REVIEW
Ahead of print publication  

Management of residual penile curvature after penile prosthesis placement


1 Central District Hospital, Outpatient Department, Kamenolomni, Rostov Region 346480, Russia
2 University College London St Peter's Andrology Centre and University College London Hospitals, London W1G 6BJ, United Kingdom
3 Monash University, Department of Surgery, Melbourne 3168, Australia
4 The Alfred Hospital, Department of Urology, Melbourne 3004, Australia
5 Department of Urology 1, City Clinical Hospital No. 4, Dnipro 49102, Ukraine
6 Department of Urology, Humanitas Gavazzeni, Bergamo 24125, Italy
7 Department of Surgery No. 1, Rostov Regional Hospital ROKB 1, Rostov-on-Don 344015, Russia

Date of Submission28-Jan-2020
Date of Acceptance26-Aug-2020
Date of Web Publication23-Oct-2020

Correspondence Address:
Denis V Krakhotkin,
Central District Hospital, Outpatient Department, Kamenolomni, Rostov Region 346480,
Russia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aja.aja_62_20

PMID: 33106463

  Abstract 


Residual penile curvature is a common situation following the implantation of a penile prosthesis in patients with Peyronie's disease. Currently, there is a variety of options for the correction of residual curvature, including penile modeling, plication techniques, as well as tunical incision/excision with or without grafting. A literature search of PubMed and Medline databases was conducted from 1964 until 2020, using search terms for all articles in the English language. In this article, we provide a review of the techniques and the outcomes, according to the published literature.

Keywords: grafting; modeling; penile curvature; penile implant; penile prosthesis; Peyronie's disease; tunical plication


Article in PDF

How to cite this URL:
Krakhotkin DV, Ralph DJ, Blecher GA, Chernylovskyi VA, Greco F, Bakurov EE, Bugaev RA. Management of residual penile curvature after penile prosthesis placement. Asian J Androl [Epub ahead of print] [cited 2020 Nov 25]. Available from: https://www.ajandrology.com/preprintarticle.asp?id=298917




  Introduction Top


Residual curvature of the penis is a well-known phenomenon after implantation of a penile prosthesis.[1],[2] This may occur in the preexisting context of Peyronie's disease (PD) or following other causes of end-stage erectile dysfunction, such as after radical prostatectomy.[3] While it may not be anticipated that there exists a penile curvature in the latter situation, residual curvatures may be so significant and they prevent penetrative intercourse and thus may require treatment at the time of the inflatable penile prosthesis (IPP) or semirigid penile prosthesis insertion.[4] While some mild curvatures may not require any correction, options for more severe curvatures range from modeling, then plication, to grafting. In this article, we review different available management options for residual penile curvature after penile prosthesis placement.

A literature review was performed with PubMed and Medline, for all articles written in the English language, from 1964 to 2020. The search terms incorporated were PD, residual penile curvature, penile prosthesis, penile modeling, incision/excision with grafting, tunical plication, and sliding technique.

It is a common finding for surgeons to note penile curvature during the insertion of penile implants. Curvature deformities may become apparent in the context of penile prosthesis implantation primarily due to PD or may appear somewhat de novo .[5]

PD is a chronic inflammatory disease characterized by excessive accumulation of collagen fibers and other extracellular matrix (ECM) components within the tunica albuginea (TA) of the corpora cavernosa.[6] The prevalence of PD ranges from 0.4% to 20%, mainly in men aged between 40 years and 70 years.[7] PD in the chronic phase frequently results in erectile dysfunction (ED), occurring in from 22% to 37.5% of cases.[8],[9] The cause of ED in this context may be related to several factors including infiltration of the plaque into the neurovascular bundle,[10] as well as veno-occlusive dysfunction from corporal scarring.[11] However, it is not only the initial disease process that causes ED. Treatments such as intracavernosal injections are well known to cause fibrosis, with possible subsequent curvature in some men.[12] Curvature correction surgeries such as tunical plication or lengthening/grafting techniques may themselves lead to ED.[13] Radical prostatectomy has also been associated with the development of penile curvature, possibly due to cavernosal denervation with subsequent fibrotic changes.[14],[15]

Preoperatively, surgeons should be prepared for the likelihood of a curvature. This may be obtained either from the patient history or from an artificial erection test. While many surgeons may not measure penile dimensions perioperatively,[16] it is the authors' opinion that performing this is vital to plan the appropriate surgery for the individual patient and manage their expectations. The penile dimensions (either stretched or erect length) should be measured and note taken of any complexity. Mild curvatures may sometimes not require any treatment, as the implant will self-correct subtle deformities over time.[17] However, when there are curvatures exceeding 45° or 60°, the requirement for correction increases up to 75%–100%.[18],[19] The surgeon must also have an understanding of the various options to correct a curvature in this setting.


