Preoperative Curvature Research Articles

Posterior vertebral column resection: Exploring practical uses in clinical settings.

The purpose of this study was to present our experience in patients who had been treated with posterior vertebral column resection (PVCR) for various spinal deformities. Thirty-seven patients who performed PVCR between 2015 and 2018 were evaluated retrospectively. The mean follow-up period was 24 months (range: 12-50 months). The demographic data of the patients, mean blood loss, amount of blood replacement, duration of operation, intensive care and hospitalization period, PVCR level, instrumentation level, amount of preoperative curvature, amount of postoperative curvature improvement, preoperative and postoperative neurological status, and complications were examined. Angular measurements were performed on X-ray. The mean age of the patients was 37.5 years (range: 3-80 years). PVCR was applied to patients due to different pathologies (congenital, tumor metastasis, posttraumatic kyphosis, revision scoliosis, and infection). The mean operation time was 445.5 min (260-720) with an average blood loss of 1903 ml (400-7000 ml). It was observed that the average local kyphosis angle decreased from 67.65° to 7.42° in 26 patients who were operated for advanced deformity (P < 0.001). When these values were compared in all 34 patients, the preoperative angle value decreased from 55.1° to 3.5° (P < 0.001) and decreased from 70° to 0° in 13 congenital kyphosis patients. PVCR is an effective method for correcting severe spinal deformities and can be used to correct curvature in different patient groups. Level 3.

(171) The Effects of Pretreatment with Xiaflex on Penile Curvature Correction with Manual Modeling During and After IPP placement

Abstract Introduction There are a variety of treatment modalities available to treat Peyronie’s disease (PD), including collagenase clostridium histolyticum (Xiaflex) injections. Patients with concomitant erectile dysfunction (ED) and PD are best served by insertion of an inflatable penile prosthesis (IPP) in order to adequately treat both conditions. Many PD patients may undergo other PD treatments, including Xiaflex, prior to IPP implantation. There are multiple methods of curvature treatment during IPP surgery, and manual modeling is the predominant method in our practice. Little data exists regarding whether Xiaflex treatments prior to IPP placement influence changes in penile curvature during and after IPP surgery with manual modeling. Objective The primary objectives were assessing the impact of pre-treatment with Xiaflex on penile curvature immediately after IPP implantation and after manual modeling. The secondary objective was change in penile curvature post-operatively. Methods All IPP patients with known preoperative penile curvature with and without a history of Xiaflex injections undergoing IPP placement by a single surgeon from January 2017 to June 2023 were included in this IRB-approved (IRB 00031589) retrospective series. All patients had a 3-piece Coloplast Titan Touch IPP (Coloplast, Minneapolis, MN, USA) ranging 16-24cm in length (mean 19.8 ± 1.9cm) with 0-3cm rear tips (mean 1.4 ± 0.9cm). Goniometer was used to assess curvature during preoperative intracavernosal injection and duplex Doppler ultrasound, at multiple points intraoperatively, and postoperatively at 2 weeks, 6 weeks, and 6 months. Biplanar curvatures were recorded as primary and secondary values. SPSS (IBM, Armonk, NY, UA) was used for statistical analyses, which included t-tests, chi-squared tests, and ANOVA. Results Sixty-one patients were included. Preoperative curvature was 35° ± 17° (10° to 70°) for the Xiaflex cohort (n=11) and 41° ± 15° (20° to 80°) for the Xiaflex naïve cohort (n=50). At the time of IPP placement, patients previously treated with Xiaflex had a 19° ± 12° absolute reduction in primary penile curvatures, corresponding to a 45% ± 36% improvement (25° reduction to 5° worsening), while Xiaflex naïve patients had a 20° ± 13° absolute reduction and 54% ± 23% improvement (50° reduction to no change). Similar mean curvature reductions were seen with IPP placement in primary dorsal curves in the Xiaflex cohort (n=7, 21° ± 4°, 51% ± 12%, 25° to 15° reduction) and Xiaflex naïve cohort (n=24, 21° ± 9°, 51% ± 22%, 40° to 5° reduction). There was little difference in change in curvature after modeling between the Xiaflex (11° ± 3°, 63% ± 23%, 15° to 5° reduction) and Xiaflex naïve patients (14° ± 9°, 70% ± 20%, 40° reduction to 5° worsening). Interval assessments postoperatively were also comparable. Sample size precluded assessment of statistical significance among groups. Conclusions Preoperative treatment of PD with Xiaflex does not impede nor significantly improve curvature correction with IPP implantation and manual modeling. Similar changes in penile curvatures were seen in both groups regardless of curvature direction, modeling, or postoperative interval. In patients with severe PD, Xiaflex may be a useful tool to improve preoperative penile curvatures such that they may be more easily correctable with an IPP. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, MenMD.

(167) Penile Plication is Well Tolerated Under Conscious Sedation: A Prospective Comparison of Deep Intravenous Vs. Nursing Administered Conscious Sedation

