Peyronie Introduction

Peyronie's (PD) disease is characterized by scaring of the tunica albuginea which losses elasticity, resulting in different deformities including curvature, shortening, narrowing, and hinge effect. In the early phase there is often an inflammatory component that causes pain. Classically, two phases of disease are described: acute, active and chronic, stable although it is often difficult to define a clear border between these two stages and to predict the progression of disease. PD has major influence on quality of life and serious psychological consequences. Incidence is 3-10% among the male population and commonly found in man between 40 to 70 years old, however it may affects younger men under 30 years. PD is commonly associated with erectile dysfunction, ranging from 20 to 54%. Surgery could be played when the disease becomes stabile. Howewer the concept of stabile disease has not been clearly defined, but is generally accepted to be at least six months-one year of disease characterized by no change in deformity and when pain during erection or plaque palpation has been resolved. The surgical candidate should also refer a compromise or inability to engage in coitus secondary to deformity or inadequate rigidity. In addition, a patient who has medical treatment failure and has extensive plaque calcification, is a proper candidate for surgery. Lastly, the patient who wants the most rapid and reliable results should select a surgical approach. Surgical treatment remains the main treatment option in great majority of patients. The goal of surgical treatment is complete penile resculpturing, restoration of penile length, girth and shape. In patients with impaired erectile function simultaneous implantation of penile prosthesis is indicated.

Preoperative consent

is critical for preparing patients with PD for surgery. Many of these men are depressed, have marked reduction of self esteem, and they often have unattainable expectations regarding the outcome from surgical reconstruction. Therefore, a detailed discussion on severity of curvature should be initiated with accepted goal of making the patient "functionally straight", which we define as a curvature of less than 15 degrees. Informed consent also involves loss of penile length, diminished rigidity, sexual sensation and problems with orgasm and ejaculation. Patient must be informed that, in some cases, progression of disease is unavoidable, and there is no exact parameters to predict it. Progression usually appears several months later or within 2 or 3 years.

Preoperative evaluation

should include the complete clinical history of the patient as well as assessment of comorbidities, such as diabetes, arterial hypertension, smoking, alcohol consumption, the cardio-vascular conditions, signs and symptoms of hypogonadism and regular medications which may affect erection. It is imperative to measure preoperatively the stretched penile length, thus patients could realize that the length loss postoperatively is mainly a result of the disease itself and not of the surgical treatment. Erection and rigidity assessment are subjectively reported by the patients (IIEF5 test). These laft parameters and the penile deformity are objectively evaluated by intracavernous injection (ICI) of alprostadil (10-20ug). Doppler ultra-sound (DUS), provides essential data for vascular assessment (arterial insufficiency and/or veno-occlusive dysfunction) as well as detection and localization of collateral vessels between dorsal and cavernous arteries. Information on penile arterial anatomy may be very useful to the surgeon in selecting the type of surgical technique to be used. The indication for surgical treatment is penile deformity, not the plaque. Surgery should focus on deformity correction, rather than on plaques. It is important to stress out that grafting procedure without penile prosthesis implantation is recommended only for men who have good quality of preoperative erection.

Surgical alternatives

Operative techniques used by our Team and 'Sava Perovic' Foundation's Team are determined on the procedures which are based on geometrically determined incision or incisions. The aim of surgery is restoration of a penile shape by penile straightening, lengthening and widening, to satisfy patients expectations as much as possible. Surgical options for severe Peyronie's disease can be organized into several categories: single graft procedure, complex graft procedure including real corporal lengthening with complete circular tunical incision. In patients with erectile dysfunction, all of these surgical options are combined with penile prosthesis implantation.

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