  Modeling Maneuver over a Penile Prosthesis Top


Modeling is a well-described maneuver for the correction of residual curvature after penile prosthesis placement.[20] This technique involves the following steps: (1) full inflation of the device; (2) clamping of the exit tubing of the device for protection of the pump; (3) steady forceful bending of the penile shaft in the opposite direction of curvature for 90 s, this may result in a partial or complete rupture of the plaque; and (4) compression of corporotomy sites for the prevention of cylinder blowout during bending. Successful modeling is defined as an angle of <10°–20°. Modeling may need to be repeated until adequate straightening results.[2],[21],[22] This method of straightening was originally described by Wilson and Delk in 1994.[22] In his series of 138 patients, he demonstrated success in 118 patients (86%). Eleven patients (8%) required tunical relaxing incisions. Further publications have revealed adequate penile straightening and satisfaction with sexual intercourse ranging from 54%–100% to 88%–100% of cases, respectively [Table 1].[23],[24],[25],[26],[27],[28],[29] Despite the high success rate, it should be borne in mind that this maneuver can lead to complications such as urethral perforation or laceration, which occurs in 2.5%–4% of cases.[30] If this occurs, the offending cylinder should be removed and a urethral catheter was placed with delayed replacement of the ipsilateral cylinder after an adequate period of urethral healing, usually 4 weeks–6 weeks. Others have proposed leaving both cylinders in place and simply repairing the urethra directly over a Foley catheter and diverting the urine with a suprapubic cystostomy for 4 weeks–8 weeks before the prosthesis is activated.[31],[32] It is the authors' opinion that surgeons should have a high threshold to perform this maneuver as it is likely to increase the prosthesis infection rate.
Table 1: Outcomes of manual modeling after insertion of penile prosthesis

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The retrospective review of 79 men (11 of whom had PD with intraoperative modeling) showed that the clamping of the tubing is required during modeling. Of the PD cohort, 3 of 11 (27%) patients had device failure, while 3 of 68 (4%) of the non-PD group exhibited device malfunction at an overall mean of 4.3 months.[33]

The exact nature of the mechanical failures was not reported. Another study comparing AMS 700 CX® versus Coloplast Titan® showed no difference in mechanical failure following modeling.[34] There is limited and conflicting evidence when comparing semirigid and IPP devices. A prospective, nonrandomized cohort of patients who underwent either IPP (n = 30) or semirigid implants (n = 136) found no significant difference in the immediate end-of-procedure curvature correction. Satisfaction rates were similar with Likert satisfaction scores of 4.3 and 4.4, respectively.[35] A retrospective review of 209 PD patients who underwent penile implant surgery concluded that modeling was more often successful (defined as curvature <10°–20°) with inflatable (84%) versus semirigid (54%) implants.[36]


  Plication Techniques Top


Tunical plication is used in patients with residual curvature after implantation of a penile prosthesis after a failed attempt of modeling. It is possible when the patient has a persistent curve of 30°–60°. Ideally, these patients should not have a short penis nor complexities such as severe waisting. The principle of penile plication is shortening of the longer convex side. The tunica can be left untouched and sutures simply placed to plicate, or tunical excision or incision can occur, with subsequent closure of the defects.[37] Several modifications of this concept have been published, including the original Nesbit's procedure,[38] Essed-Schroeder technique,[39] 16/24-dot,[40] Heineke-Mikulwicz-based repair (Yachia technique),[41] as well as the Rolle et al .42 adaptation. The surgeon must consider the following nuances when correcting residual curvature over a penile prosthesis: incision, location of correction, and protection of the implant. If a penoscrotal incision is used, it is common to obtain good access and retraction to visualize most of the penile shaft tunica, if required. This obviously requires some further dissection. During an infrapubic approach, a second incision, either ventral, penoscrotal, or degloving, may need to occur to access the point of maximal curvature, depending on the location and direction of the curve. Once the site of curvature is identified by inflating the implant, the device should be deflated and pushed proximally or removed from the corpora.[3],[28],[43],[44],[45],[46],[47] While it is possible to place sutures with an implant in situ , the possibility of puncture with subsequent mechanical failure exists.