Abstract Introduction Penile plication is a common and effective surgical treatment for Peyronie's Disease. Although generally performed under general or spinal anesthesia, patient tolerability of penile plication under conscious sedation (CS) has several advantages: reduced anesthetic risk, health care cost savings, decrease wait times, and the ability conduct in outpatient facilities. While CS would provide significant potential benefit, there have been no evaluations of patient-reported tolerability to penile plication completed under conscious sedation nor comparisons with varying administrations. Objective To evaluate and compare patient-reported tolerability of penile plication performed under two CS sedation approaches: (1) deep intravenous conscious sedation (IVCS) administered by anesthesiologists and (2) nursing administered conscious sedation (NACS). Methods We evaluated procedure tolerability in a prospective cohort of 40 adult patients (23 IVCS; 17 NACS) undergoing primary penile plication between August 2022 and May 2023. Revision surgeries, and those with hourglass or hinge deformities were excluded. IVCS patients were administered midazolam (5mg) and ketamine (20mg) along with a continuous infusion of propofol (25-50 mcg/kg/min) and remifentanil (0.05 mcg/kg/min). NACS sedation protocol consisted of midazolam (1-2 mg) and fentanyl (50-100 ug). Patient baseline characteristics, procedure information, pain assessments (Likert scale; 0 [no pain]-10[most pain]) made by the patient and surgeon before during and after the procedure were collected. Following a post-surgical healing period, patients were contacted and administered an evaluated standardized patient tolerability questionnaire. Overall patient tolerability, pain assessments, and complication rates were compared descriptively, and using Wilcoxon sign-rank tests and McNemar tests. Results Baseline characteristics were similar between IVSC and NACS groups. Median pre-operative curvature of the IVCS cohort was 55 degrees (IQR=43.75-76.25) whereas the NACS curvature was 45 degrees (IQR=45-60). There was a 100% procedural success rate with no intra-operative concerns leading to the abortion of the procedure or conversion to general anesthetic. At six-week post-operative follow up, all patients had functional curvature. 100% of patients in the IVCS and NACS cohorts reported that they would recommend CS to others. Additionally, 95% (19/20; CI95=75.3%-99.0%) of those undergoing IVCS and 93.3% (14/15; CI95=70.2-98.8%) of the NACS cohort would choose CS over general anesthetic if they had to undergo the same surgery again. Sedation choice did not differ between CS groups (p=1.0). Most patients reported no pain pre-operatively (IVCS:[18/20]; NACS:[13/15]; p=1.0), peri-operatively (IVCS:[16/20]; NACS:[13/15]; p=0.68), or immediately post-operatively (IVCS:[14/20]; NACS:[14/15]; p=0.20). Two-hour post-operative pain did not differ between groups (p=0.89). Median two-hour post-operative IVCS pain was 2.5 (IQR=0-5.0) whereas median NACS pain was 3.0 (IQR=1.5-3.0). Conclusions Penile plication is exceptionally well tolerated when completed under either anesthesiologist administered intravenous conscious sedation or nursing administered conscious sedation. Most patients would choose conscious sedation over general anesthetic for the procedure in the future and all would recommend conscious sedation to others. Self-reported pain did not differ between groups and most patients reported no pain pre-, peri-, or immediately post-operatively. These results suggest that penile plication surgery can be completed in an outpatient setting under conscious sedation administered by trained nursing staff, which is expected to decrease costs, risks and wait-times of the procedure. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

(169) New Findings Regarding the Degree of Penile Curvature Correction with IPP Alone

Abstract Introduction Inflatable penile prosthesis (IPP) insertion is an effective treatment for men with erectile dysfunction and Peyronie’s disease. Most literature on this subject focuses on the utility of adjunct curvature correction maneuvers after IPP placement. There has been little investigation regarding the degree to which the implant alone improves penile curvature prior to the implementation of adjunct curvature correction maneuvers. Objective The primary objective was assessing the impact of IPP on known penile curvature immediately after insertion. Secondary objectives were changes in penile curvature after adjunct curvature correction maneuvers and postoperatively. Methods This is an IRB-approved (IRB 00031589) retrospective series of all IPP patients with known preoperative penile curvature undergoing IPP placement with a single surgeon from January 2017 to June 2023. Extensive investigation of available patient chart information was conducted. All patients had a 3-piece Coloplast Titan Touch IPP (Coloplast, Minneapolis, MN, USA) ranging 16-24cm in length (mean 19.8 ± 1.9cm) with 0-3cm rear tips (mean 1.4 ± 0.9cm). Goniometer was used to assess curvature during preoperative intracavernosal injection and duplex Doppler ultrasound, at multiple points intraoperatively, and postoperatively at 2 weeks, 6 weeks, and 6 months. Biplanar curvatures were recorded as primary and secondary values. SPSS (IBM, Armonk, NY, UA) was used for statistical analyses, which included t-tests, chi-squared tests, and ANOVA. Results Sixty-one patients were included. Mean known primary preoperative curvature was 40° ± 16° (10 to 80°). IPP placement prior to adjunctive maneuvers resulted in 21° ± 10° absolute reduction in primary penile curvatures, corresponding to a 52% ± 26% improvement (50° reduction to 5° worsening). Dorsal curvatures improved by 21° ± 8° (51% ± 17%, 40° to 5° reduction) with IPP alone. Ventral curvatures improved by 24° ± 18° (49% ± 51%, 50° reduction to 5° worsening) with IPP alone. Lateral curvatures improved by 19° ± 10° (54% ± 24%, 40° to 0° reduction) with IPP alone. Eight patients had resolution of primary curvature with IPP alone, with mean preop curves 32° ± 11° (range 15° to 50°). Three of these needed modeling for secondary curvatures, leaving five total who did not require adjunct curvature correction maneuvers. Subsequent modeling for all patients resulted in 14° ± 9° absolute reduction in primary penile curvatures and up to 68% further improvement. Sample size precluded assessment of statistical significance among groups. Conclusions IPP placement appears to correct approximately 20° of penile curvature in this series, with similar effect on all curvature directions. These data may help clarify patient preoperative counseling and guide surgical planning. Further multicenter studies incorporating more patients and additional IPP types are warranted. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, MenMD.

Grafts in Peyronie's surgery without the use of prostheses: a systematic review and meta-analysis.

Peyronie's disease (PD) is characterized by abnormal penile curvature, and various surgical methods have been developed using different graft materials. However, there is currently no universal agreement on which type of graft is the best. The objective of this review was to evaluate the available literature and identify the most effective graft material for penile curvature correction in PD. A literature search was conducted using electronic databases, including PubMed, Scopus, and the Cochrane Library. The patients, intervention, comparison, and outcome (PICO) approach was used to define the eligibility of studies. Two authors independently selected studies, evaluated them, and extracted data. Random-effect models using the DerSimonian-Laird method were used. Most studies were single-arm studies and had a high risk of bias. Buccal mucosa grafts (BMG) were found to result in the highest penile straightening rates and were associated with the least de novo erectile dysfunction. TachoSil grafts demonstrated a high success rate in straightening despite a higher mean preoperative curvature, while Tutoplast grafts had a higher incidence of postoperative erectile dysfunction. BMG had the highest percentage of postoperative penile straightening. Overall, the TachoSil graft showed the best performance when preoperative curvature is taken into account. Based on the available literature, BMG appear to be the most effective for penile curvature correction in PD, but this is offset by the requirement for low preoperative curvature. The TachoSil graft shows the best overall performance when preoperative curvature is considered. Comparative randomized clinical trials are still needed to determine graft superiority.

