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« on: November 02, 2005, 12:46:56 PM » |
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Lariche technique for the treatment of Peyronie’s disease.
Karim KHOUAJA, Vincent DELMAS, Laurent BOCCON-GIBOD
Urology Clinic, Hospital Bichat, Paris.
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Summary
Objective: The treatment of Peyronie’s disease comprises medical treatment during the inflammatory phase and surgical treatment at the stage of stabilisation of the lesions. This technical report describes the Lariche technique for the treatment of the stable phase of Peyronie’s disease.
Operative technique: Patients are operated on an outpatient basis under local anaesthesia, after location of the plaque by intraoperative ultrasound of the penis with erection induced by phsiological saline. A percutaneous tear of the plaque is performed with an 18 gauge needle.
Materials and methods: Ten patients with a mean age of 58 years (range 32-82 years) were operated for Peyronie’s disease between January 2002 and January 2004. They all presented with painless penile curvature on erection, but severe discomfort or impossibility of sexual intercourse. The patients were reviewed at 1 and 3 months. The results were assessed in terms of the degree of penile straightening and resumption of sexual activity.
Results: Three patients obtained complete cure. Two patients gained sufficient penile straightening to allow sexual intercourse and recovery was insufficient to allow sexual intercourse for 3 patients, but the result was improved after a second or even a third attempt. The last two patients were classified as treatment failures and were treated by penile prosthesis in one case and by the Nesbit technique in the other case. The results observed at 1 month persisted at 3 months.
Conclusion: The Leriche technique for the treatment of Peyronie’s disease is a simple, minimally invasive technique with satisfactory results. It does not compromise a subsequent procedure and does not present short-term or long-term complications.
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Peyronie’s Disease is characterised by a sclerotic infiltration of the albuginea of the corpora cavernosa of which the etiopathogenesis is unknown.
Several therapeutic approaches are possible. Medical treatment is justified during the initial phase of the disease [6]. Surgical treatment is suggested for stable lesions after at least 6 month [6]. Several techniques have been put forward which include the Nesbit procedure and its variants (Yachia, Sasmi and Licht, Esser and Schneider), plastic surgery of the albuginea after excision of the plaque, and penile prostheses [6]. A new technique has been proposed by Leriche [1]: percutaneous tearing the plaque using an 18 gauge needle, under penile block. We here present the Leriche technique as we practice it, and the results of 10 patients.
OPERATING TECHNIQUE.
The procedure takes place during day surgery. A local anaesthetic (penile block) of 1% Xylocaine is used. After a constricting ring is put in place at the root of the penis, an erection is induced by a physiologic serum in the cavernosa. A preoperative ultra-sound is used to confirm that the plaque can be seen, and its clinical position. After manual location of the plaque, it is lacerated using an 18 gauge needle, making several passes, with the specific objective of fragmenting the fibrous or calcified tissue. The degree of penile straightening is verified with a new induced erection. When the straightening is judged satisfactory, a compressive dressing is put in place for 3 hours. Patients are discharged the same day, and reviewed at 1 month and 3 months. An early resumption of sexual activity is recommended, in the absence of which an erection should be induced daily with vacuum for 1 month. The effectiveness is judged by the straightening of the penis and the resumption of sexual activity.
MATERIAL
From January 2002 to January 2004, 10 patients with Peyronie’s Disease were presented. The average age of the patients was 58 years (32-82 years). The patients had presented with a penile curve involving discomfort, and sometimes an impossibility of sexual intercourse. None of them had previous surgery for the illness. All the patients had been able to maintain an erection. On examination, the patients had had the curvature for at least a year with an average period of 18 months (1 – 7 years). The curvature was stable and painless. All the patients had received medical treatment previously for at least 3 months (Vitamin E, Vitamin C, Piascledine). The angles ranged from 45° to 90°. For 9 patients the bend was dorsal: the seat of the curvature for 5 of them was medial, for 3 it was distal and for 1 proximal. For 1 patient, the bend was ventral. On clinical examination all the patients had a palpable nodule in the penis. They all had a doppler ultra-sound of the penile cavernosa arteries, which showed a calcification of the plaque for 5 of them, and a good permeability of the cavernosa arteries.
