The extra-tunical grafting procedure for Peyronie's Disease hourglass and indent deformities
Reed-Maldonado, AB1; Alwaal, A; Lue, TF2
1: Madigan Army Medical Center, United States; 2: Univeristy of California, San Francisco
Background: To describe a novel, tunica-sparing surgical technique -- extra-tunical grafting (ETG) -- for the treatment of penile indent and hourglass (HG) deformities and to describe patient-reported outcomes after the ETG procedure.
Methods: An IRB-approved, retrospective chart review of ETG patients was performed to collect data including pre-operative deformity, operation performed, and post-operative patient-reported perception of deformity, erectile function, penile sensation, and overall satisfaction with the ETG operation. The indications for surgery were difficulty with sexual intercourse due to deformity and/or poor cosmesis of the penis. Pre-operatively all patients had erections adequate for intercourse with or without medications. The ETG procedure is performed through a ventral longitudinal penile skin incision. The Buck’s fascia of the erect penis is exposed in the area of deformity. The dissection is continued circumferentially for HG deformity. The neurovascular bundle (NVB) is left undisturbed. A cadaveric fascia graft is applied, singly or in multiple layers, to fill the exposed tunical depressions. Our preferred graft material is Tutoplast Suspend® (Coloplast; Minneapolis, MN). The graft is then sutured into position with multiple interrupted, long-lasting absorbable sutures to achieve the desired contour. The urethra is excluded from the graft.
Results: From October 2013 to June 2017, 36 patients had the ETG procedure for HG and/or indent with or without penile curvature. Results with a minimum of 6 months of follow up could be extracted for 18 of the patients. One was excluded as he required concurrent excision of a large calcified tunical plaque, which necessitated incision into the tunica albuginea. Follow up was between 6 and 44 months (average 21 months). All patients reported satisfactory resolution of the HG or indent. No patient reported worsened erectile function. Two patients (11.8%) reported slight penile hypoesthesia, with one of these having had multiple previous penile degloving surgeries for trauma. Ten of the patients reported being “very satisfied”, and six reported being “satisfied” with the procedure. One was neutral. All reported that they would recommend the ETG procedure to a friend, and all would repeat the same surgery again.
Conclusions: The ETG procedure is a straightforward approach to HG and indent deformities that does not violate the tunica albuginea (TA) and does not require dissection of the NVB. Thus, ETG carries a very low risk of de novo impotence or hypoesthesia as highlighted by this patient series. With such low risk and high patient-reported satisfaction rates, the ETG procedure is a valuable surgical technique for the treatment of complex penile deformities.
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