peyronie’s disease 30 minutes · presentation and natural history • curvature - improves in...
TRANSCRIPT
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June 23, 2017Floyd A Fried Advances in Urology Symposium
Brad Figler MDDepartment of Urology
University of North Carolina-Chapel Hill
Peyronie’s Disease
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OUTLINE• Introduction
• Presentation and natural history
• History & physical exam
• Management – active phase
• Management – stable phase
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INTRODUCTION• Inelastic scar of the tunica albuginea secondary to trauma
• Prevalence: 3.2 to 8.9%
• Palpable scar
• Pain (secondary to inflammation)
• Erectile deformities:- Curvature- Shortening- Narrowing- Hinge effect
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PRESENTATION AND NATURAL HISTORY• Curvature
- Improves in 12%; worse in 48%- Usually stabilizes by 12 months
• Narrowing: 12%
• Unable to have intercourse: 22%
• Loss of penile length: 84% over 18 months (mean 2cm)
Mulhall et al. J Urol (2006)
Dorsal(72%)
Ventral(17%)
Lateral(11%)
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DIAGNOSIS• History
- Curvature/narrowing/hinge- Change in deformity- Pain- Presence of ED- Loss of length- “What’s your goal?”
• Physical Exam- Stretched penile length- Plaques – location, size, tenderness
• Assess erectile deformity- When considering treatment- Most helpful in stable phase
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ASSESS ERECTILE DEFORMITY
• Intracavernosal injection- Measure curvature- Evaluate for narrowing, hinge, distal flaccidity- Evaluate erectile function
• Ultrasound- Characterize plaque- Other penile lesions
• Doppler for hemodynamics
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TREATMENT – ACTIVE PHASE (AUA GUIDELINES)
• NSAIDs for pain management
• May offer- Intralesional verapamil (weak evidence)- Extracorporeal shock wave therapy (ESWT) for pain
(risk of adverse events, particularly increased pain)
• Not enough data: Colchicine, pentoxifylline, potaba, Co Q-10, topical Magnesium, topical verapamil, topical or intralesional LrhSOD, electromotive therapy, traction
• Do NOT offer:- Oral Vitamin E, tamoxifen, procarbazine, Omega-3 fatty acids- Electromotive therapy with verapamil- Radiotherapy- Extracorporeal shock wave therapy (ESWT) for curvature
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TRACTION FOR ACUTE PHASE PEYRONIE’S• N=55 (acute phase) vs N=41 (control)
• Traction 6-9 hours/day (not during sleep)
• Rest at least 30 minutes every 2 hours
• Recommend because- Pts feel empowered- Downside is minimal
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TREATMENT – STABLE PHASE (AUA GUIDELINES)
• Intralesional therapy- Xiaflex- Interferon
• “Shortening”(e.g., Nesbit, plication)
• “Lengthening”(e.g., incision/excision + graft)
• Inflatable penile prosthesis (IPP)
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“LENGTHENING” SURGERY
• Plaque is excised or incised; defect filled with graft
• Autologous- Temporalis fascia- Tunica vaginalis- Dermis- Saphenous vein
• Non-autologous- Cadaver pericardium- Bovine pericardium- Porcine small intestine submucosa (SIS)
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TUNICAL LENGTHENING
• Circumcising incision
• Elevate neurovascular bundle
• Incise plaque
• Apply graft
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INCISION AND GRAFT - OUTCOMES
Kalsi et al (2005). Knoll et al (2007). Talor et al (2008)
• 3 studies (N=356, mean f/u 12-58 months)
• Effective for curvature: 79-91%
• Side effects• de Novo ED: 15-20%• Glans numbness: 9-17% (resolved in 80-100%)
• Length reduction• Measured: 29-33%• Subjective: 59%
• Effective for curvature, but not a lengthening surgery
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“SHORTENING” PROCEDURES• Nesbit (1965): Resect tunica albuginea
• Saalfeld (1973): Heineke-Mikulicz
• Essed-Schroeder (1985): No tunica albuginea incision
• Lue (1992 & 2002): “No touch” 16-dots
• Hudak (2013)- Complex curvature- 2cm longitudinal incision
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PLICATION - OUTCOMES• Baseline Curvature
- Hudak: simple (51%), complex (42%)- Gholami: mean 64° (range 30°-120°)
• Effective for curvature: 93-96%
• de Novo erectile dysfunction: 3%
• Measured penile length decrease: 16%• Perceived loss of penile length: 78%
• Effective for curvature with minimal side effects/shortening
Hudak et al (J Urol, 2013). Gholami et al (J Urol, 2002)
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PLICATION – ADVERSE EVENTS
• Bother from suture knots: 12%
• Pain with erection: 11%
• Decrease in penile sensation: 6%
• Hematoma: 4%
• Rare- Dysuria/urinary retention- Phimosis
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Plication GraftN 87 101Pt reported curvature No difference No differenceRigidity in 19% in 32%; 50%Measured length in 18% in 33%
PLICATION VS GRAFT – HEAD TO HEAD STUDIES
Kim et al. J Urol (2008). Taylor et al. J Sex Med (2008)
• Plication and graft are both effective for curvature• Plication less morbid
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• FDA approved 2013: Palpable plaque, stable, ≥30°
• 2 injections Q6 weeks x 4
• Improvement: 32.4% (17.5°)
• Modeling is necessary
• Adverse events- Bruising (87%%)- Edema (45%)- Pain (52%)- Rupture (0.5%)
XIAFLEX
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XIAFLEX: POST-APPROVAL PROVIDER SURVEY (n=100)• Protocol modifications
• Compressive dressing: 63%• Anti-platelet/anti-coagulation: 46%• Patient modeling: 89%• Penile stretching device: 39%
• Corporal rupture: 34% (median 5, range 0.5 – 30) days- Cause
- Vigorous intercourse (38%)- Nocturnal erections (31%)
- Surgical intervention: 67%
• Effective (~30% improvement), safe, well tolerated
Yafi et al. J Sex Med (2016)
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TRACTION AFTER PEYRONIE’S SURGERY
• Post-op: Traction vs control
• Mean length change (post-op vs pre-op)
• No perceived length loss if using traction
• Recommend because- Pts feel empowered- Downside is minimal
Rybak et al (2012)
Traction No traction P Value
Plication 0.9 0.5 <0.001
Graft 1.5 0.2 <0.001
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PENILE PROSTHESIS FOR PEYRONIE’S + ED
• Evaluate erection before placing prosthesis (in office or intra-op)
• Techniques - curvature- Plication- Modeling- Scratch- Yachia (Heineke-Mikulicz) corporoplasty
• Techniques – narrowing- Scratch- Incision ± Graft- Narrow cylinders
- Titan Narrow- AMS CXR
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PEYRONIE’S DISEASE - SUMMARY
• History & physical- Change in deformity- Pain
• Assess deformity with intracavernosal injection
• Active phase – management options limited (NSAIDs)
• Stable phase- Graft best for narrowing and good erectile function- Plication effective and minimally invasive- Xiaflex safe and effective- IPP for significant ED