The indication of fusion to the pelvis in neuromuscular scoliosis is based on the underlying disease rather than on pelvic obliquity.

The decision to instrument to L5 or ilium, in NMS, is usually based on radiologic factors, including pelvic obliquity (PO) > 15°, apex of curvature < L3, and Cobb angle > 60°. Since scoliosis in these patients is caused by a neurologic disease, we based our decision to stop at L5 on the presence of spasticity or flaccidity. The senior author did 109 primary fusions in NMS. Of those with DMD or SMA only 16% were instrumented to the ilium. The main factor for our decision was the correction potential of the truncal shift and PO in the supine traction radiographs and the absence of severe spasticity. The 57 patients with DMD/SMA had a mean preoperative curvature of 68°, PO of 17°, and truncal shift of 20°. 74% should have been instrumented to the pelvis, but only 16% were. Those instrumented shorter as the rule, were corrected from 74° to 26° and had a postoperative PO of 8°. There was no significant difference in postoperative correction and PO compared to those instrumented to L5 on standard protocol. Subsequent extension to the pelvis was needed in 1 CP patient. There were no significant changes after 2years. Of the 20 patientsinstrumented to the pelvis 11 had cerebral palsy and a preop curvature of 89°, a PO of 21° and a truncal shift of 25°. The decision on instrumentation length should take flexibility and disease into consideration. If the trunk is centred over the pelvis, deterioration will not occur in absence of spasticity.

The Association of Lumbar Plexus Lengthening With Neurological Deficit After Adult Spinal Deformity Surgery.

Retrospective cohort study. This study aimed to evaluate the association between nerve lengthening after adult deformity correction and motor deficits dervied from the upper lumbar plexus or femoral nerve. Adult spinal deformity (ASD) surgery is associated with high rates of neurological deficits. Certain postoperative deficits may be related to lengthening of the upper lumbar plexus (ULP) and/or femoral nerve (FN) after correction of lumbar deformity. Patients with ASD who underwent posterior-only corrective surgery from the sacrum to L3 or above were included. The length of each lumbar nerve root was calculated geometrically using the distance from the foramen to the midpoint between the anterosuperior iliac crest and pubic symphysis on AP and lateral radiographs. The mean lengths of the L1 to 3 and L2 to 4 nerve roots were used to define the lengths of the ULP and FN, respectively. Preoperative to postoperative changes in nerve length were calculated. Neurological examination was performed at discharge. Proximal weakness (PW) was defined as the presence of weakness compared with baseline in either hip flexors or knee extensors. Multiple linear regression analysis was used for estimating the postoperative lengthening according to the magnitude of preoperative curvature and postoperative correction angles. A total of 202 sides were analyzed in 101 patients, and PW was present on 15 (7.4%) sides in 10 patients. Excluding the 10 cases with three-column osteotomies, those with PW had a significantly higher rate of pure sagittal deformity ( P <.001) and greater nerve lengthening than those without PW (ULP 24 vs. 15mm, P =0.02; FN 18 vs. 11mm, P =0.05). No patient had advanced imaging showing neural compression, and complete recovery of PW occurred in eight patients at one-year follow-up. After ASD surgery, lengthening of the ULP was associated with PW. In preoperative planning, surgeons must consider how the type of correction may influence the risk for nerve lengthening, which may contribute to postoperative neurological deficit.

A novel technique for unilateral dissection of the penile neurovascular bundle to prevent loss of penile sensation during treatment of Peyronie's disease-Initial results of a pilot study.

Plaque incision/excision and grafting are surgical techniques used to treat patients with Peyronie's disease who are refractory to less invasive interventions, have severe penile curvature, or have an hourglass deformity. However, the procedure carries the risk of penile sensory loss because of the need for dissection of the neurovascular bundle (NVB). The aim of this study was to assess the feasibility of a novel technique for unilateral NVB dissection and its ability to preserve penile sensitivity while maintaining adequate correction of the penile curvature. Charts of patients who underwent unilateral NVB dissection during Peyronie's plaque incision/excision and grafting were retrospectively reviewed. All patients received preprocedural intracavernosal injections of TriMix, and the curvature was measured to be >70 degrees. In 3 cases, an incision and minimal excision of the plaque were performed at the point of maximum curvature on the concave side of the curvature. In 3 cases, Tutoplast allografts (Coloplast US, Minneapolis, MN) were used, whereas autografts were used in 2 other cases. All patients were examined at 1, 3, and 6 months after the procedure when curvature and penile sensation were assessed. Five patients underwent this procedure. The mean age of patients was 55 years (45-70 years). All plaques were dorsally located. The mean preoperative curvature was 78 degrees (75-90 degrees). At the 6-month follow-up, all patients had <15 degrees residual curvature and were satisfied with their cosmetic results. Only 1 patient continued with phosphodiesterase-5 inhibitors to improve potency at the 6-month follow-up. All patients reported normal penile glans sensation. Four patients experienced decreased sensation at the site of NVB dissection, but this was only detected when compared with the contralateral side. Only 2 patients reported a difference after 6 months, and only a minor area of involvement was noted. Unilateral NVB dissection is a feasible technique that does not compromise surgical success in curvature correction and helps avoid sensory injury to the penile glans.

Influence of Preoperative Sagittal Alignment on Functional Recovery in Operated Cases of Cervical Spondylotic Myelopathy.

