Surgery for Peyronie’s Disease: Weighing the Options

[Dr. Jonathan Clavell]
Seeing a patient with Peyronie's, it was the greatest thing because, at that time, when I was a resident, I still remember we had to wait one year without any changes before considering treatment. Whenever the patient presented, I always ask them, so how long have you had the curvature, or when was the last time you noticed a change? If they told me, "Doc, it was three months ago," I'm like, "Okay, well, great, I'll see you in nine months." Then we go on to the next patient. Those conversations tended to be very quick. Now, it's very different.

Now, we considered the stable phase when they have had no changes within three months. I always ask them, "When was the last time you noticed a change?" If they have a picture, I ask them, "How long has your penis been like this? Has it changed?" We need to know these things as it may change our treatment algorithm a little bit. Right now, it's very important that we remember that it's only three months before a change for us to consider it to be within the stable condition.

[Dr. Jose Silva]
Pain is no longer a determinant in that sense? It's just the change in angulation.

[Dr. Jonathan Clavell]
That's very interesting because, again, patient who presents with penile pain, first of all, penile pain alone is not considered Peyronie's disease. Pain in the penis can be secondary to infection. It can be potential nerve entrapment, it can be pelvic floor dysfunction. There are so many things that can be causing penile pain. However, when you have pain in combination with an acquired deformity, it can be considered Peyronie's. Another thing we need to remember is that, just like you're saying, pain is a subjective complaint.

There recently was a debate on Twitter regarding a review article published by the Mayo Clinic, in which they were discussing the inconsistencies in the literature when it comes to differentiated acute versus chronic disease. Pain is one of the things that is considered inconsistent. Why? Because pain is objective. Many men can have stable curvature or deformities for months or even years but if they also have a good, strong erection, that scar tissue will start tethering on that erection, that tunic albuginea, and the patient can complain of pain. The other thing that I also take into consideration is, are we talking about pain or are we talking about them having discomfort? Again, with Peyronie's disease, the scar tissue is not allowing the penis to stretch out to its full capacity, therefore, if you have a patient who has a strong erection and that scarred tissue is holding the penis back, it will at least be uncomfortable. Not a reliable indicator at least for me.

[Dr. Jose Silva]
In terms of pain with erection versus, really it's a matter of the curvature. Will that symptom of erection of pain with erection versus will push you toward thinking something else?

[Dr. Jonathan Clavell]
I offer all surgical procedures depending on what they're willing to risk. I'm going to repeat that. I offer all surgical procedures and it depends on what they are willing to risk. I explained there are three categories. Number one, Peyronie's Disease plication surgery; number two, grafting procedures; and number three, penile implant. The cool thing about this is that we can even combine these to give a better result for men. Whenever we are offering treatment options to these men, remember, again, this is a quality-of-life issue, not a matter of life and death. We already discussed that.

The patient, the individual patient should be the one deciding what they want. We can orient them and we can inform them about the risks and benefits of each option. We need to always explain the risks of each procedure. For example, men with plication. What's the biggest risk? Penile shortening. You could also have problems with sensation, recurrence of curvature, small risk of worsening erectile dysfunction, but the main risk is penile shortening.

Men undergoing grafting procedures, what's the biggest risk? Erectile dysfunction. Usually, there's about a 20% to 30% chance of having worsening ED. Even though smaller risk, there could also be risk of shortening. These require more attention post op as well. Specifically, if they have a big plaque.

Whenever I talk about grafting procedures without placing an implant, we have to explain to the patients that, "Hey, you have to massage your penis post-op. You have to do some traction therapy post op. If you have some contraction of that graft, you might need a vacuum pump." In general, we try to incise rather than excise because with excision, the risk of erectile dysfunction is worse because the veno-occlusive mechanism within the penis can actually get worse whenever you excise a plaque versus whenever you incise a plaque.

Then the other thing we have to take into consideration is what graft material will we be using? Are we going to be using Tutoplast or are we using one of these newer hemostatic patches like TachoSil, EVARREST?

Then the other things that we need to take into consideration, the risk factors when it comes to penile implant. Is the patient diabetic? Is a patient a smoker? Does he have peripheral vascular disease? Are we risking ischemia of his penis? Most importantly, what are the patient's goals? Does he want to be functionally straight or does he want to be straight like an arrow? Does he want to restore length? Does he not want to risk losing sensation? Because as a surgeon again, we need to be equipped to tackle these complex cases.

If you're not comfortable doing these complex cases, you should probably refer them out. Are you as a surgeon equipped to tackle these complex cases? Adjunct procedures, elevated neurovascular bundle. Is it better to refer out? I remember even when I graduated from fellowship and I started out, I had two very complex cases that presented to my office. I'm like, "You know what? You should go see this other doctor because I don't feel comfortable taking care of you right now." Again, I did a fellowship in this.