RECONSTRUCTIVE UROLOGY

Complications of Porcine Small Intestine Submucosa Graft for Peyronie’s Disease
Breyer BN, Brant WO, Garcia MM, Bella AJ, Lue TF
Department of Urology, University of California-San Francisco, San Francisco, California, USA
J Urol. 2007; 177: 589-91

• Purpose: We report outcomes and complications of the use of porcine small intestine submucosa for correcting penile curvature due to Peyronie’s disease.
• Materials and Methods: A retrospective study was performed in patients with severe penile curvature (greater than 60 degrees) requiring surgical correction for sexual function. Preoperatively all patients underwent evaluation, including history, physical and penile duplex ultrasound. Of these patients 19 underwent tunical grafting with 1-layer Surgisis small intestine submucosa. Postoperatively patients were evaluated with clinic visits and telephone interviews to assess results.
• Results: A total of 19 patients 46 to 69 years old (mean age 54) were treated with tunical incision or excision and grafting with small intestine submucosa between March 2002 and July 2005. Average followup was 15 months (range 3 to 43). Patients reported less penile pain with intercourse after surgery. There was no difference in Sexual Health Inventory for Men scores. Preoperatively 12 men (63%) had erectile dysfunction, defined as Sexual Health Inventory for Men less than 21, while 10 (53%) reported postoperative erectile dysfunction. Seven of the 19 patients (37%) had recurrent penile curvature (greater than 10 degrees) and 5 (26%) had recurrent Peyronie’s disease plaque. Our complication rate was 37%, including hematoma at the graft site in 5 cases (26%), graft infection in 1 (5%) and Peyronie’s disease recurrence requiring plication in 1 (5%).
• Conclusions: Small intestine submucosa carries potential for grafting applications because it is easy to use and readily available. Our experience resulted in a 37% complication rate, which exceeds those previously reported with saphenous vein graft repair.
  
  
• Editorial Comment
  The surgical management of penile deformations due to Peyronie’s Disease with various types of grafts is still under discussion. Autologous tissue used for corporeal reconstruction include tunica vaginalis, fascia lata, fascia temporalis, rectus sheath, and venous patches, reports on heterologous tissue include cadaveric fascia and xenogenic tissue such as porcine small intestine submucosa (SIS, Stratasys®), dermal porcine collagen (Permacoll®) (1), and bovine pericardium graft (2). Due to either limited availability or immunogenic problems bioabsorbable artificial materials such as tissue sealant coated collagen fleece (Tachosil®) (3) have been tested lately (4,5).
  In the current report, the authors present a retrospective study dealing with complications in the application of small intestine submucosa (SIS). The treatment of 19 patients with a follow-up of 15 months is currently the largest study concerning xenogenic material in penile reconstruction. The use of SIS was successful in a recent report in 11 of 12 treated patients (6). The same author reported about straightening of the penis and reconstruction of tunica albuginea defects due to excised plaques with penile prosthesis implantation in conjunction with SIS (7). Contrary to this report, the authors in this paper reported a complication rate of 37% mainly due to hematoma, infection or disease recurrence.
  Do we have a new standard for penile reconstructive surgery now with off the shelve bioartificial material such as small intestine submucosa available? Nineteen selected patients clearly cannot be representative for all patients with Peyronie’s disease necessitating surgery. We need larger series with randomization, direct comparison of various materials, standardizations in the timing of surgery, selection of patients, surgical technique, postoperative management, and evaluation of the outcome. In addition, with a complication rate in more than a third of the patients in this study and an improvement in sexual function of merely 10 % (which is in 2 patients) there is ample room for better materials, advancements in surgical technique, and further studies.

References

1. Lloyd S, Hetherington J: Plaque excision and Permacol grafting for Peyronie’s disease. BJU Int. 2000; 85 (Supl. 5): 16.
2. Egydio PH, Lucon AM, Arap S: Treatment of Peyronie’s disease by incomplete circumferential incision of the tunica albuginea and plaque with bovine pericardium graft. Urology. 2002; 59: 570-4.
3. Lahme ST, Gotz T, Bichler KH: Collagen fleece for defect coverage following plaque excision in patients with Peyronie’s disease. Eur Urol. 2002; 41: 401-5.
4. Sievert KD, Tanagho EA: Organ-specific acellular matrix for reconstruction of the urinary tract. World J Urol. 2000; 18: 19-25.
5. Santucci RA, Barber TD: Resorbable extracellular matrix grafts in urologic reconstruction. Int Braz J Urol. 2005; 31: 192-203.
6. Knoll LD: Use of porcine small intestinal submucosal graft in the surgical management of Peyronie’s disease. Urology. 2001; 57: 753-7.
7. Knoll LD: Use of porcine small intestinal submucosal graft in the surgical management of tunical deficiencies with penile prosthetic surgery. Urology. 2002; 59: 758-61.

Dr. Karl-Dietrich Sievert &
Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany