Multiple plaque incisions with or without grafting for Peyronie's disease

Abstract Objectives To assess novel surgical techniques in management of Peyronie's disease. Subjects Forty‐three men underwent corrective surgery using either partial plaque incision and nongraft (PPING) or multiple plaque incisions and graft (MPIG). The technique used was determined intra‐operatively. Patients were assessed at baseline and follow‐up based on Peyronie's disease questionnaire patient‐reported outcome measure (PDQ‐PROM) and erectile function. Results The two groups were well matched in age and erectile function. At baseline MPIG group had greater deformity and poorer patient‐reported outcome. Penile curvature improved from 67.9° to 10.5° in the PPING group and 77.9° to 7.1° with MPIG. PDQ‐PROM improved from 29 to 13 in those who underwent PPING and 38.5 to 17.6 in those undergoing MPIG. Erectile function was preserved in both groups. Conclusions These novel surgeries are effective in restoring penile shape and length while preserving erectile function. This is reflected in improved patient‐reported outcomes. These findings should be verified by multi‐institutional study.


| INTRODUCTION
Peyronie's disease (PD) is a common but poorly understood condition.
Incidence increases with age and affects 3%-20% of men depending how incidence is studied. 1,2 Fibrosis of the tunica albuginea may cause deformity and shortening of the erection to the extent of limiting or precluding penetrative intercourse. The management of PD ranges from oral agents 3,4 in the acute phase to traction therapy, 5 plaque injection, 6,7 and various surgeries. [8][9][10][11] The two main strategies of corrective surgery are either to shorten the convex side diametrically opposite the site of deformity or to incise the plaque and graft to eliminate the concavity. These have inherent limitations. Shortening the convexity is thought to reduce erect length by 1 cm for every 30 corrected. This can be achieved by excising an ellipse such as in the Nesbit, 8 use of the Heineke-Mikulicz principle as in the Yachia,9 or the use of plicating sutures. 10 Incision and grafting is described by Lue 11 whereby the plaque is typically incised transversely with extension longitudinally or obliquely at each end of the transverse incision to create a rectangular defect in the tunica albuginea where a graft such as vein or xenograft is applied. This can achieve straightening of the erection without loss of length; however, erectile dysfunction is reported in up to 45% of men undergoing this surgery. 11 As the tunica albuginea has two layers, inner circular and outer transversely across the plaque was developed. For patients in whom this is insufficient to straighten, full thickness incisions can be made.
Collagen fleece (TachoSil, Takeda Pharmaceutical Company Limited) has been used to bridge defects when inserting a penile prosthesis. [12][13][14] We have developed this further to cover multiple defects on a functional penis without need for suturing. The concept of multiple transverse incisions is to limit the damage to subtunical veins and smooth muscle thereby protecting erectile function. We describe a prospective series of men undergoing these surgeries. The aim is to assess the surgery in terms of patient satisfaction and measurement of deformity and length. The two procedures are described together as the decision for the need to graft or not is made intra-operatively on an intention to treat basis.

| Population
Ethical approval for this study was granted by Clinical Research Ethics were also instructed on how to model the penis in the flaccid state in the initial days after surgery when vacuum therapy was not feasible.
Vacuum therapy was used so as to maintain the benefit of surgery.
Traction therapy was not used perioperatively so as to not confound the results of surgery. All data was entered on an Excel database.
Two-tailed Student t-tests were used for comparison of pre-operative and postoperative data. Statistical significance was defined as p < 0.05.

| Surgical technique
All cases were under general anesthetic in the supine position. An artificial erection was established using saline via a butterfly needle placed through the glans penis into one corpus cavernosum to confirm the curvature prior to degloving the penis ( Figure 1A). Once degloved ( Figure 1B), the erect length from pubis to meatus was recorded along with the curvature using a goniometer. Buck's fascia was mobilized via the dorsal midline over the deep penile vein in most case where the target plaque was predominantly dorsal or paraurethrally if mostly ventrally located. Exposure was to include normal tunica for at least 1 cm beyond plaque. The plaque was then marked with a surgical marking pen.

| Partial plaque incision Nongraft
Multiple transverse incisions 2-3 mm apart were made with a size 15 scalpel transversely through the plaque and extended into normal tunica albuginea for up to 1 cm ( Figure 1C). These were made shallow enough to preserve the inner circular fibers. If there was a small breach into the corpus cavernosum, this was closed with a horizontal mattress suture of 2/0 polyglactin. Larger breaches required grafting and reflected a thicker plaque involving the inner tunical layer. As the inner layer is preserved, it is easy to frequently check the gradual correction of the deformity. Provided the curvature was reduced to 10 or less, there was no need to progress to MPIG. Buck's fascia was closed with 3/0 polyglactin running suture. If there was any concern about hemostasis of that layer, a liquid haemostatic agent (Surgiflo, from Ethicon) was applied deep to Buck's fascia prior to passing the final sutures ( Figure 1D). The penile layers were restored with closure

| Multiple plaque incisions and graft
These were cases where the PPING was insufficient to straighten the penis or where there was complexity such as waist deformity. The decision to proceed to MPIG was made intra-operatively (Figure 2A).
Here the incisions are again 2-3 mm apart made through the plaque with a size 15 scalpel ( Figure 2B). If there was a waist deformity, the incisions may have been oblique or longitudinal to restore the shape.
The concept was not to excise any of the tunica thereby protecting subtunical veins and erectile tissue and to provide a scaffold over which the fleece is applied. The collagen fleece was then applied with a 1-cm margin beyond all incised areas ( Figure 2C). Manufacturer's instructions were followed by applying it dry without touching and activating with a damp sponge for 2 min. Buck's fascia is closed over this in the same way as the PPING (Figure 2D), followed closure of Dartos fascia and skin. Supporting the applied graft with an overlying sponge allows for checking of the final shape and if necessary further incisions made. Dressing and postoperative care is the same as the PPING.

| RESULTS
The pre-operative findings are summarized in Table 1. The groups were similar in age. Those undergoing MPIG had a statistically significant greater deformity and poorer PDQ-PROM compared with those who underwent PPING.
The outcome of surgery is described in Table 2

| CONCLUSION
These surgeries are effective in restoring penile shape and length without compromise of erectile function. This is reflected in improved patient-reported outcomes when compared with their scores at baseline. These findings should be verified by multi-institutional study.