LONG-TERM
PATIENT SATISFACTION AFTER SURGICAL CORRECTION OF PENILE CURVATURE VIA
TUNICAL PLICATION
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ALVARO PAEZ, JUAN
MEJIAS, JORGE VALLEJO, IGNACIO ROMERO, MIGUEL DE CASTRO, FERNANDO GIMENO,
ON BEHALF OF GRUPO UROLOGICO DEL SUROESTE MADRILENO (GUSOM)
Department
of Urology (AP, JV), Fuenlabrada Hospital, Madrid, Spain, Department of
Urology (JM), Severo Ochoa Hospital, Madrid, Spain, Department of Urology
(IR), Getafe University Hospital, Madrid, Spain, Department of Urology
(MC, FG), Mostoles Hospital, Madrid, Spain
ABSTRACT
Objective:
To assess patient satisfaction and functional results at long term follow-up
after surgical correction for Peyronie’s disease (PD) and congenital
penile curvature (CPC) with the technique of tunical plication.
Materials and Methods: One hundred and two
men operated for PD (n = 76) or CPC (n = 26) in four different departments
of urology in public hospitals agreed to answer a six-question telephone
questionnaire about treatment satisfaction. Tunica albuginea plication
procedures represented the standard surgical approach. Subjects under
investigation were correction of the deformity, feeling of bumps under
the skin, pain during erection, penile sensory changes, development of
erectile dysfunction (ED) and postoperative ability for complete vaginal
intromission. Subjective response rates were compared using the chi square
test on the basis of the etiology of the disease (CPC or PD).
Results: Significant differences (p <
0.05) between patients with CPC and PD were noticed in the prevalence
of postoperative penile deformity, sensory changes, ED and ability to
complete vaginal intromission, PD patients always showing a more pessimistic
view. No significant differences (p = ns) were detected in terms of unpleasant
nodes under the penile skin or pain during erection.
Conclusions: Long-term outcome after surgical
correction for PD and CPC with the technique of tunical plication can
be poor. Probably patient expectations are above the real performance
of surgical techniques. Preoperative information should be more exhaustive.
Key
words: penis; Peyronie’s disease; surgery; erectile dysfunction
Int Braz J Urol. 2007; 33: 502-9
INTRODUCTION
Peyronie’s
disease (PD) and congenital penile curvature (CPC) are the most frequent
causes of penile deformity. PD is an acquired disorder of the tunica albuginea
of the penis characterized by the formation of a plaque of fibrotic tissue,
which may be associated to penile deformity, pain on erection and erectile
dysfunction (ED). PD affects up to 9% of men (1,2). CPC is caused by asymmetry
in compliance of tunica albuginea of the corpora cavernosa due to developmental
arrest during embryogenesis (3). Mostly, ventral and/or lateral deviation
of erected penis occurs. The reported prevalence of this condition is
0.04 - 0.6% (4,5).
Pharmacologic therapy has limited efficacy
in both entities. Surgical treatment is necessary when significant curvature
does not allow coitus. Rarely, penile deformity is also associated with
psychological problems in adults with PD disease, but this is a frequent
concern in younger patients.
While postoperative satisfaction is the
rule, a number of patients find some side effects of surgical procedures
unacceptable; apart of residual curvature, frequent reasons for dissatisfaction
are unpleasant feeling of bumps under the skin (6), penile sensory changes
and penile shortening (7), among others.
The aim of our questionnaire-based study
was to assess patient satisfaction and functional results at long-term
follow-up after surgical correction for PD and CPC using tunical plication
procedures.
MATERIALS
AND METHODS
Two
hundred and forty men operated for PD or CPC throughout a 16-year period
(January 1990-December 2005) using tunical plication techniques were contacted
by telephone and invited to answer a six questions questionnaire about
treatment satisfaction.
For different reasons (wrong telephone numbers,
patient or spousal reluctancy) telephone contact was impossible in 124
cases. Eventually contact was substantiated in 118 cases. One hundred
and two patients (102/240, 42.5%) agreed to participate.
Difficulty with intercourse was the most
frequent preoperative complaint (82/102, 80.4%). Poor self-image accounted
for the rest of consultations (20/102, 19.6%). At the time of surgery,
the disease was stable for at least 1 year, and there was no pain.