This problem will clearly not occur when using a semirigid device. Plication sutures can then be placed opposite the angle of maximal curvature using the near-far-far-near technique.

One can consider replacing and reinflating the IPP once the sutures are in place, but not tied. The sutures can then be tied and adjusted to optimize the degree of straightening. Outcomes of plication techniques after insertion of the penile prosthesis are summarized in [Table 2].
Table 2: Outcomes of plication techniques for correction residual curvature after implantation penile prosthesis

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  Tunical Scratch Technique for Correcting Residual Penile Curvature Top


Perito and Wilson[48] first described the scratch technique in 2013 as an effective complementary maneuver to modeling, performed intraoperatively immediately before insertion of a penile prosthesis. This technique involves internal disruption of a PD plaque in a three-dimensional fashion with 12-blade scalpel or pair of sharp Metzenbaum scissors. The basics of this approach were derived from intracorporeal incision technique described by Bella et al .[49] in 2006 using a triangle-shaped scalpel designed for endoscopic carpal tunnel release. There is some evidence that supports the use of postoperative vacuum device following the scratch technique, where after 24 weeks, penile curvature deviation decreased to 8.7° ± 2.5°, 9.1° ± 2.9°, and 7.7° ± 0.9° for proximal third, middle third, and subcoronal areas, respectively.[50]


  Tunical Incision With or Without Grafting Top


These procedures for the treatment of PD curvature are based on the concept of lengthening of the shorter concave side, by either single or multiple tunical incisions at the point of maximum curvature with or without subsequent grafting of the defect. Indications for these procedures include a residual penile curvature more than 60°, severe hourglass deformity, as well as a lack of adequate penile length.[51] In the case of significant residual curvature that exceeds 30° after two unsuccessful attempts of manual modeling, one can consider tunical relaxing incisions.[52] Similar to plication, the surgical approach can be either via penoscrotal access, ventral, or circumferential incision. However, the neurovascular bundle should be elevated to ensure its safety. If ventral curvature is present, mobilization of the urethra may be required.[53],[54] For preserving the integrity of the cylinder, relaxing incisions should be performed with low energy electrocautery until complete penile straightening is achieved. Multiple bilateral transverse incisions should be made, each roughly 5 mm–9 mm long. Care should be taken to avoid making these incisions too large or else herniation of the prosthesis may result. In the case of waist deformities, the incisions can be performed in a longitudinal plane.

In some situations, for example, when a significant defect (>1.5 cm–2 cm) is created, the surgeon should consider grafting for the prevention of prosthetic herniation or cylinder aneurysm.

To perform this, the IPP is deflated and potentially removed from the corpora. A semirigid implant can be left in situ . The corners of the graft are secured to the tunica albuginea. Running watertight sutures are then performed with 4-0 polydioxanone. Various graft types are available and have been documented in the literature. While there is currently no single universally accepted graft, the ideal properties include cheap, inert, readily available, and simple to implant.

Autologous options include rectus fascia, or saphenous vein, although these incur additional operative time and donor site morbidity. Allografts afford ease of use and reduce operating time and morbidity. Options include bovine pericardium, fibrin sealant patch (Evarrest), collagen fleece (Tachosil), and oxidized regenerated cellulose (Nu-Knitl), which have been used with reasonable rates of satisfaction and penile straightening.[55],[56],[57],[58],[59],[60] A combination of tunical incision with grafting has been described in several studies, utilizing a collagen fleece (Tachosil). These studies have demonstrated penile straightening rates ranging from 80% to 83.3%, residual curvature rates from 16.7% to 20%, and overall major complication rates of 5.5%–6.9%.[4],[61],[62],[63] Outcomes of grafting techniques after insertion of the penile prosthesis are summarized in [Table 3].
Table 3: Outcomes of grafting techniques after insertion of penile prosthesis

