treatment of complex penile curvatures with or without simultaneous PPI and summarized the available evidence on the matter. Identified studies suggest that TachoSil is considered highly effective, reliable and safe in patients with PD. Moreover, it displays favorable properties compared to other grafting materials. It should be stressed that, despite some limitations of available data, TachoSil presents key strengths, which include easy application, decreased operative times, no risk of damaging the implant during PPI, preservation or increase in penile length, fewer cases of penile hypoesthesia, low risk of other adverse events, additional hemostatic effects and low cost. Still, randomized trials comparing TachoSil with different grafting materials are necessary to establish its efficacy.

MP33-13 MODIFIED GRID PLAQUE INCISION AND SEALING WITH COLLAGEN FLEECE FOR TREATMENT OF PEYRONIE’S DISEASE: ITS FEASIBILITY AND SAFETY

INTRODUCTION AND OBJECTIVE:Surgery is gold-standard for correction of Peyronie's curvature. Recently, there have been reports on partial plaque excision and grafting with collagen fleece technique ...

Characteristics of Men With Peyronie's Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes

BackgroundA subset of patients with Peyronie's disease (PD) treated with collagenase clostridium histolyticum (CCH) experience persistent bother and some require surgery. AimWe characterize patients experiencing persistent bother after CCH treatment and identify associations and predictors of surgical intervention/outcomes. MethodsWe retrospectively identified patients with PD from October 2014 to October 2019 and identified those presenting with persistent bother after CCH treatment by other urologists. Intracavernosal injection and penile Doppler ultrasonography were performed, and subsequent interventions/outcomes were recorded. Baseline characteristics were compared with Student t-test and chi-square test. Predictors of surgical intervention and complications were assessed using multivariable logistic regression. OutcomesThe primary outcome was surgery after CCH treatment. Secondary outcomes included worsened erectile function, sensory deficits, and penile length change. ResultsOf 573, 67 (11.7%) patients with PD had undergone prior CCH treatment with median 6 injections (range 2–24). Mean post-CCH PD Questionnaire bother score was 10.1 (SD: 3.1), and total International Index of Erectile Function-5 was 15.3 (SD: 8.7). Mean PD duration was 27.8 (SD: 35.7) months, with a mean composite curvature (MCC) of 69.0° (SD: 33.8) measured after injection. Of 67, 44 (65.7%) patients had MCC >60°. Of 67, 52 (77.6%) patients had indent, narrowing, or hourglass and 26 (38.8%) had hinge effect (buckling of the erect penis with axial pressure) on examination. Calcification was identified in 26 of 67 (38.8%) patients, with grade 3 calcifications comprising 6 of 23 (26.1%) patients. Of 67, 33 (49.3%) patients underwent surgery, with 20 (60.1%) undergoing partial plaque excision and grafting with/without tunica albuginea plication, 6 (18.2%) undergoing tunica albuginea plication alone, and 7 (21.2%) undergoing penile prosthesis with plaque incision and grafting. Surgical patients had greater mean curvature (82.6 vs 55.4, P = .001) and were more likely to have hinge (54.5% vs 20.6%, P = .005). On multivariable analysis, MCC ≥60° predicted patient’s decision for surgery (odds ratio: 2.99, P < .01, 95% confidence interval: 1.62–4.35). There were no associations between surgical complications and number of injections or CCH-associated adverse events. Clinical ImplicationsPatients presenting with persistent bother after CCH treatment often have narrowing and calcifications (despite calcifications being a contraindication to CCH treatment), and those who have hinge or severe curvature are more likely to undergo surgery with low rates of complications. Strengths/LimitationsThis study's generalizability is limited by selection bias, but useful data are provided for patient counseling. ConclusionPatients with persistent bother after CCH treatment had high rates of indentation/narrowing, plaque calcifications, and MCC >60° at completion of CCH treatment. Surgical intervention is more common with hinge and is safe and feasible in these patients, with low rates of complications. These findings suggest possible negative prognostic factors for CCH treatment, which merit further investigation.Bajic P, Wiggins AB, Ziegelmann MJ, et al. Characteristics of Men With Peyronie's Disease and Collagenase Clostridium Histolyticum Treatment Failure: Predictors of Surgical Intervention and Outcomes. J Sex Med 2020;17:1005–1011.

Incision de plaque et greffe de Tachosil chez les patients atteints d’une maladie de Lapeyronie

Surgery is a treatment for correction of penile curvature in Peyronie's disease. Partial plaque excision and grafting is recommended for severe and complex curvature. Patients with stable penile curvature who underwent a partial plaque excision and grafting between January 2017 and April 2018 were retrospectively included. The graft was realized using a self-adhesive collagen fleece (Tachosil®). Penile curvature, penile length and erection score were measured before and after surgery. Twenty-one patients, aged 52,13 (18-70years) were included. The average follow-up after surgery was 8,36months (1-14months). Early complications included two hematomas and one dysuria (Clavien 1). One patient had a penile prosthesis hernia 3 months after surgery, and needed a new surgery (Clavien 3B). Patients stayed at the hospital 1.38 night (1-5) and operating time was 158min (102-249min). Average penile curvature after surgery was 5.88° (0-30°), while it was 82.75° (50-100°) before. Erection score increased from 7.62 (3-10) to 7.86 (4-10). There was no modification of the penile length 11.92cm (11-14.5) after surgery and 12.09cm (10-15cm) before. The use of TachoSil® reduces the operative time, is easy to use and has hemostatic properties at a low cost. However, prospective randomized trial and long terms results are required to confirm our encouraging results. 3.