Objective We examine the influence of preoperative cervical sagittal curvature (lordotic or nonlordotic) on the functional recovery of surgically managed cases of cervical spondylotic myelopathy (CSM). The impact of sagittal alignment on the functional improvement of operated CSM cases has not been thoroughly investigated. Materials and Methods We did retrospective analysis of consecutively operated cases of CSM from March 2019 to April 2021. Patients were grouped into two categories: lordotic curvature (with Cobb angle > 10 degrees) and nonlordotic curvature (including neutral [Cobb angle 0-10 degrees] and kyphotic [Cobb angle < 0 degrees]). Demographic data, and preoperative and postoperative functional outcome scores (modified Japanese Orthopaedic Association [mJOA] and Nurick grade) were analyzed for dependency on preoperative curvature, and correlations between outcomes and sagittal parameters were assessed. Results In the analysis of 124 cases, 63.1% (78 cases) were lordotic (mean Cobb angle of 23.57 ± 9.1 degrees; 11-50 degrees) and 36.9% (46 cases) were nonlordotic (mean Cobb angle of 0.89 ± 6.5 degrees; -11 to 10 degrees), 32 cases (24.6%) had neutral alignment, and 14 cases (12.3%) had kyphotic alignment. At the final follow-up, the mean change in mJOA score, Nurick grade, and functional recovery rate (mJOArr) were not significantly different between the lordotic and nonlordotic group. In the nonlordotic group, cases with anterior surgery had a significantly better mJOArr than those with posterior surgery ( p = 0.04), whereas there was similar improvement with either approach in lordotic cases. In the nonlordotic group, patients who gained lordosis (78.1%) had better recovery rates than those who had lost lordosis (21.9%). However, this difference was not statistically significant. Conclusion We report noninferiority of the functional outcome in the cases with preoperative nonlordotic alignment when compared with those with lordotic alignment. Further, nonlordotic patients who were approached anteriorly fared better than those approached posteriorly. Although increasing sagittal imbalance in nonlordotic spines portend toward higher preoperative disability, gain in lordosis in such cases may improve results. We recommend further studies with larger nonlordotic subjects to elucidate the impact of sagittal alignment on functional outcome.

(104) A Multicenter Evaluation of Penile Curvature Correction in Men with Peyronie’s Disease Undergoing Inflatable Penile Prosthesis Placement

Abstract Introduction Inflatable penile prosthesis (IPP) insertion is recommended for the treatment of patients with Peyronie’s Disease (PD) and significant erectile dysfunction (ED). Adjunctive procedures such as modeling, plication, or incision/excision and grafting can be used when there is residual curvature after IPP placement. Objective To evaluate the management of curvature correction in patients with PD undergoing IPP among high-volume prosthetic urologists. Methods We performed a retrospective study of 205 patients diagnosed with PD undergoing IPP by 7 high volume penile prosthetic surgeons. Demographic, intraoperative, and postoperative data were collected and analyzed. Descriptive statistics were performed using mean and standard deviation for continuous variables, while incidence and percentages were used for categorical variables. We calculated the mean change in penile curvature after IPP insertion for each of the adjunctive correction techniques. Intra- and post-operative complications were collected. Results 205 patients met inclusion criteria with a mean age of 60.7 years (SD=9.2) and a median follow-up of 6 months (0.5-58.5 months). The mean preoperative curvature was 43.4° (SD=18.9°) with dorsal curvature being the most common. Overall, 73 (35.60%) patients had IPP only with no adjunctive curvature correction procedure, 24 (11.70%) underwent plication, 10 (4.90%) underwent grafting, and 98 (47.80%) underwent modeling. Preoperatively, the mean starting curvature was 35.7° for the IPP-only group, 48.1° for the plication group, 60.6° for the grafting group, and 46.0° for the modeling group, p&amp;lt;0.001. Patients undergoing grafting had significantly fewer comorbidities compared to the other groups: only 1 (10%) had diabetes and none were smokers or had cardiovascular disease, p&amp;lt;0.001. After penile curvature correction, the mean curvature change was 25.5° for the IPP-only group, 40.0° for the plication group, 55.0° for the grafting group, and 35.0° for the modeling group, p &amp;lt;0.001 (Figure 1). Intraoperatively, proximal perforation occurred in 2 (0.96%) patients, managed by a rear tip extender sling. Post-operatively, there were 33 (16.10%) non-infectious and 4 (1.90%) infectious complications. There was no significant difference in complications between groups. Conclusions Although incision/excision and grafting seem to provide the greatest penile curvature correction for PD patients undergoing IPP placement, this adjunctive correction procedure is less commonly performed among high volume prosthetic urologists. Our results suggest grafting is reserved for patients with greater preoperative curvature and fewer preoperative comorbidities. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Antares Pharma: SpeakBoston Scientific, Clarus Therapeutics, Coloplast, Cynosure, Promescent, Sprout, Viome, Hims &amp; Hers Health, Inc.

MP36-16 A MULTICENTER EVALUATION OF PENILE CURVATURE CORRECTION IN MEN WITH PEYRONIE’S DISEASE UNDERGOING INFLATABLE PENILE PROSTHESIS PLACEMENT

