Kurtzman JT, Sukumar S, Piush DB et al: The rising incidence of penile prosthesis surgery as the first line surgical treatment for Peyronie’s disease. Urol Pract 2021; 8: 503.

Peyronie’s disease (PD) is a potentially debilitating connective tissue disorder of the penis. It is characterized by anomalous and inelastic plaque formation in the tunica albuginea, often resulting in penile deformities. The prevalence of PD is as high as 9% in the general population and the rate of spontaneous resolution is as low as 13%.¹ Approximately 1 in 4 PD patients have associated veno-occlusive erectile dysfunction (ED).²

PD treatment depends on the phase of the disorder, disease severity, patient preference and surgeon experience.³ For patients with chronic, stabilized disease, surgery is the gold standard for severe deformities. Surgical options include tunical plication, including plaque incision or excision; tunical grafting; and insertion of a penile prosthesis implantation (IPP) with or without adjunctive intraoperative procedures (ie modeling, tunical incision or grafting).³

Most of the literature on PD surgery are single-institution case series or cohort studies from high-volume centers. Therefore, very little is known about the practice patterns among providers in the community. In an era of health care disparities research and initiatives to eliminate barriers to care, understanding practice patterns using population-based data can help expose inequities in care delivery. In addition, changes in practice over time may beget the need to innovate new technologies or procedures in the future. For these reasons, we performed the first population-based study to identify surgical practice patterns in treating PD across the entire state of New York (NY), using the NY Statewide Planning and Research Cooperative System (SPARCS) database.⁴

We identified a total of 1,733 patients who underwent surgical treatment for PD between 2003 and 2016. Sixteen percent of patients underwent plication, 14% underwent grafting, and 70% underwent IPP (of which 57% involved adjunctive procedures). Among all patients, 30% had a documented diagnosis of ED.

We found that the utilization of IPPs significantly increased over time, while the utilization of grating and plication significantly decreased (see part A of figure). Over the study period, 21% of patients without documented ED underwent IPP (with/without adjunctive procedures). This became increasingly more common between 2011 and 2015 (see part B of figure).

Figure. Trends in surgical treatment utilization among all patients (A) and among patients without documented erectile dysfunction (B) from 2003 to 2015.

We demonstrated that low-income patients were significantly more likely to undergo grafting than plication, but significantly less likely to undergo IPP than grafting. Patients treated by high-volume surgeons or at high-volume facilities were more likely to undergo IPP than plication but had a similar likelihood of IPP or plication when compared to grafting.

The increasing incidence of IPP as the first line surgical treatment for PD is both noteworthy and provocative. It suggests a shift in the practice patterns among community-based urologists. Historically, plication was the most common surgical method to treat PD.³ It is highly effective at correcting most curvatures <60 degrees, with most studies reporting straightening rates of 90% or higher.³ Penile grafting has similar outcomes, with most studies reporting a success rate of >80%.³

Current AUA guidelines recommend plication or grafting as first line surgical treatment for patients with bothersome penile curvature but preserved or therapy-responsive erectile function.³ Plication is generally recommended for patients with longer penile lengths (>10 cm), moderate curvature (<60°) and/or no evidence of structural deformities, and grafting for patients with shorter penises (<10 cm), more severe curvature (>60°) and/or structural deformities.⁵

Surgical decision making for PD treatment can be influenced by more than simply guidelines, however. Patient preference, the availability of nonoperative treatment options, surgeon comfort with operative techniques and systemic socioeconomic forces may ultimately impact treatment selection.

Plication is associated with a substantial risk of penile shortening (41–90%), sensory loss (0–21%), ED (0–23%), and palpable sutures (<36%).^5,6 Grafting, even when performed at high-volume centers or by experienced surgeons, can also result in significant penile sensory loss (up to 25%), hematoma (up to 26%), and vascular ED (variable results, up to 40%).⁷ While the overall satisfaction scores for these procedures are variable, ranging from 65% to 100% for plication and from 41% to 96% for grafting,⁸ up to 80% of patients who undergo prosthesis insertion for the treatment of PD with concomitant ED are satisfied with their procedure.⁹ This may, in part, explain trends reported in our study.

The advent of collagenase clostridium histolyticum (CCH) injection therapy has also changed the landscape of PD treatment. Since its U.S. Food and Drug Administration approval, there has been a dramatic decrease in the use of surgery as a first line treatment for PD and a corresponding increase in CCH use.⁶ Patients with intact erectile function and those with mild/moderate disease may therefore be receiving CCH therapy, explaining the decline in grafting and plication in recent years. CCH alone, however, does not explain the prevalence of IPPs for patients without documented ED.

The decline of grafting and plication may also be, in part, self-perpetuating. Decreased utilization translates to decreased exposure, potentially compromising surgeon comfort in performing these technically challenging procedures over time. Surgeons working in the community and/or at nonacademic centers may be particularly at risk. Since low-income patients often seek care at public and/or community hospitals, this may also help explain why we found that poorer patients were more likely to be treated with IPP than grafting. The tendency to perform plication instead of grafting in low-income patients, on the other hand, may reflect worse disease at the time of presentation. Previous literature on other medical conditions, including urological ones, has demonstrated that low-income patients often present later in a disease course and with worsened severity because of delays in initial access to care.¹⁰

Penile prosthesis is by far the most commonly performed surgery for PD in NY State. The incidence of prosthesis surgery as the primary surgical treatment for PD is increasing, with as many as 1 in 5 patients without ED receiving an IPP, while the incidence of grafting and plication are decreasing. While our study is unable to definitively explain why this is happening, we raise this question for future studies to pursue. The declining utilization of plication and grafting could render these procedures inaccessible to patients in the community and risk exacerbating disparities in access to effective, and erectile preserving, treatment options over time.