The diagnosis of PD was based on a palpable
penile plaque or acquired penile curvature. Preoperatively the deformity
was assessed from self-photographs. Degree of angulation was not recorded.
No reliable records on preoperative potency were available. Nevertheless,
it is not our policy to use plication procedures in PD or CPC patients
also diagnosed with ED; it could be indirectly induced that patients in
our study were potent before surgery.
Thirty-one different urologists in four
different public hospitals participated in operations. Circumcision was
performed to avoid postoperative edema and paraphimosis. After penile
degloving, a tourniquet was applied at the base of the penis to facilitate
artificial erection injecting saline into the corpora cavernosa through
small gauge butterfly needles. Tunica albuginea plication procedures represented
the standard surgical approach; briefly, Buck’s fascia opposite
to the point(s) of maximal curvature was incised to expose the tunica
albuginea. No major differences between PD and CPC cases in terms of tissue
dissection could be accounted. Care was taken to avoid injury to neurovascular
structures. Transversal or longitudinal (Yachia’s modification for
treatment of CPC) plication sutures of unabsorbable materials (mainly
polyester) were placed through the full-thickness of the tunica albuginea.
A new artificial erection was created at the end of the procedure to confirm
that penile straightening was adequate. Once correction was achieved,
the penis was closed in layers and a light compression dressing applied.
A specialized clerk assistant contacted
all patients. Subjects under investigation were postoperative correction
of the deformity (yes/no), feeling of bumps or lumps under the skin (yes/no),
pain during erection (yes/no), penile sensory changes (yes/no), diminished
erection (yes/no) and inability to complete vaginal intromission due to
penile deformity (yes/no).
Subjective response rates were compared
using the chi square test on the basis of the etiology of the disease
(congenital or acquired). A commercial software (SPSS v.11.5) was used
for statistical treatment. Confidence intervals (CI) of 95% were used
for all comparisons.
RESULTS
Median
time from the intervention to the interview was 56 months (min 1, max
194). Mean age at surgery was 48.6 years (SD 15.4, min. 12, max. 69).
Table-1 shows the principal patients’ characteristics at diagnosis.
According to the patient answers, correction
of the curvature was only achieved in 50% of the cases (51/102). Similarly,
41 patients (41/102, 40.2%) complained of suture-related complications
as unpleasant feeling of bumps under the skin; in 24.5% of the cases (25/102),
pain was present during erection while 56% (57/102) suffered penile sensory
changes. Forty-eight patients (48/102, 47.1%) declared some degree of
postoperative ED while 46 out of 82 (46/82, 56.1%) preoperatively unable
to have vaginal penetration due to penile deformity were eventually able
to complete sexual intercourse.
A significant difference (chi square = 0.006)
was noticed in terms of subjective improvement in penile deformity between
patients with CPC (19/26, 73.1%) and PD patients (32/76, 42.1%). Also,
postoperative sensory changes were significantly more prevalent (chi square
= 0.001) among PD patients (50/76, 65.8%) compared to patients with CPC
(7/26, 26.9%). Different degrees of postoperative ED were significantly
more prevalent among PD patients (60.5% and 7.7% for PD and CPC patients,
respectively). The proportion of men with CPC able to complete vaginal
intromission after surgery (15/17, 88.2%) was significantly higher (chi
square = 0.003) compared to the results in PD patients (31/65, 47.7%).
No significant differences (p = 0.21) were detected in terms of unpleasant
nodes under the penile skin or pain during erection. Table-2 summarizes
this phase of the study.
COMMENTS
Treatment
end points after surgical correction for penile curvature include erection
that is pain-free, coitus comfortable for patient and partner, and deformity
that does not interfere with vaginal intromission.
Overall, the reported success rate with
tunica albuginea plication procedures is 85-100% (8-11); in our experience,
patient dissatisfaction was the rule. Why such discrepancy? Most studies
dealing with postoperative outcome rely on non-validated questionnaires
thus making comparisons pointless (12,13). It is generally agreed that
self-applied validated questionnaires should be used when possible. Nevertheless,
there is no well-structured questionnaire for penile curvature correction.
The present study was based in a telephone interview using a 6-questions
questionnaire elaborated ad hoc. It is difficult to disclose to what extent
it really reflects the domain of patient post-operative satisfaction;
it might well be mirroring dissatisfaction with the medical establishment
or translating couple frustration. In our four centers, tunical plication
procedures are considered “low complexity” surgical interventions;
this is why mainly general urologists participated in surgical interventions.