You have accessJournal of UrologyCME1 Apr 2023MP36-16 A MULTICENTER EVALUATION OF PENILE CURVATURE CORRECTION IN MEN WITH PEYRONIE’S DISEASE UNDERGOING INFLATABLE PENILE PROSTHESIS PLACEMENT Muhammed A. Moukhtar Hammad, David W. Barham, Tuan Nguyen, Lawrence Jenkins, Daniel Swerdloff, Kelli Gross, Georgios Hatzichristodoulou, James Jones, James Hotaling, Ian Pearce, Hossein Sadeghi-Nejad, Chad A. Service, Jay Simhan, Paul E. Perito, Faysal Yafi, and Martin S. Gross Muhammed A. Moukhtar HammadMuhammed A. Moukhtar Hammad More articles by this author , David W. BarhamDavid W. Barham More articles by this author , Tuan NguyenTuan Nguyen More articles by this author , Lawrence JenkinsLawrence Jenkins More articles by this author , Daniel SwerdloffDaniel Swerdloff More articles by this author , Kelli GrossKelli Gross More articles by this author , Georgios HatzichristodoulouGeorgios Hatzichristodoulou More articles by this author , James JonesJames Jones More articles by this author , James HotalingJames Hotaling More articles by this author , Ian PearceIan Pearce More articles by this author , Hossein Sadeghi-NejadHossein Sadeghi-Nejad More articles by this author , Chad A. ServiceChad A. Service More articles by this author , Jay SimhanJay Simhan More articles by this author , Paul E. PeritoPaul E. Perito More articles by this author , Faysal YafiFaysal Yafi More articles by this author , and Martin S. GrossMartin S. Gross More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003270.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) insertion is recommended for the treatment of patients with Peyronie’s Disease (PD) and significant erectile dysfunction (ED). Adjunctive procedures such as modeling, plication, or incision/excision and grafting can be used when there is residual curvature after IPP placement. We evaluated the management of curvature correction in patients with PD undergoing IPP among high-volume prosthetic urologists. METHODS: We performed a retrospective study of 499 patients diagnosed with PD undergoing IPP by 10 high volume penile prosthetic surgeons. Demographic, intraoperative, and postoperative data were collected and analyzed. RESULTS: 499 patients were included with mean age of 61.5 years (SD=10) and a median follow-up of 13.1 months (0-58.5 months). The mean preoperative curvature was 39.4° (SD=17.8) with dorsal curvature being the most common. Overall, 88 (17.6%) patients had IPP only with no adjunctive curvature correction procedure, 24 (4.8%) underwent plication, 10 (2.0%) underwent grafting, and 373 (74.7%) underwent modeling. Preoperatively, the mean starting curvature was 38.2° for the IPP-only group, 48.1° for the plication group, 60.6° for the grafting group, and 38.7° for the modeling group, p<0.001. Patients undergoing grafting had significantly fewer comorbidities: 1 (10%) had diabetes, none were smokers or had cardiovascular disease, p<0.001. After penile curvature correction, the mean curvature change was 30.0° for IPP-only group, 40.0° for plication group, 55.0° for grafting group, and 35.0° for the modeling group, p<0.001 (Figure 1). Intraoperative complications occurred in 5 (1%) patients. Post-operatively, there were 43 (14.30%) non-infectious and 11 (2.20%) infectious complications. No significant difference in complications between groups. CONCLUSIONS: Although incision/excision and grafting seem to provide the greatest penile curvature correction for PD patients undergoing IPP placement, this adjunctive correction procedure is less commonly performed among high volume prosthetic urologists. Our results suggest grafting is reserved for patients with greater preoperative curvature and fewer preoperative comorbidities. 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 Muhammed A. Moukhtar Hammad More articles by this author David W. Barham More articles by this author Tuan Nguyen More articles by this author Lawrence Jenkins More articles by this author Daniel Swerdloff More articles by this author Kelli Gross More articles by this author Georgios Hatzichristodoulou More articles by this author James Jones More articles by this author James Hotaling More articles by this author Ian Pearce More articles by this author Hossein Sadeghi-Nejad More articles by this author Chad A. Service More articles by this author Jay Simhan More articles by this author Paul E. Perito More articles by this author Faysal Yafi More articles by this author Martin S. Gross More articles by this author Expand All Advertisement PDF downloadLoading ...

Autologous testicular tunica vaginalis graft in Peyronie's disease: a prospective evaluation.

Peyronie's disease (PD) is a two-phase progressive condition characterized by inelastic plaques in the tunica albuginea of the penis, leading to curvature of the penis. Men with PD also suffer from psychological distress, and sexual life and overall quality of life. Although the preferred surgical treatment modality in Peyronie's disease is plaque incision and grafting, there is lack of studies assessing the erectile function and penile vasculature after the treatment. We aimed to evaluate the efficiency and safety of plaque incision and tunica vaginalis of testis grafting in PD. This was a prospective analysis. Erectile dysfunction was assessed via International Index of Erectile Function Questionnaire (IIEF-5). Penile Doppler ultrasound was performed to assess peak systolic velocity (PSV) and end-diastolic velocity (EDV). Postoperative follow-ups were scheduled at 3, 12, and 24months. Twenty patients (mean age 47.2 ± 10.8years) were included. The mean preoperative penile curvature was 48 ± 6.6°. The technical success rate was 100% at 3months and 90% at 24months. At follow-up visits, mean erect penile length was no different from the baseline. The baseline mean IIEF-5 score was 18.4 ± 2.5. The mean IIEF-5 score was 20.6 ± 2.6 at 24-month visit (p < 0.0001). Mean PSV significantly increased, while EDV significantly reduced after surgery. There were no serious complications related to surgery. We conclude that surgical reconstruction of penile curvature with tunica vaginalis grafting was a safe and effective procedure in PD.

The SAPOC technique: A novel approach utilizing multiple slices around point of maximal curvature for the correction of penile curvature at the time of penile prosthesis placement in patients with severe Peyronie's Disease