RESULTS (See Table 1)
There were no complications either during the operation (Haematoma) or afterwards (new erectile dysfunction, pain, infection).
3 patients had a cure which they considered complete and stable at least 3 months on. Two of them had had a curve of 45° and one of 70°. The curvature was in the middle third for 2 patients and in the distal third for the other. The plaque had calcified for two of them.
2 patients had a straightening sufficient and satisfactory for sexual activity. They had had a curve of 80° and 90° which had reduced to 30° for each of them.
3 patients had an incomplete straightening which was insufficient for a resumption of sexual activity after 1 month. They were treated again with their agreement or at their request after a minimum delay of 3 months. After this treatment, 2 of then had a residual bend of 20° which was sufficient and satisfactory for sexual intercourse. The third had a repeat procedure three times, with a minimum gap of 3 months between them with a result considered satisfactory but not complete.
All of these patients had a stable result during successive consultations, with a follow-up for some of them lasting for two years.
2 patients had a therapeutic failure, one of whom, aged 45 and diabetic with a short penis with a bend of 45° in the middle third, and calcified plaque. He underwent the implantation of a penile prosthesis. The other patient had a ventral curve of 90° which had appeared following a penile trauma, and non-calcified plaque. He underwent a cure using the Nesbit technique.
DISCUSSION
Peyronie’s Disease is characterised by the sclerotic infiltration of the conjunctive tissue separating the erectile tissues of the corpora cavernosa from their tunica albugina leading to the appearance of one or several fibro-inflammatory plaques, thus reducing the elasticity at the level of the lesions and giving rise to pain, bending of the penis, erectile difficulties, and sometimes sexual discomfort.
Several factors have been implicated it its genesis [4]: a trauma or excessive tension on the penis during an erection could bring about a haemorrhage inside the albugina. Peyronie’s Disease would thus be the evolution of a faulty scarring procedure [4]. The other suggested mechanism is an auto-immune factor in the light of certain immunological tests such as the Walter-Rose test and the presence of anti-elastin antibodies. Other factors have been thought to be implicated, such as a medical history of Dupuytren’s Contracture, or genetic factors.
At the clinical level, the illness develops in two phases. A sharp inflammatory phase which lasts 2 – 8 months is characterised by a maximum inflammatory reaction and a pain which can be intense [10]. In the course of this phase, patients present with, above all, a nodule in the penis, and/or painful erection, and/or a deformation of the penis during erection[4]. During this phase, only a medical treatment can be proposed for the patient. Medicines most frequently used are Vitamin E, colchicine, tamoxifen, or local corticoid injections. Vitamin E therapy appears to give the least side-effects, and is the least restrictive, but for effectiveness, it needs to be taken continuously for several months {11}. Another treatment has been proposed consisting of extra-corporeal lithotripsy (ECL), the results of which have been discussed: in fact, the indications are different, dealing with symptomatic young plaques of less than 6 months. Lebret, reporting the results on 26 patients at 3 months, shows that it is effective on erectile pain in 73% of cases, and has a 31% reduction in the bend on erection, this latter only being found objectively in 11% of cases. All our patients had received a medical treatment of at least 3 months prior to the operation.
The other phase is a phase of stabilisation of the lesions, characterised by a stable deformation of the penis, and the disappearance of the pain [6]. It appears on average about 18 months after the start [11]. Diagnosis is mainly clinical, but a penile ultra-sound can be used to study the size, location and number of plaques. All our patients had a known, stable lesion after an average of 18 months (1 to 7 years).
