Peyronie’s disease: surgical options

Surgery for Peyronie’s disease (PD) should only be offered to patients with stable disease and evident functional impairment. In PD patients with concomitant erectile dysfunction (ED) unresponsive to medical treatment, penile prosthesis implantation with or without additional straightening procedures is recommended. In other cases, factors such as penile length, erection rigidity, degree of curvature, the presence of complex deformities, and patient choice must be taken into account in order to decide on a tunical shortening or lengthening technique.

The current decision-making tree for surgical approaches in PD (see Figure) was presented by Dr Juan Ignacio Martínez-Salamanca (University Hospital Puerta de Hierro Majadahonda, Spain) [1,2]. Surgery indications are stable disease for at least 6 months, compromised ability to have coitus, extensive plaque calcification which may or may not respond to collagenase, failed conservative treatment, and a strong desire of the patient for complete resolution of the curvature [1].

Figure: Decision-making tree for PD management, including surgical and medical approaches. Based on the EAU Guidelines [2]



PD, Peyronie’s disease; ED, erectile dysfunction; NSAIDs, non-steroidal anti-inflammatory drugs; LI-ESWT, low-intensity extracorporeal shock waves therapy; CCH, collagenase Clostridium histolyticum; IFN, interferon.
Figure adapted from the EAU guidelines 2020.

The outcomes of tunical shortening procedures indicate that significant shortening occurs in less than 10% of individuals, although any amount of shortening occurs in 30-40% of patients. However, outcomes are good, with very low rates of de novo ED, as well as low penile hypoaesthesia rates. High satisfaction rates are reported. On the other hand, tunical lengthening procedures have a 90% success rate, although patients should be advised that some shortening could happen. However, de novo ED was high, up to 20-25% post procedure.

The recommendations, as listed by Dr Martínez-Salamanca, are [2]:

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    • Perform surgery only when PD has been stable for at least 3 months without pain or deterioration of the deformity;
    • Prior to surgery, assess penile length, curvature severity, erectile function, and patient expectations;
    • Use tunical shortening procedures as the first treatment option for congenital penile curvature or for PD with adequate penile length and rigidity, non-severe curvature, and absence of complex deformities. The type of procedure used is dependent on surgeon’s and patient's preference;
    • Use tunical lengthening procedures for patients with PD and normal erectile function without adequate penile length, severe curvature, or presence of complex deformities such as hourglass or hinge shapes;
    • The type of graft used is dependent on the surgeon and patient factors, no graft has proven superior;
    • Do not use synthetic grafts in PD reconstructive surgery;
    • Use sliding techniques with great caution as there is a significant risk of life-changing complications such as glans necrosis;
    • Use penile prosthesis implantation with or without any additional procedures such as modelling, plication, incision, or excision with or without grafting in PD patients with ED not responding to pharmacotherapy.

Dr Martínez-Salamanca ended with take-home messages: (1) try to individualise each patient, to form an approach in line with the guidelines; (2) engage in an extensive discussion with your patient before surgery, balancing the patient’s expectations against real outcomes and the practitioner’s own experience; (3) be certain the surgeon and entire surgical team is fully trained and skilled, even to fix major complications. However, should complications occur, keep the patient updated and discuss all options openly.

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   1. Martínez-Salamanca JI, et al. EAU20 Virtual Congress, 17-26 July 2020.
   2. EAU Guidelines. Edn. presented at the EAU Annual Congress Amsterdam 2020. ISBN 978-94-92671-07-3.

Posted on 24 August 20205 August 2021