ABSTRACT Introduction Placement of an inflatable penile prosthesis (IPP) is indicated for patients with severe Peyronie's disease (PD) and erectile dysfunction (ED) that do not respond to medications. When utilizing plaque incision and graft placement, most surgeons perform an incision at the point of maximal curvature. In most cases of severe PD, this incision results in a large defect that requires placement of a large graft while postoperative penile shortening remains a concern among patients. Objective To present a novel technique for the treatment of severe PD and ED during IPP implantation, in which multiple relaxing incisions are made around the point of maximal curvature. This technique minimizes the size or even the need of a graft and maximizes length restoration. Methods A total of 35 patients with PD and severe ED underwent IPP placement with penoplasty by a single surgeon from October 2018 to March 2021. 27 of these patients underwent the SAPOC technique at the time of IPP placement through a non-degloving approach. This technique involves elevation of the neurovascular bundle for dorsal or lateral curvatures along with elevation of the urethra for ventral curvatures. After the point of maximal curvature is identified, 2 to 4 transverse relaxing incisions (slices) are made around the point of curvature approximately 1 to 1.5cm apart in order to minimize the size of the defect, and hence the size of the graft, while allowing for maximal restoration of length. Primary outcome measurements included straightening rates, patient satisfaction, change in penile length, immediate and late complications. Results The SAPOC technique was applied to 27 patients. Mean patient age was 58.2. Mean preoperative curvature was 71.9 degrees. Mean pre-operative stretched penile length at the time of surgery was 14.18 cm. Mean increase in erect penile length after IPP with SAPOC technique was 0.94 cm (p=0.006) (range 0 to 2.5 cm). A total of 12 patients (44.4%) did not require graft placement. After a mean follow-up of 13.5 months, 23 of 27 (85.2%) patients had a totally straight penis. 4 patients (14.8%) had less than 20 degrees residual curvature which was sufficient for penetrative intercourse. 26 patients (96.2%) were satisfied with their postoperative result. Complications included delayed ejaculation (n=4, 11%, all of which resolved within 12 months), device malfunction (n=1) after 2 years of initial surgery which was revised successfully, device infection at 6 weeks (n=1) and intractable pain 2 years after implantation (n=1), both of which required removal of the prosthesis. Conclusion The SAPOC technique at the time of IPP placement is a novel, safe and feasible technique for the management of complex Peyronie's disease and erectile dysfunction. This technique allows the surgeon to complete the procedure without graft placement in some occasions which theoretically will decrease operative time. It also provides for length restoration which will increase patient satisfaction. Disclosure Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Consultant for Coloplast and Boston Scientific).

Shaeer's punch technique: Trans-corporeal Peyronie's plaque surgery and penile prosthesis implantation

ABSTRACT Introduction Penile prosthesis implantation in cases of severe Peyronie's disease may require plaque excision/incision and grafting, that may require mobilization of the neurovascular bundle (NVB) or urethra, posing the risks of penile hyposensitivity or urethral injury, and is time consuming, possibly increasing infection risk. Objective Evaluating trans-corporeal debulking of Peyronie's plaques by “Shaeer's Punch Technique”. Methods Penile prosthesis implantation and Punch technique (PPI-Punch) was performed for 26 patients. Following corporotomy and dilatation, Peyronie's plaques were punched-out from within the corpora cavernosa using the punch forceps then a penile prosthesis implanted. Comparison to a matching retrospective group of 18 patients operated upon by plaque excision-grafting and penile prosthesis implantation was performed. Outcomes were in terms of straightness of the erect penis, complication, satisfaction with length on a 5-point scale , the International Index of Erectile Function-5 (IIEF), and the Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire (EDITS). Results Average pre-operative curvature angle was 58.1 ± 11.7 in the Punch group and 58 ± 14.8 in the excision-grafting group, p=0.99. Following surgery, all patients had a straight penis. No tunical perforations, urethral injuries or extrusions were noted. Average additional operative time for Punch technique ranged from 5 to 10 minutes (7.3 ± 1.7), in contrast to the excision-grafting group where plaque surgery duration was 50.8 minutes ± 11.1, an 85% difference, p &amp;lt; 0.0001. Septal plaques in the latter group could not be removed. In the PPI-Punch group, penile sensitivity was preserved in all patients, compared to the excision/grafting group with 7/18 patients reporting hyposthesia of the glans. Infection occurred in 1/26 patients in the PPI-Puch group, compared to 2/18 patients in the excision/grafting group. Satisfaction with length on a 5-point scale was 3.8 ± 0.9 in the punch group, versus 3.1 ± 1.1 in the excision-grafting group, p=0.009.. Conclusions Shaeer's Punch Technique is a minimally invasive procedure for trans-corporeal excavation of Peyronie's plaques prior to penile prosthesis implantation. There is no need for mobilization of the neurovascular bundle or spongiosum, hence low or no risk for nerve or urethral injury and brief plaque surgery time. Disclosure Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Coloplast, BSC, Rigicon).

Peyronie's Disease Does Not Significantly Impact Patient-Reported Outcomes After Penile Prosthesis Implantation

ABSTRACT Introduction Penile prosthesis (PP) implantation with concurrent straightening maneuvers is the gold standard surgical therapy for men with Peyronie's Disease (PD) and concurrent medication-refractory ED. Satisfaction rates exceed 80-90% in modern series. PD is characterized by other bothersome effects on penile morphology (i.e. penile shortening) that also negatively impact patient satisfaction with PP. We hypothesized that men with both PD+ED would report lower overall satisfaction with PP implantation compared to those with ED alone. Objective To compare patient outcomes in a cohort of patients undergoing PP implantation for ED with and without concurrent PD. Methods We identified all patients who underwent PP implantation by a single surgeon between May 2012 and August 2019 (n=354). A retrospective chart review was performed to evaluate pertinent clinical demographics and surgical outcomes. A survey was mailed to all patients in July 2019. This included validated ED questionnaires (IIEF, EDITS, and QOLSP) and clinician-derived questions to evaluate subjective outcomes. Survey results were compared between those patients with and without a history of PD, using two-sample student t- and chi-squared tests (p-value &amp;lt; 0.05 considered significant). Results 79 patients completed the survey (response rate 22%), including 38 (48%) with PD+ED. Mean survey follow-up duration was 45.5 (SD 19.5) months. There was no significant difference in patient demographics amongst those patients who did and did not respond to the survey. Amongst survey respondents, the mean preoperative IIEF-EF score was significantly higher for patients with PD+ED (10.2; SD 9.1) compared to those with ED alone (3.9; SD 5.0, p=0.003). Respondents with a history of both PD+ED were also less likely to have previously used oral therapy and intracavernosal injection to treat ED prior to PP implantation (p&amp;lt;0.009). For those respondents with PD+ED, mean preoperative curvature was 59O (SD 43). Adjunctive straightening maneuvers at the time of PP implantation included manual modeling (87%), plication (5%), and incision/grafting (50%). Overall, device infection occurred in 4/79 patients (5%), and mechanical malfunction occurred in 3/79 (4%). 87% of all survey respondents felt their ED was “very much” or “much” improved. 80% stated they would recommend PP to a friend. 60% reported postoperative penile length loss, but only 35% were “dissatisfied” with current length and only 20% were dissatisfied with penile girth. In those with PD+ED, 91% were satisfied with the degree of penile straightening. There was no significant difference in patient-reported outcomes pertaining to length, girth, and overall satisfaction between those with and without PD. The mean follow-up IIEF-EF was 27.4 (SD 5.7), mean EDITS was 18 (SD 8), and mean QOLSP was 55 (SD 15). Once again, there was no significant difference in these outcomes based on the presence of PD. Conclusions PP results in high rates of patient satisfaction. The presence of concurrent PD, even amongst those requiring adjunctive maneuvers, does not appear to significantly impact patient outcomes. While there are inherent limitations to a survey-based study including reporter bias, these results support the use of PP and concurrent straightening as an excellent treatment option for men with PD and ED. Disclosure Yes, this is sponsored by industry/sponsor: This project was funded by an investigator-initiated grant from Coloplast Corporation. Clarification: Industry funding only - investigator initiated and executed study Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast Corporation (Dr. Laurence Levine - consultant); Boston Scientific (Dr. Laurence Levine - Consultant)

