Figure 1. Peyronie’s disease with 60-degree dorsal curvature demonstrated with goniometer (top right) and inside plaque depiction (bottom right). Illustration by Dr Helen L. Bernie and Vanessa Dudley.

Figure 2. Peyronie’s disease dorsal curvature.

Figure 3. Xiaflex injection into plaque.

Figure 4. Hour-glass deformity commonly seen with Peyronie’s disease.

Figure 5. Neurovascular bundle elevation after Xiaflex treatment for Peyronie’s disease.

Figure 6. Extratunical grafting with TachoSil.

Among various special sessions on sexual function and dysfunction presented at the 2023 AUA Annual Meeting, a compelling plenary presentation reunited experts discussing a common Peyronie’s disease (PD) index case many of us see in the office: a man with a 60° dorsal curvature, with erectile dysfunction (ED), and penile size concerns (Figures 1 and 2). In 2015 the AUA came out with guidelines for the diagnosis and treatment of PD with the goal of giving a man a functionally straight erection. Even with guidelines in place to aid providers in making treatment decisions, it is clear there is no one-size-fits-all solution when it comes to many of these complex cases. Dr Helen L. Bernie moderated this exciting session giving us an introduction into PD and guidelines for treatment, which kicked off with the experts discussing the best options available to treat this index patient.

Treating PD requires addressing not only the penile curvature, but also maintenance of penile length and sexual function. Dr Amy Pearlman initiated the discussion focusing on stretching devices as a therapeutic intervention. Citing a randomized, single-blind, controlled trial, she demonstrated that using the RestoreX device could yield a substantial improvement in curvature (up to 17°) compared to placebo, with a 77% success rate.¹ Furthermore, there was also improvement in erectile function (4.3 points on the International Index for Erectile Function) for 63% of the participants, and almost 94% of them experienced an increase in penile size (up to 1.6 cm). In addition to its high patient satisfaction, RestoreX devices are cost-effective and yield long-term results. Dr Pearlman concluded that traction does not require a prescription, encourages patient engagement, and is noninvasive.

Next up to bat was Dr Jesse N. Mills, who gave us a great rundown on Xiaflex, highlighting that it is the only Food and Drug Administration–approved treatment for PD, and what does one have to lose by starting with this (Figure 3)? Despite being time-consuming (4- to 6-month treatment course) and expensive (each course wholesaling at approximately $45,000), Xiaflex remains a low-risk therapy that yields reasonable outcomes to help your patient get “better.” Citing a paper from his own group, he demonstrated a retrospective analysis reporting a 50% improvement in curvature after 1 to 2 courses of Xiaflex.² In another prospective study, the safety and effectiveness of combining the RestoreX device with collagenase Clostridium histolyticum (CCH) was compared to using CCH alone and CCH in conjunction with other penile traction therapy devices. The findings indicate that combining RestoreX with CCH yielded more favorable outcomes, with more significant improvements in curvature and length (mean length improvement of 1.9 cm) compared to using CCH alone or CCH in combination with other penile traction therapy devices.³ Dr Mills concluded that objective data outside of goniometer measurements should be the focus and patient satisfaction should be a key measure.

Next, Dr Allen F. Morey delved into the topic of penile plication surgery. Using a modified 16-dot procedure, with a minimally invasive penoscrotal incision, multiple parallel plications, with inverting knots (tie as you go), he demonstrated that plication can be safe, reliable, cost-effective, and versatile, and with minimal length loss.⁴ His technique is versatile and can also be applied not only to dorsal curvatures, but also to hourglass deformity (Figure 4). Furthermore, since most penile deformities are dorsal or lateral, neurovascular and urethral dissections can frequently be avoided by this technique.

Lastly, Dr Morey cited their retrospective study analyzing 102 men who underwent plication repair for complex penile deformity, including biplanar curvature or curvature ≥60°.⁵ All patients underwent tunical plication via a 2-cm penoscrotal incision mobilized distally along the penile shaft without degloving. Among 32 men with severe curvature (≥70°), an average of 11 sutures corrected the median angle of curvature from 70° to 15° (5° correction per suture). The stretched penile length was unchanged in 29 patients, increased by an average of 0.65 cm in 7 patients, and decreased by 0.5 cm in only 6 patients. Dr Morey concluded that plication is safe, reliable, versatile, roughly 8 times cheaper than a course of Xiaflex, and the discussion on whether it leads to penile shortening is up for debate.

Dr Rafael Carrion led the panel on encompassing the use of the excision and grafting surgical technique to treat PD. He began by affirming that patch grafting (PG) can be technically challenging, and surgical education is paramount, but it is a viable surgical option for the management of PD, and one that may lend to the “best way” to achieve an accurate correction. Highlighting that many urology residencies do not train residents in this technique, he emphasized that one of the most crucial steps is the neurovascular bundle dissection, which must be thoroughly mastered to achieve the ideal plaque excision while avoiding any harm to critical structures that could cause permanent consequences (Figure 5). Again, surgical training is paramount. Another challenging point is the marking, which is “everything” because with artificial tumescence in real time, you are appreciating the exact pathology of the patient’s curvature. Dr Carrion stressed that there is no surgery without risks. Lastly, reassessment is essential, because other techniques can be introduced to improve the final result after PG if needed. Using colorful pictures and hard facts, he gave an eloquent description of a difficult maneuver (Figure 6). Finally, he concluded that PG has risks (erectile dysfunction, decreased penile sensation, ischemia, bleeding, and pain) and importantly benefits for which the patient and surgeon must navigate carefully prior to proceeding with surgery.

Lastly, Dr Martin Gross had the audience laughing with his humor and straight facts on using an inflatable penile prosthesis (IPP), for our index patient. Starting off with intracavernosal injections and a penile duplex Doppler ultrasound, as recommended by the guidelines, he argued that an IPP can effectively treat not only PD, but also erectile dysfunction and penile length loss, which are frequently co-occurring conditions. In addition, combination of an IPP with adjunct procedures like manual molding, plications, sliding technique variations, or tunical expansion procedures, the options are limitless for restoring penile length, curvature, and erectile dysfunction. There are also numerous procedures that can cosmetically give the appearance of improved length loss, such as ventral phalloplasty or suprapubic lipectomy, which can be performed in accordance with an IPP.

The discussion was insightful, educational, and entertaining, and demonstrated that for most patients, and certainly our index patient, there are multiple options that can correct curvature, preserve length loss, and/or treat erectile dysfunction. Patient counseling and expectation management are paramount. But don’t worry: if you missed this year’s AUA plenary, you can register for the Sexual Medicine Society of North America’s Fall Scientific Meeting, which will be held in San Diego, November 16-19, 2023, to hear more on management of your most complex sexual dysfunctions by these and many more experts in the field.