madman
Super Moderator
Complex Penile Surgery Plication, Grafting, and Implants (2022)
Ziho Lee, MD, Jolie Shen, MD, Hunter Wessells, MD
INTRODUCTION
The pathophysiology of penile defects requiring surgical reconstruction may be classified into injuries of the soft tissue and skin, tunica albuginea (TA), and corpora cavernosa. Although most patients requiring penile reconstruction have a single anatomic defect to the TA or corpora cavernosa, there is a subset of patients with overlapping defects involving multiple anatomic sites (Fig. 1). Herein, we focus our discussion on the surgical management of patients with Peyronie’s disease (PD), which primarily affects the TA and erectile dysfunction (ED) which primarily affects the corpora. Additionally, we discuss complex decision-making and surgical management of patients with PD and ED with overlapping defects involving multiple anatomic sites including defects in skin and soft tissues of the glans and shaft.
Surgical treatments for PD and ED are associated with excellent outcomes. However, certain clinical factors may make reconstruction more challenging. In patients with PD, severe (>60°) and multidirectional curvature, hourglass deformity, and severe penile shortening and an ossified plaque benefit from the application of reconstructive principles including mobilization and resection of scarred and damaged tissue; use of grafts and flaps according to the vascularization of the affected tissue; and a willingness to embark on time-consuming and difficult surgeries. Similarly, severe corporal fibrosis related to prior surgery (ie, infected implant), injury, or priapism may complicate implant surgery in men with ED and cannot be solved solely by implant selection and application of standard techniques. Although there are numerous studies that have reported encouraging surgical outcomes in the setting of complex PD and ED, the current literature highlights the vast variation in surgical techniques and the limitations of retrospective study designs with short-term follow-up and small sample sizes.
The purpose of our report is to review the literature regarding surgical management of complex PD and ED with an emphasis on plication, grafting, and implants. Where appropriate, we have illustrated this review of the literature with our own observations and technical solutions to some of the challenging problems in complex penile surgery.
COMPLEX PEYRONIE’S DISEASE
PD is an acquired disorder that is characterized by fibrosis of the TA of the corpora cavernosa. The formation of scar tissue may lead to the development of penile curvature and deformities such as hourglass and hinge defects, which may result in penile pain, ED, and emotional distress.1 For patients with stable clinically significant PD, in which symptoms have been clinically quiescent or unchanged for at least 3 months, surgical reconstruction provides the most reliable and durable clinical outcomes.2,3 Intralesional collagenase, approved by the Food and Drug Administration under the trade name Xiaflex (Endo Pharmaceuticals Inc., Malvern, United States), has expanded nonsurgical options for PD.4 When insufficient correction of curvature is achieved, surgeons face the additional complexity of post-Xiaflex inflammatory changes, and rarely, a rupture in the area of the plaque.5,6 In patients with complex PD, which we define as severe (>60°) and multidirectional curvature, hourglass deformity, severe penile shortening, and an ossified plaque, surgical reconstruction requires creative application of multiple techniques to achieve successful outcomes.
*Penile Plication
*Tunica Albuginea Grafting
*Penile Implant Surgery
PENILE IMPLANT SURGERY FOR CORPORAL FIBROSIS
Corporal fibrosis significantly complicates the insertion of a penile implant, imparting a higher risk of septal and crural perforation, urethral injury, surgical site infection, penile shortening, hypoesthesia, and procedural abandonment.64–67 Severe corporal fibrosis generally occurs following explantation of an infected implant,68–71 trauma,72 chronic intracavernosal injections,73,74 priapism requiring corporal shunting procedures,70,75–77 and in patients who have undergone construction of a neophallus. Rarely, PD, poorly-controlled diabetes, or end-stage renal disease can result in severe corporal fibrosis.78 Of these etiologies, the most severe fibrosis generally occurs after removal of the infected implant, as the empty and inflamed corporal body space allows for excessive deposition of collagen and extracellular matrix.79 Although no standards exist to define or quantify “severe” corporal fibrosis, a clinical history of inability to passively dilate the corporal bodies at the time of penile implant placement is generally used as inclusion criteria in the literature.78
*Dilation
*Counter Incision
*Minimal Scar Tissue Extraction and Counter Incision
*Transcorporal Scar Resection
*Wide Scar Excision
*Soft Tissue Defects and Penile Implants
SUMMARY
Surgical management of patients with complex PD and ED may be challenging and necessitate sophisticated techniques for reconstruction. Although patients with severe or multiplanar curvature may be managed with penile plication or grafting, patients with hourglass deformity and severe penile shortening require penile grafting. Patients with complex PD and ED generally require penile plication or grafting in conjunction with penile implant placement. In the setting of severe corporal fibrosis, placement of a penile implant may be facilitated via dilation with cavernotomes, utilization of a counter incision with or without minimal scar tissue extraction, transcorporal scar resection, and wide scar excision with or without grafting. With extensive soft tissue defects, additional tissue transfer techniques should be considered to allow adequate coverage of implants and grafts.