The SAPOC Technique: A Novel Approach Utilizing Multiple Slices Around Point of Maximal Curvature for the Correction of Penile Curvature at the Time of Penile Prosthesis Placement in Patients with Severe Peyronie's Disease

ABSTRACT Introduction Placement of an inflatable penile prosthesis (IPP) is indicated for patients with severe Peyronie's disease (PD) and erectile dysfunction (ED) that do not respond to medications. When utilizing plaque incision and graft placement, most surgeons perform an incision at the point of maximal curvature. In most cases of severe PD, this incision results in a large defect that requires placement of a large graft while postoperative penile shortening remains a concern among patients. Objective To present a novel technique for the treatment of severe PD and ED during IPP implantation, in which multiple relaxing incisions are made around the point of maximal curvature. This technique minimizes the size or even the need of a graft and maximizes length restoration. Methods A total of 35 patients with PD and severe ED underwent IPP placement with penoplasty by a single surgeon from October 2018 to March 2021. 27 of these patients underwent the SAPOC technique at the time of IPP placement through a non-degloving approach. This technique involves elevation of the neurovascular bundle for dorsal or lateral curvatures along with elevation of the urethra for ventral curvatures. After the point of maximal curvature is identified, 2 to 4 transverse relaxing incisions (slices) are made around the point of curvature approximately 1 to 1.5cm apart in order to minimize the size of the defect, and hence the size of the graft, while allowing for maximal restoration of length. Primary outcome measurements included straightening rates, patient satisfaction, change in penile length, immediate and late complications. Results The SAPOC technique was applied to 27 patients. Mean patient age was 58.2. Mean preoperative curvature was 71.9 degrees. Mean pre-operative stretched penile length at the time of surgery was 14.18 cm. Mean increase in erect penile length after IPP with SAPOC technique was 0.94 cm (p=0.006) (range 0 to 2.5 cm). A total of 12 patients (44.4%) did not require graft placement. After a mean follow-up of 13.5 months, 23 of 27 (85.2%) patients had a totally straight penis. 4 patients (14.8%) had less than 20 degrees residual curvature which was sufficient for penetrative intercourse. 26 patients (96.2%) were satisfied with their postoperative result. Complications included delayed ejaculation (n=4, 11%, all of which resolved within 12 months), device malfunction (n=1) after 2 years of initial surgery which was revised successfully, device infection at 6 weeks (n=1) and intractable pain 2 years after implantation (n=1), both of which required removal of the prosthesis. Conclusions The SAPOC technique at the time of IPP placement is a novel, safe and feasible technique for the management of complex Peyronie's disease and erectile dysfunction. This technique allows the surgeon to complete the procedure without graft placement in some occasions which theoretically will decrease operative time. It also provides for length restoration which will increase patient satisfaction. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Coloplast, Boston Scientific, and Endo Pharmaceuticals

V07-08 PENILE PLICATION FOR PEYRONIE'S DISEASE: THE 8-DOT TECHNIQUE

You have accessJournal of UrologySexual Dysfunction & Transgender (V07)1 Sep 2021V07-08 PENILE PLICATION FOR PEYRONIE'S DISEASE: THE 8-DOT TECHNIQUE Mark Ehlers, Brad Figler, and Alysen Demzik Mark EhlersMark Ehlers More articles by this author , Brad FiglerBrad Figler More articles by this author , and Alysen DemzikAlysen Demzik More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002034.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile plication is a minimally invasive and effective technique for managing mild to severe curvature from Peyronie’s disease. METHODS: Retrospective chart review of all patients undergoing penile plication for Peyronie’s disease by one surgeon at one academic institution from November 2016 – December 2020 was conducted. Those occurring during IPP placement were excluded. Technical aspects of surgery were detailed and intraoperative video footage was made to illustrate the technique including papaverine injection, incision and variations, tissue dissection, iterative 8-dot plication with absorbable suture, and post operative evaluation. Primary outcomes were intra-operative and long-term success. RESULTS: A total of 66 patients were included. Median age was 58 years old (Range 24-73 years old). Average preoperative curvature was 45 degrees (Range 20-90 degrees). Curvature direction included 64% dorsal, 20% dorsolateral, 8% ventral, 5% ventrolateral, 3% lateral. Overall, 55% had complex deformities (biplanar curvature (38%), curvature of >60 degrees (50%), or both (11%)). Hinge effect was present in 14% of patients. Erectile dysfunction was present in 57% of patients. Ventral minimally invasive incisions were most common (64%) followed by circumcising incisions (24%), only 9% of patients had concurrent circumcision. Median number of 8-dot plication sutures used was 3 (Range 1-12). Intraoperative success, defined as completely straight was 97%. The 2 technical failures were directly related to ability to maintain intraoperative erection. Mean follow up was 4.5 months (IQR 1.1–4.2) and 91% of patients reported straight erections at follow up. No patient with hinge effect had a intraoperative failure or recurrence. There were no major complications. Rate of minor complication (superficial dehiscence, hematoma) was 6%. There were no revision plication procedures or patients who proceeded to penile implant surgery. CONCLUSIONS: This iterative approach to penile plication with absorbable suture is an effective, minimally invasive, and reproducible technique for correcting acquired penile curvature. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e553-e553 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mark Ehlers More articles by this author Brad Figler More articles by this author Alysen Demzik More articles by this author Expand All Advertisement Loading ...

