Saturday, 22 August 2009

Surgery

In cases where curvature is significant (usually indiciated by the ability to comfortably have sexual intercourse), some men choose to undergo a surgical procedure. Surgery should not be considered where the condition is not entirely stable, as further changes to curvature post surgery will negate undergoing surgery to begin with. As a general rule, you should be painfree for six months and not undergoing further physical changes before you consider this option. Waiitng 9-12 months would not be unwise.

There are several different approaches to sugery and the condition of your penis typically dictates the procedure you will undergo. Plication is typically carried out on men with a less prounced curve, and the grafting surgeries are more suited to men with curves over 40 degrees.

Plication - This is typically seen as a less invasive and more straightforward surgical option than others, and involves shortening the convex side of the curvature (so essentially not touching the scarred side at all). It involves placing stitches opposite of the PD scar resulting in the penis being straightened, or thereabouts. This type of treatment cannot treat bottleneck or hourglass deformaties, it is used to treat simple curvature. As with many procedures, improvements are made to the procedure over time. This is true of plication, and Dr Lue's 16 dot technique, is a slightly updated version of the procedure.

Incision and Grafting and Excision and Grafting - With "Incision and Grafting", shallow incisions are made in the scar tissue. This is done to open up the plaque somewhat. A graft (autologous or synthetic) is used to effectively patch up these incisions. In "Excision and Grafting" the scar tissue is actually removed and replaced, again with a graft. With grafting satisfaction is typically high, but for a minority of men erectile dysfunction can become an issue, as well as loss of sensitivity. There are various oral treatments for ED though, and for many men these are effective.

Penile Implant Surgery - For cases where erectile dysfunction is not helped by testosterone injections, viagra and other ED treatment options, penile implant surgery may be the only available route.

Depending on the surgery in question, loss of length may occur during the procedure. Therefore some men attempt to minimise this by using a traction or vacuum device for several months in order to stretch the scar tissue and reduce curvature somewhat before undergoing surgery. In much the same way, men often use vacuum therapy after surgery in order to exercise the penis and reduce any scar tissue and ED issues that may develop post surgery.

2 comments:

Richard said...

This is an excellent executive summary on Peyronie's -- except for your link to your 1 Sept post. Are you going too far when you promote Dr Lue's plication solution (1 Sept) as a "cutting edge version of the procedure" when it straightens only 85% of his patients and 41% end up with a shorter penis? Those figures mean that calling plication an "important" tool in 2009 is becoming very debatable and the surgery usually inadvisable since, at best, it is only appropriate for men with minimal curvature. Why take such a very high risk of a shorter penis and 15% chance of continued curvature?

JB said...

My question for Richard is: what other therapy on this site works 85+% of the time for Peyronie's disease? As a urologist that specializes in Peyronie's treatment (surgical and non-surgical) I and perhaps others have encouraged the editor of this site to discuss all options when discussing PD therapy.

The advantages of plications are many. Corrections are instant and durable. No months of pills, traction, vacuum, and praying. Penile shortening does NOT happen in most, and in Dr. Tom Lue's paper to which you refer (J Urol 2002; 167: 2066.) MOST men (that is, 59%) did not experience shortening at all. Those that did note shortening of the penis had shortening between 0.5-1.5cm.

Also, Dr. Lue sees some of the most difficult cases from around the country. Indeed, in this paper, plication was attempted in men with up to 120 degrees curvature. Some degree of shortening is guaranteed in this type of extreme plication. When correcting a more reasonable curvature experienced by most men (30-45deg) loss of length is often negligible. De novo ED after plication in this study was low, under 3.5% (4 patients), consistent with others’ reports.

Urologists are not out to shorten men. The penis curves in PD because there is a short side and a long side to the corporal bodies. Plication just makes the longer side equal length to the existing short side, which has shortened due to the Peyronie's plaque. The plaque already did the shortening; the plication just takes up slack on the unaffected side so the penis is straight. Care can be taken to make the penis functionally straight (rather than arrow straight) to lessen the possibility of shortening. For example, I can correct the penis from 40 degrees dorsal curve to 10 degrees, rather than all the way to 0 degrees. The penis is then functionally straight within the realm of normal variants, intercourse is possible again, and loss of length is minimalized.

If you read the 2002 Lue paper carefully, I would strongly point out that while 15% of the 124 patients reported recurrence of penile curvature, it was severe in only 4 of these men (3%).

Plication is a very successful, instant cure for the majority of men. Many of Dr. Lue's patients in this case series were re-do surgeries from previous failed attempts, also, which may make complications more likely in this cohort.

Many men have busy schedules or may have small children in the home that prevent the ability to wear traction for 2-4 hours a night for months. Peyronie’s patients that are non surgical purists will quickly and unwaveringly shun surgical options, but in my urology practice, plication is a very valuable tool for the treatment of stable Peyronie’s curvature in men with good pre-operative erectile function. I much favor plication over corporal lengthening procedures (higher risk of de novo ED (20-30%), significant risk of late fibrosis/shortening.)



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