It remains a matter of speculation if technical aspects were responsible
for the current results. In spite of this limitation, a clear difference
in outcomes was detected between patients with congenital and acquired
disease. It has been suggested that after tunica albuginea plication procedures
the force of penile erection might allow the sutures to cut through the
albuginea layers thus partially explaining a number of failures. This
hypothesis does not explain the differences detected in the present study
between PD and CPC patients. Actually, our results are in contradiction
with already published material, using absorbable sutures where younger
patients (< 24 yr) had a higher chance of suture failure than elder
patients (14).
Long-term results of plication techniques
in the pediatric setting are rarely reported, but success seems to be
the rule (8,9,15,16). In our experience, the long-term degree of subjective
satisfaction among patients with CPC was remarkable and supports the philosophy
of corporoplasty in this setting.
In our study, more than half of the PD patients
declared unresolved difficulties for complete vaginal intromission after
surgery; again, the degree of satisfaction of patients with CPC in this
topic was higher, perhaps reflecting a better long-term anatomical result.
Some authors have raised concerns about
the possibility of postoperative loss of glanular sensation (7,10,11).
In our study, penile sensory changes were more prevalent in PD patients.
While the surgical principles were identical for both PD patients and
patients with CPC, it is unlikely that technical aspects could explain
those differences. Indeed, most of CPC were ventral thus deserving dorsal
plicatures, which theoretically could result in a higher rate of damage
to the dorsal sensory nerves. Anyway, diminished postoperative penile
sensitivity due to irritation and/or damage of the dorsal neurovascular
bundles can be avoided by careful attention to spare the penile dorsal
nerves.
A common problem after plication procedures
is the formation of granulomas around the sutures at the plication sites.
Palpable induration and irregularity have been noted by patients in previous
studies (6,12,15). In this study, postoperative induration was highly
prevalent. Probably this was one of the most objective questions in our
questionnaire thus ending in similar results both for patients with congenital
and acquired (PD) penile curvature.
Postoperative de novo pain during erection
is a frequent complaint after plication procedures (17-19). It can act
against full sexual activity in up to 60% of the patients (17,19). In
this experience, while highly prevalent, no major differences between
patients with CPC and PD were noticed. It is also remarkable the prevalence
of different degrees of subjective impotence among PD patients. Due to
the nature of the study -questionnaire-based and focused in overall results
of plication procedures- it cannot be clarified if the reported incidence
of different degrees of ED really translates late side-effects of curvature
correction or it simply mirrors naturally occurring events. What is evident
is that CPC patients’ answers to question #6 were significantly
more optimistic.
In general, comparisons between men operated
for CPC and PD yield interesting findings. In previous studies, satisfaction
results were almost identical in both settings (16,20). In our experience,
the differences affected all aspects including those related to the curvature
correction, perhaps reflecting a better performance of plication techniques
in the management of totally stable deformity, as in congenital curvatures;
in other words, it might be that patients with PD presumed stable were
still in progression. Otherwise, it is difficult to explain why plication
techniques were more successful in patients with CPC in terms of mere
curvature correction. Given most of them presented with ventral deformities,
it could be argued that Nesbit procedures are more effective in this particular
type of curvature. This has not been proven yet. Another hypothesis to
explain the differences detected in this study is that younger patients
could have a more optimistic approach to the postoperative outcome. It
has been reported elsewhere that quality of life issues heavily depend
on age (21,22).
Anyway, achieving a good correction at the
end of the case (as shown in all cases in our study by creating an artificial
erection) represents a subjective criterion for clinical success that
does not necessarily means that patients will be satisfied in the long
run (11). Quality of life is multifactorial and aspects related with sexual
life can be even more complicated. Subjectivity could be playing a very
important role in this study. A more elaborated approach to the performance
of tunical plication procedures in the field of penile deformity correction
is needed.
CONCLUSIONS
Long-term
results of surgical correction for penile deformity, via tunica plication,
in the hands of general urologists - irrespectively of patient’s
age at surgery and etiology - can be poor. Patient expectations are above
the real performance of surgical techniques. Probably, preoperative information
should be more exhaustive.
CONFLICT
OF INTEREST
None
declared.