Evaluation of the effect of preoperative corneal curvature on the successful formation of the big bubble formation in deep anterior lamellar keratoplasty for keratoconus

Background New approaches have been created to raise the chances of achieving big bubble (BB) in deep anterior lamellar keratoplasty (DALK); however, the BB formation is still uncertain in all cases. Other factors likely contribute to the success of bubble formation. Aim To evaluate the effect of preoperative curvature of the cornea on the success of BB formation in DALK for keratoconus. Design A prospective, comparative, nonrandomized study. Patients and methods The study was performed on 50 keratoconus patients. We compared the data of 25 patients who had successful type-1 bubble formation versus another 25 patients in whom the bubble formation failed. Both groups were compared regarding the keratometric readings recorded from the preoperative pentacam. Results The analysis showed statistically significant lower K1, K2, and Km values in the group where BB has been successfully achieved. We also found that lower K1 value was the only significant studied factor after the multivariate analysis. Conclusion Keratoconus patients with preoperative flatter corneas have slightly higher chances for successful BB formation during DALK surgery.

Comparing Outcomes of Grafts Used in Peyronie’s Disease Surgery: a Systematic Review

Peyronie’s disease (PD) is a scarring condition of the tunica albuginea. Various graft materials are used to fill defects following plaque incision (PIG) or partial excision (PEG), but the optimal graft material remains unknown. This systematic review compares outcomes of different grafts, performed with or without concurrent penile prosthesis implantation (PPI). Studies reported quantitative curvature assessment, with adequate follow-up to assess straightening, change in penile length, postoperative erectile dysfunction (ED), and patient satisfaction. From a total of 41 study arms, 1732 patients underwent PEG/PIG without and 302 with PPI. For PIG/PEG without PPI, the most frequently used grafts are cadaveric human pericardium (38.3%), autologous saphenous vein (21.2%), and porcine small intestinal submucosa (13.5%) with reported mean preoperative curvature of 69.3° and curvature recurrence ≥ 30° in 6.6%, 5.4%, and 15.4%, respectively. Grafts used most commonly with PPI include hemostatic patches (36.4%), bovine pericardium (34.8%), with similar mean preoperative curvature of 70.0° (p < 0.01). Satisfaction rates for PIG/PEG without PPI ranged from 70 to 100% with lowest satisfaction rates associated with dermis (70%) and human pericardium (73.4%). In the prosthesis cohort, satisfaction rates exceeded 88% with all grafts. Human pericardium seems to be the most commonly used graft when PPI is not indicated, with low rates of curvature recurrence, an acceptable rate of ED and satisfaction. Hemostatic patches are the most favorable graft choice with concurrent PPI. In general, the PD treatment literature is limited to low evidence grade retrospective studies, and further prospective investigation is warranted.

Shaeer’s Punch Technique: Transcorporeal Peyronie’s Plaque Surgery and Penile Prosthesis Implantation

BackgroundPenile prosthesis implantation in cases of severe Peyronie’s disease may require plaque excision/incision and grafting, which may require mobilization of the neurovascular bundle or urethra, posing the risks of penile hyposensitivity or urethral injury, and is time-consuming, possibly increasing infection risk. AimEvaluating transcorporeal debulking of Peyronie’s plaques by “Shaeer’s punch technique.” MethodsPenile prosthesis implantation and punch technique (PPI-Punch) was performed for 26 patients. After corporotomy and dilatation, Peyronie’s plaques were punched out from within the corpora cavernosa using the punch forceps, and then a penile prosthesis was implanted. Comparison to a matching retrospective group of 18 patients operated upon by plaque excision-grafting and penile prosthesis implantation was performed. OutcomesThe study outcomes were straightness of the erect penis, complication, satisfaction with length on a 5-point scale, the International Index of Erectile Function-5, and the Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire. ResultsAverage preoperative curvature angle was 58.1 ± 11.7 in the Punch group and 58 ± 14.8 in the excision-grafting group, p=0.99. After surgery, all patients had a straight penis. No tunical perforations, urethral injuries, or extrusions were noted. Average additional operative time for Punch technique ranged from 5 to 10 minutes (7.3 ± 1.7), in contrast to the excision-grafting group where plaque surgery duration was 50.8 minutes ± 11.1, an 85% difference, p < 0.0001. Septal plaques in the latter group could not be removed. In the PPI-Punch group, penile sensitivity was preserved in all patients, compared with the excision/grafting group, with 7 of 18 patients reporting hyposthesia of the glans. Infection occurred in 1 of 26 patients in the PPI-Punch group, compared with 2 of 18 patients in the excision/grafting group. Satisfaction with length on a 5-point scale was 3.8 ± 0.9 in the punch group, versus 3.1 ± 1.1 in the excision-grafting group, p=0.009. Clinical ImplicationsThe proposed technique is minimally invasive and prompt, possibly decreasing the known complications of plaque surgery and PPI including sensory loss. Strengths & LimitationsOne limitation is the inability to accurately measure preoperative erect length in patients with erectile dysfunction with poor response to intracavernous injections. ConclusionShaeer’s punch technique is a minimally invasive procedure for transcorporeal excavation of Peyronie’s plaques before penile prosthesis implantation, omitting the need for mobilization of the neurovascular bundle or spongiosum, and hence, there is low or no risk for nerve or urethral injury and brief plaque surgery time.Shaeer O, Soliman Abdelrahman IF, Mansour M, et al. Shaeer’s Punch Technique: Transcorporeal Peyronie’s Plaque Surgery and Penile Prosthesis Implantation. J Sex Med 2020;17:1395–1399.