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There are both general and specific complications in the context of curvature postimplant, which need to be considered. Herniation of a cylinder through a graft material or tunical incision is a specific issue in these surgeries. The complications of penile implants clearly still exist and include device infection, glans hyposensitivity, cylinder erosion, urethral injury, as well as mechanical failure.[64],[65]


  Sliding Techniques Top


The sliding technique was first developed by Rolle et al. [66] in 2012. This approach includes ventrodorsal incisions of the tunica albuginea, penile implant placement, and double dorsal-ventral patch grafting. Its aim is to address simultaneously ED, curvature, and length correction. In the initial series of three patients, none suffered major intraoperative or postoperative complications and resumed sexual activity. In a further cohort of 28 men, the same author published their results of IPP and semirigid devices using porcine small intestinal submucosa and acellular porcine dermal matrix and Tachosil, respectively. There were not any differences regarding penile lengthening or curvature correction between the groups. However, the operative time was less in the semirigid prosthesis group.[67] Egydio described a modification of the procedure, using Bucks fascia alone for closure, without the need to graft material.[68],[69] The same author more recently describes the multiple-slit technique, whereby multiple small tunical defects replace one large tunical incision.[70] These techniques have been shown to be effective in correcting penis length and girth in other studies.[71],[72] The sliding techniques have demonstrated high rates of penile straightening ranging from 80% to 100% after insertion of the penile prosthesis. A summary is shown in [Table 4].
Table 4: Outcomes of sliding techniques for correction residual penile curvature during insertion penile prosthesis

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  Collagenase Clostridium Histolyticum (CCH) Top


CCH is an enzyme, produced by the bacterium Clostridium histolyticum , that hydrolyses collagen, and was first used in 1982 for the treatment of PD.[73] While CCH is ideally used as a sole treatment, when failure occurs, some men may choose to proceed with curvature correction surgery. There is limited literature available in this context.[74]

DeLay et al .[75] reported on ten patients who underwent curvature corrective surgery, three of whom underwent IPP, following a mean of 5 months after CCH injections. Increased surgical difficulty was encountered in three patients, all of whom had CCH <6 months before curvature surgery. The authors therefore also suggest that curvature correction surgery should be deferred by at least six months following the last injection of CCH. Despite the small sample size, they concluded that surgery following CCH was safe and feasible. There are no studies investigating the use of CCH following penile implants. While Fischer et al .[76],[77] reported an animal study whereby CCH reduced fibrotic changes around a silicon implant, one would imagine that the financial implications as well as the risk of damage to IPP cylinders would prevent many surgeons from choosing such an option.


  Treatment Algorithm Top


Despite a variety of treatment options, there are no specific guidelines thus far for the management of residual curvature in penile prosthesis surgery. That said, we propose a fairly logical algorithm, which assumes that curvatures <20° will either not pose a functional issue or will self-correct over time. Modeling or scratch techniques should be employed for residual curvatures between 20° and 60°. Tunical plication should be performed for residual curvatures between 20° and 60° after failed modeling/scratch. Tunical incisions with or without grafting is reserved for curvature >60°, complex changes such as waisting or hourglass deformities and in case when penile length is a significant concern. Summary and comments of techniques used for correction of residual penile curvature are shown in [Table 5].
Table 5: Summary of techniques used for correction of residual penile curvature

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  Conclusions Top


Following penile implant, a residual curvature is a common finding. While conservative options exist, the surgeon should be aware of the variety of treatment options at their disposal, with an understanding of their place and disadvantages.


  Author Contributions Top


DVK, RAB, and VAC performed literature searching and data collection. DVK prepared and designed the manuscript. RJD and GAB contributed to critically revising the manuscript. FG and EEB reviewed and edited the manuscript. All authors read and approved the final manuscript.


  Competing Interests Top


All authors declared no competing interests.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

 
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  In this article
Abstract
Introduction
Modeling Maneuve...
Plication Techniques
Tunical Scratch ...
Tunical Incision...
Sliding Techniques
Treatment Algorithm
Conclusions
Author Contributions
Competing Interests
Collagenase Clos...
References
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