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of the tunica albuginea in treating congenital penile curvature. BJU
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corporoplasty for Peyronie’s disease: a review of 218 patients
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- Chertin B, Koulikov D, Fridmans A, Farkas A: Dorsal tunica albuginea
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KP: Treatment of penile curvature with Essed-Schroder tunical plication:
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____________________
Accepted after revision:
March 30, 2007
_______________________
Correspondence address:
Dr. Alvaro Paez
Servicio de Urologia
Hospital de Fuenlabrada
C. Del Molino 2
Fuenlabrada, Madrid, 28942, Spain
Fax: + 349 1600-6186
E-mail: apaez.hflr@salud.madrid.org
EDITORIAL COMMENT
Long
term outcome of surgery for penile curvature is quite important to evaluate
the durability of the procedure and treatment strategies. Authors presented
a poor long term outcome of tunical plication surgery especially in cases
with Peyronie’s disease (PD).
One
crucial point is timing of the surgery. In cases with congenital penile
curvature, the direction of curvature is usually ventral and the surgery
is usually performed at diagnosis. On the other hand, in cases with PD,
their presenting symptoms are plaque, painful erection and penile deformity
at erection, and the surgery should be performed once the disease has
stabilized. There are some differences in treatment strategies between
both groups though tunical placation was performed for penile curvature.
Another
point is a surgical procedure. Surgical approaches for the correction
of PD can be divided into three basic categories; tunical plication, plaque
excision (incision) and grafting procedures, and penile prosthesis implantation
(1). In addition, new insights of penile anatomy (2,3) plication technique
(4) have been reported. Timing of surgery, understanding of the penile
anatomy, selection of surgical method and the meticulous surgical procedures
to preserve neurovascular bundles may be important to improve the long
term outcome and to reduce the complications.
REFERENCES
- Kendirci M, Hellstrom WJ: Critical analysis of surgery for Peyronie’s
disease Curr Opin Urol. 2004; 14: 381-8.
- Baskin LS, Erol A, Li YW, Cunha GR: Anatomical studies of hypospadias.
J Urol. 1998; 160: 1108-15.
- Hsu GL, Lin CW, Hsieh CH, Hsieh JT, Chen SC, Kuo TF, et al.: Distal
ligament in human glans: a comparative study of penile architecture.
J Androl. 2005; 26: 624-8.
- Gholami SS, Lue TF: Correction of penile curvature using the 16-dot
plication technique: a review of 132 patients. J Urol. 2002; 167: 2066-9.
Dr. Kimihiko
Moriya
Dept. of Urology, Hokkaido University
Graduate School of Medicine
Sapporo, Japan
E-mail: k-moriya@med.hokudai.ac.jp
EDITORIAL COMMENT
It
is unexceptionally advisable on penile curvature correction surgeries
regardless of using Nesbit procedure, tunical plication or a grafting
surgery in the literature. These procedures might, subsequently, be regarded
as easy uro-surgical works. Among them, the plication surgery seems to
be recently popular because of its simplicity and reproducibility. Should
their outcomes be consistently reliable since all methods are based on
a traditional description of the tunica albuginea in which a single layer
with uniform thickness and strength circumferentially is unequivocally
depicted (1)?
After
the efforts of chronological studies have been made we find that the three
dimensional ultra-architecture of tunica albuginea is, however, a bi-layered
structure with inner circular and outer longitudinal collagen bundles
which account for the variable thickness and strength circumferentially
and can be clearly seen even under naked eye with an os-equivalent structure
- distal ligament extending into glans penis (2-4). The outer longitudinal
layer is the determinant tissue of establishing penile morphology as well
as functional integrity since it is essential in making the most ideal
environment in the entire human body to apply Pascal’s law which
depicts that pressure applied to any part of the enclosed fluid at rest
is transmitted undiminished to every portion of the fluid and to the walls
of the containing vessel (5). It is the tissue being operated during penile
morphological reconstruction surgery because it acts as the wall. Therefore,
it is not surprise to see this unfavorable report on the tunical placation
surgery since this determinant layer is consistently overlooked in urology
literature.