Ziho Lee, MD, Jolie Shen, MD, Hunter Wessells, MD
INTRODUCTION
The pathophysiology of penile defects requiring surgical reconstruction may be classified into injuries of the soft tissue and skin, tunica albuginea (TA), and corpora cavernosa. Although most patients requiring penile reconstruction have a single anatomic defect to the TA or corpora cavernosa, there is a subset of patients with overlapping defects involving multiple anatomic sites (Fig. 1). Herein, we focus our discussion on the surgical management of patients with Peyronie’s disease (PD), which primarily affects the TA and erectile dysfunction (ED) which primarily affects the corpora. Additionally, we discuss complex decision-making and surgical management of patients with PD and ED with overlapping defects involving multiple anatomic sites including defects in skin and soft tissues of the glans and shaft.
Surgical treatments for PD and ED are associated with excellent outcomes. However, certain clinical factors may make reconstruction more challenging. In patients with PD, severe (>60°) and multidirectional curvature, hourglass deformity, and severe penile shortening and an ossified plaque benefit from the application of reconstructive principles including mobilization and resection of scarred and damaged tissue; use of grafts and flaps according to the vascularization of the affected tissue; and a willingness to embark on time-consuming and difficult surgeries. Similarly, severe corporal fibrosis related to prior surgery (ie, infected implant), injury, or priapism may complicate implant surgery in men with ED and cannot be solved solely by implant selection and application of standard techniques. Although there are numerous studies that have reported encouraging surgical outcomes in the setting of complex PD and ED, the current literature highlights the vast variation in surgical techniques and the limitations of retrospective study designs with short-term follow-up and small sample sizes.
The purpose of our report is to review the literature regarding surgical management of complex PD and ED with an emphasis on plication, grafting, and implants. Where appropriate, we have illustrated this review of the literature with our own observations and technical solutions to some of the challenging problems in complex penile surgery.
COMPLEX PEYRONIE’S DISEASE
PD is an acquired disorder that is characterized by fibrosis of the TA of the corpora cavernosa. The formation of scar tissue may lead to the development of penile curvature and deformities such as hourglass and hinge defects, which may result in penile pain, ED, and emotional distress.1 For patients with stable clinically significant PD, in which symptoms have been clinically quiescent or unchanged for at least 3 months, surgical reconstruction provides the most reliable and durable clinical outcomes.2,3 Intralesional collagenase, approved by the Food and Drug Administration under the trade name Xiaflex (Endo Pharmaceuticals Inc., Malvern, United States), has expanded nonsurgical options for PD.4 When insufficient correction of curvature is achieved, surgeons face the additional complexity of post-Xiaflex inflammatory changes, and rarely, a rupture in the area of the plaque.5,6 In patients with complex PD, which we define as severe (>60°) and multidirectional curvature, hourglass deformity, severe penile shortening, and an ossified plaque, surgical reconstruction requires creative application of multiple techniques to achieve successful outcomes.
*Penile Plication
*Tunica Albuginea Grafting
*Penile Implant Surgery
PENILE IMPLANT SURGERY FOR CORPORAL FIBROSIS
Corporal fibrosis significantly complicates the insertion of a penile implant, imparting a higher risk of septal and crural perforation, urethral injury, surgical site infection, penile shortening, hypoesthesia, and procedural abandonment.64–67 Severe corporal fibrosis generally occurs following explantation of an infected implant,68–71 trauma,72 chronic intracavernosal injections,73,74 priapism requiring corporal shunting procedures,70,75–77 and in patients who have undergone construction of a neophallus. Rarely, PD, poorly-controlled diabetes, or end-stage renal disease can result in severe corporal fibrosis.78 Of these etiologies, the most severe fibrosis generally occurs after removal of the infected implant, as the empty and inflamed corporal body space allows for excessive deposition of collagen and extracellular matrix.79 Although no standards exist to define or quantify “severe” corporal fibrosis, a clinical history of inability to passively dilate the corporal bodies at the time of penile implant placement is generally used as inclusion criteria in the literature.78
*Dilation
*Counter Incision
*Minimal Scar Tissue Extraction and Counter Incision
*Transcorporal Scar Resection
*Wide Scar Excision
*Soft Tissue Defects and Penile Implants
SUMMARY
Surgical management of patients with complex PD and ED may be challenging and necessitate sophisticated techniques for reconstruction. Although patients with severe or multiplanar curvature may be managed with penile plication or grafting, patients with hourglass deformity and severe penile shortening require penile grafting. Patients with complex PD and ED generally require penile plication or grafting in conjunction with penile implant placement. In the setting of severe corporal fibrosis, placement of a penile implant may be facilitated via dilation with cavernotomes, utilization of a counter incision with or without minimal scar tissue extraction, transcorporal scar resection, and wide scar excision with or without grafting. With extensive soft tissue defects, additional tissue transfer techniques should be considered to allow adequate coverage of implants and grafts.
