AUA2021 Crossfire Debate: Peyronie's Disease: Xiaflex vs Surgery Is There One Best Approach?

By: Laurence A. Levine, MD | Posted on: 03 Sep 2021

Peyronie’s Disease (PD) has emerged over the last several decades as a serious disorder that is regularly seen by all urologists, especially sexual medicine experts. It is that much more complex because we still do not understand the underlying pathophysiology.1 Simply put, it is a wound healing disorder which leaves behind an inelastic scar that fails to remodel over time.2 This results in physically and psychologically devastating consequences. Unfortunately, there is no known, reliable nonsurgical treatment option. Xiaflex® is the only Food and Drug Administration approved nonsurgical option with a good deal of published reports on its efficacy and safety, but Xiaflex is far from a cure and rarely corrects the deformity. In fact, many men who undergo this treatment appear to experience little benefit.3 On the other hand, surgery remains the gold standard for treatment as it can reliably correct the deformity and can provide a functionally straight and functional penis with respect to rigidity.4 Surgical options include plication and grafting for men who have good preoperative erections. For those men who do not have reliable rigidity, they will need placement of a prosthesis with straightening maneuvers.5 As good as surgery is, there are risks and many men with PD prefer not to have surgery. Therefore, finding the best nonsurgical option is incumbent upon science.

We still don’t know who the optimum candidates for Xiaflex are. It appears to me to be best for those who have a more acute rather than extended area of curvature, those who do not have extensive plaque calcification, particularly in the area of maximum curvature, and who have curvature less than 60°, as virtually all studies have shown average curvature reduction in the 17° to 25° range, which may be enough for some men but clearly not enough for those with severe curvature.6 In those men who have failed Xiaflex, there are several articles indicating that successful surgical reconstruction can be accomplished albeit with added difficulty due to ablation of the plane between Buck’s fascia and the tunica albuginea.7 Xiaflex clearly has a place in modern medicine, and possibly with further research we will find a better mode for administration, which may include changing the dose, volume injected and distribution of the drug.

Our panel of debaters including Wayne Hellstrom (Tulane University), Lawrence Hakim (Cleveland Clinic Florida), Allen Morey (University of Texas-Southwestern) and Serge Carrier (McGill University) are recognized experts in this field with loads of experience treating men with PD. They will provide a lively discussion on the pros and cons of these treatment options, which will be both educational and entertaining for the attendees. Urologists should be familiar with these treatment options, their limitations and risks. A competent urologist should be able to discuss the most appropriate treatment for the patient presenting with PD through shared decision making.

  1. Li EV, Esterquest R, Pham MN et al: Peyronie’s disease: pharmacological treatments and limitations. Expert Rev Clin Pharmacol 2021; 14: 703.
  2. Del Carlo M, Cole AA and Levine LA: Differential calcium independent regulation of matrix metalloproteinases and tissue inhibitors of matrix metalloproteinases by interleukin-1beta and transforming growth factor-beta in Peyronie’s plaque fibroblasts. J Urol 2008; 179: 2447.
  3. Tsambarlis PN, Yong R and Levine LA: Limited success with Clostridium collagenase histolyticum following FDA approval for the treatment of Peyronie’s disease. Int J Impot Res 2019; 31: 15.
  4. Levine LA and Lenting EL: A surgical algorithm for the treatment of Peyronie’s disease. J Urol 1997; 158: 2149.
  5. Nehra A, Alterowitz R, Culkin DJ et al: Peyronie’s Disease: AUA Guideline. J Urol 2015; 194: 745.
  6. Natale C, McLellan DM, Yousif A et al: Review of intralesional collagenase Clostridium histolyticum injection therapy and related combination therapies in the treatment of Peyronie’s Disease (an update). Sex Med Rev 2021; 9: 340.
  7. Bajic P, Wiggins AB, Ziegelmann MJ et al: Characteristics of men with Peyronie’s Disease and collagenase Clostridium histolyticum treatment failure: predictors of surgical intervention and outcomes. J Sex Med 2020; 17: 1005.