Some
adverse complications are not indispensable since the surgical tissue
is the tunica albuginea where neither significant vascular or lymphatic
vessels nor nominate nerve is distributed. After degloving of the tissues
superficial to the Colle’s fascia is made, we consistently use a
hydro-pressure technique in which normal saline solution is injected into
the expected surgical region between the tunica albuginea and its overlying
tissue in order to expand and separate them before immobilization attempt.
This is very helpful in facilitating the completeness of dissection at
minimal expense of damaging the neurovascular bundle otherwise (6). A
postoperative penile sensory change is no more observed as usual. Similarly,
the prevalence of penile lump can be minimized while using finer 6-0 nylon
suture to replace a coarser-unabsorble ones. Besides from these interesting
observational factors in this study in order to avoid the penile shortage
which was frequently complained postoperatively by patients who underwent
either a modified Nesbit procedure or a tunical plication surgery despite
it is not remarkable from surgeon’s view, a grafting surgery was,
therefore, meticulously developed and recommended despite it is challenging
and might be away from consensus (7,8). Accordingly, on penile morphological
surgery all procedures seem intriguing rather than easygoing uro-surgical
entities, which should be more exhaustive preoperatively as advised by
authors in this study. Overall, it appears that neither surgical methodology
nor surgical outcome for penile curvature correction, including tunical
plication method, has been elucidated already. Further scientific study
is warranted.
REFERENCES
- Eardley I, Sethia K: Anatomy and Physiology of Erection. In: Eardley
I, Sethia K (eds.), Erectile Dysfunction - Current Investigation and
Management. London, Mosby. 2003, pp. 7-23.
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TF: The three-dimensional structure of the tunica albuginea: anatomical
and ultrastructural levels. Int J Impot Res. 1992; 4: 117-29.
- Hsu GL, Hsieh CH, Wen HS, Hsu WL, Wu CH, Fong TH, et al.: Anatomy
of the human penis: the relationship of the architecture between skeletal
and smooth muscles. J Androl. 2004; 25: 426-31.
- Hsu GL, Lin CW, Hsieh CH, Hsieh JT, Chen SC, Kuo TF, et al.: Distal
ligament in human glans: a comparative study of penile architecture.
J Androl. 2005; 26: 624-8.
- Halliday D: Pascal’s Principle, Fluids. In: Halliday D, Resnick
R, Walker J (eds.), Fundamentals of Physics. New York, John Wiley &
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determining the dimensions of venous graft required for penile curvature
correction. Int J Androl. 2006, 29: 515-20.
- Hsu GL, Hsieh CH, Wen HS, Hsieh JT, Chiang HS: Outpatient surgery
for penile venous patch with the patient under local anesthesia. J Androl.
2003; 24: 35-9.
- Hsu GL, Chen HS, Hsieh CH, Chen RM, Wen HS Liu LJ, et al.: Long-term
result of an autologous venous grafting for penile morphological reconstruction.
J Androl. 2007; 8: 225-34.
Dr. Geng-Long
Hsu
Microsurgical Potency Reconstruction &
Research Center
Taiwan Adventist Hospital
Taipei, Taiwan, China
E-mail: glhsu@tahsda.org.tw
EDITORIAL COMMENT
This
paper tries to compare the outcome of tunical plication surgery for congenital
curvature of the penis and Peyronie’s disease (PD). This is a retrospective
study based on cases done over a 16-year period.
The
cases were done by 31 urologists, which does not reflect uniformity in
surgical technique. One drawback of this study is the fact that there
is no documentation of preoperative erectile dysfunction. Peyronie’s
disease is frequently associated with erectile dysfunction. Inability
for penetration could be due to penile deformity, erectile dysfunction
(ED) or a combination of both.
The
congenital curvature group has a lower mean age (31 years). This group
is more likely to have good erectile function and be satisfied with the
results of surgery, even if there is some amount of residual curvature.
On
the other hand, the mean age of the PD group is significantly higher (54.5
years). The incidence of preoperative erectile dysfunction will be higher
and very likely to contribute to patient dissatisfaction with surgery.
Surgery could lead to worsening of ED.
The
apparent difference between the two groups in ability to have penetration
may be a reflection of the difference in erectile function and may not
be a difference in surgical outcome.
The
authors are correct in stating that preoperative information should be
more extensive in Peyronie’s disease surgeries.
Dr. T.
John
Department of Urology
Wayne State University
4160 John R
Detroit, MI 48201, USA
E-mail: tonytjohn@yahoo.com
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