A new original surgical technique for Peyronie disease: albugineal graft-free lengthening z-plasty. Results with mean follow up over 24 months
We present an original lengthening albugineal Z-plasty for the treatment of penile curvature due to Peyronie Disease (PD) with the aim to reduce the post-operative Erectile Dysfunction (ED) due to Veno-Occlusive Dysfunction (VOD) as major functional complication of incision and grafting surgical procedures performed for PD(1,2).
Materials and Methods
Surgical technique: circumcision and deglooving of the penis; dorsal neurovascular bundle isolation and setup plaque size and direction by saline hydraulic erection; Z-shape plaque incision and translocation of albugineal flaps using 4/0 Vycril suture; saline hydraulic erection to confirm absence of residual curvature. From May 2013 to September 2016, 20 patients affected by PD have been enrolled in a surgical experimental pilot study with local Aethical Comitee certification. Inclusion criteria comprise: age up to 18 years (yr), penile curvature due to PD in stable phase(3) (=>6 months), no ED (IIEF-5>19; EHS>3(4)), specific informed file subscription. History (IIEF-5 and PDQ Scale Q2 to Q6(5)), physical examination (EHS), dynamic penile ecocolorDoppler ultrasound examination (longitudinal plaque size, curvature degree) have been reported for each patients as soon as operating time procedure, intraoperative complications, post-surgical complication. Each patients has been re-evaluated after surgery at 1, 3, 6 and 12 mo.
Median values of age, curvature degree, plaque diameter, IIEF-5, PDQ Scale and operating time has been: 59 yr; 66° dorsal site; 24,4 mm; 22,8 points, 3,33 points; 140 minutes. Fourteen patients has been available for evaluation with post-surgery follow up (FU) up to 18 mo. Complete resolution of the curvature has been jointed all cases with a complete subjective satisfaction with median IIEF-5 22,8; median PDQ Scale 3,33; non residual ED. Minor gland hypoesteshia in all of the ten patients from 6 to 12 mo. from surgery.
Our results seem to be effective in term of restoration of the penile shape with a complete functional straight of the penis and also effective in terms of erection rigidity for sexual intercourse (all patients refers absence of ED with a post-operatory mean IIEF-5 score of 22,8) in a range follow up observation over 24 months. We assay the subjective satisfaction of the patients using the PDQ Scale (from Q2 to Q6) score, that decrease from a mean value of 16,7 at baseline to 3,33 post-operatory and, with a “clinical” intent, using three direct questions submitted to them at the time of the 12 month follow up visit. All the fourteen patients eligible for the evaluation describe as full satisfaction (Q1, answer 1) after surgery and, at the same time, they answer “yes” at the Q2 and Q3 question. The answers at these last two questions represent the most important result that encourage us to continue in this surgical strategy for PD, because patients suggest that they would re-do the surgery and they would be suggest the same surgery to relations or friends meaning the complete real subjective satisfaction in terms of sexual behavior and sexual wellbeing.
Moreover, we focus our attention on the operating time and immediate or delayed post-operative complication. Mean operating time has been 140 minutes (ranging from 120-170) is lower than the 180 minutes that could be considered the limit to perform surgery with spinal anesthesia. We have had not any immediate complication and all our patients was discharged in post-op day one achieving a short hospitalization time that, considering that this is a graft-free procedure, leads to reduction of the economic impact of this kind of surgery on the budget destined to our unit. The only delayed post-op complication referred by patients has been a persistence of glandular hypo-anesthesia that otherwise improving until a complete resolution in six months after surgery. This complication is basically due to the extensive penile dorsal neurovascular bundle (DNVB) isolation and it is a common post-op complication in all the surgical procedure for PD in which it is necessary to proceed to isolate the DNVB and producing a transitorial neuropraxy of the DNVB itself.
Results obtained suggests that the length of the PD plaque, and the traslocation of the PD scar forces, on the short site of the penis with a graft free Z-plasty seems to be effectiveness to reduce penile curvature and avoid post-operative ED due to VOD.
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