Novel approaches and new grafting materials in Peyronie's disease reconstructive surgery.

The aim of this study is to review the current literature that reports outcomes of Peyronie's disease (PD) grafting surgery, with a special focus on novel approaches and grafting materials. For this purpose, a literature review was performed through PubMed between 2014 and 2019 regarding grafting techniques in PD reconstructive surgery. Keywords used for the search were: Peyronie's disease, penile curvature, surgical therapy, surgical outcomes, grafting techniques, grafts, and graft materials. Outcomes discussed in this review include post-operative penile straightening rates, penile shortening, erectile function, sensation at the glans penis, and patient satisfaction rates. There are several techniques and grafts available that can be used to close the tunical defect after partial plaque excision or plaque incision. Autologous and non-autologous grafts have been investigated for this purpose. Currently, non-autologous off-the-shelf grafts are being used predominantly because of some advantages that include: no harvesting from the patient's body, ready availability, decreased operative times, easy handling, and reduced morbidity. Patients scheduled for grafting surgery do need to have sufficient and documented erectile rigidity preoperatively. Moreover, realistic expectations should be set before surgery. By meeting these requirements, patients can expect good and satisfactory surgical outcomes. The most important predictors of success in PD grafting surgery still remain surgeon experience and careful patient selection.

Evolution of the surgical sealing patch TachoSil® in Peyronie's disease reconstructive surgery: technique and contemporary literature review.

The aim of this study is to review the current literature that reports outcomes of Peyronie's disease (PD) reconstructive surgery using the collagen fleece TachoSil® (Baxter, CA, USA), a novel graft that has self-adhesive properties and gained popularity in recent years. A literature review was performed through PubMed between 2013 and 2018 regarding the use of TachoSil® in PD penile reconstructive surgery. Keywords used for the search were: Peyronie's disease, surgical therapy, surgical outcomes, grafting techniques, graft materials, collagen fleece, surgical patch, and TachoSil. Grafting procedures are indicated for men with PD and preserved erectile function. TachoSil® is a novel graft used for defect closure after tunical incision or partial plaque excision. Long-term results of this technique are encouraging and reliable. One major advantage over other grafts is that the TachoSil® does not require suture fixation leading to significantly decreased operative times. Another indication is residual curvature correction by plaque incision and grafting/sealing with TachoSil® during penile prosthesis implantation in patients with PD and severe erectile dysfunction. Besides reduced operative times, the major advantage is that there is no risk of device puncture because of the self-adhesive properties of the TachoSil®. The TachoSil® has emerged as a safe, reliable, and promising graft in PD reconstructive surgery. Until now, this graft has met the expectations as a durable and effective graft, not only for grafting techniques but also for residual curvature correction during penile prosthesis implantation. However, future research is encouraged, preferably within prospective multicenter studies.

Long-term outcome after grafting with small intestinal submucosa and collagen fleece in patients with Peyronie's disease: a matched pair analysis.

Advanced Peyronie's disease (PD) with severe penile curvature requires grafting following plaque incision or partial plaque excision. So far, the ideal graft material has not been identified although various grafts have been studied. In this first matched pair analysis we compared the outcome after grafting with small intestinal submucosa (SIS) and self-adhesive collagen fleece (CF). We retrospectively identified 43 patients after SIS grafting with complete follow-up data sets to be eligible for the present study. A total of 43 patients after CF grafting were matched case by case to the SIS group using the degree of preoperative penile curvature as the primary matching factor. Postoperative outcome was compared with the focus on penile straightening, penile length, potency, relapse rates and long-term complications. Median degree of curvature was 80° in each group. Mean follow-up periods were 31 months after SIS and 39 months after CF grafting. The CF grafting procedure was significantly faster than SIS grafting (80 vs. 104 min, p < 0.001). No major short-term complications were observed. Both techniques gained good long-term penile straightening rates. Relapse of penile curvature was observed after SIS grafting only. Postoperative penile shortening occurred more often after SIS grafting (28% vs. 5%, p = 0.007). With a mean preoperative IIEF-5 score of 16, the SIS cohort significantly differed from the CF cohort with a mean IIEF-5 score of 19 (p = 0.016). The median IIEF-5 score improvement was higher after SIS grafting (+4.5 vs. +1, p = 0.002). Diminished penile sensation was the main long-term side effect with low rates after both procedures (9% and 7% in the SIS and CF group respectively, p = 0.100). In this first matched pair analysis both techniques showed promising long-term results. CF seems to have advantages regarding duration of surgery and preserving penile length. More comparative studies with larger collectives are desirable.