Minimally-invasive treatments have been proposed apart from the ECL used on the young plaques. Ruffion [9] has described a treatment using radial shock waves on stabilised plaques, but as for the ECL, the results show that they are effective against the symptoms, but have little effect on the bending of the penis, or on the morphology of the plaque. The therapeutic approach at this stage is surgical, and is proposed for lesions that have been stable for at least 6 month. Several techniques are suggested [9] among them that of Nesbit and its variants (Yachia, Sasmi and Licht, Esser and Schneider), with good results of between 82% and 100%, but with a shortening of the penis of at least 1 cm [8]. There are other techniques such as a resection-graft of the albuginea, which gives good results in 0% to 70% of cases, or the implantation of a prosthesis, which gives good results in 88% of cases. All these operations are more or less invasive, requiring hospitalisation for several days, with undesirable effects which may be more or less important.
Recently, Leriche has proposed a less invasive technique which can be used for out-patients [1]. This technique was inspired by that used by hand surgeons to treat Dupuytren’s Contracture [5]. It consists of lacerating the plaque with and 18 gauge needle under a penile block. It recommends, as we have done, using an induced erection, and ultra-sound in order to localise the plaque, and to treat it. The result is judged on a significant improvement in the symptoms. The reduction or disappearance of the curve is not one-to-one. It is linked, maybe to the fragmentation of the plaque, whether calcified or not, maybe to the severing of the fibrous partitions between the cavernosa, thus freeing the albuginea of the corpora cavernosa. In our study, 25 patients submitted to this procedure with a 28% success in 6 months. In our study of 10 patients, 3/10 (30%) were cured, 5/10 (50%) had resumed satisfactory sexual activity 3 months after 1 or more attempts, and 2/10 (20%) had failed to straighten the penis. The early resumption of sexual activity after the operation, or in its absence, the use of a vacuum device daily for one month, appears to be indispensable for keeping the results obtained by this technique [1] and could explain the success after several attempts. It should be noted that in the failure with an incomplete result, the patients demanded, or accepted without reticence a further attempt before more invasive surgery such as the Nesbit, for example. We have followed Leriche’s recommendations with stable results in the times our patients have been treated with success.
This technique can be used in day surgery, as we did it, but may also be done in a consulting room.
This technique is a simple procedure, minimally invasive, without compromising a later procedure, as we have shown with the 2 patients, one who underwent a Nesbit procedure and the other the implanting of a penile prosthesis, without particular difficulty and with a good result; and above all, presented no complication either immediately or later. This technique is mainly indicated for stabilised lesions, calcified or not, which have not spread too far. This requires a long follow-up but could be recommended as an initial stage for a later more invasive procedure. The principle causes of our failures were a penile retraction, as was the case with the patient who went on to the penile prosthesis, a ventral plaque, a situation where the plaque extends for more than a third of the penis, or several plaques.
CONCLUSION
The Leriche technique is a new procedure for the treatment of Peyronie’s Disease. Its indications seem to be for those patients who do not present any co-morbidity such as having diabetes or taking anti-coagulants and with the illness still developing, who are stabilised, with not too extensive plaque, and without penile retraction. It is a simple procedure, minimally invasive which can be carried out on an outpatient with local anaesthetic. These encouraging results require a study to be carried out on a larger population. This technique does not give rise to complications, either in the short or medium term, and do not appear to compromise a later, more invasive operation.
Commentary by Albert Leriche, Urology Department, Hospital Henry Gabrielle, Saint Genis Laval.
The technique of severing the plaque with a needle gives, in our experience, an overall level of satisfaction to about 30% of patients, which is worse than that reported by the authors. For this reason we have actually modified the treatment protocol by using a transcutaneous section of the plaque using a lancet. It is too soon to evaluate how effective this is, but we have initiated a protocol to compare this method of treatment with the simple section with a needle. The other minimally invasive method of treatment is extra-corporeal lithotripsy, whose results are somewhat flattering in the literature, but which do not correspond with our experience. A certain number of patients have Peyronie’s plaques in the proximal part of the corpus cavernosum which cannot be effectively treated by lithotripsy, but which are accessible for surgical section.
Commentary by Pierre Bondil, Urologie, Chambery.
The laceration of the plaque with a needle is a new therapy which has the advantage of simplicity, low cost, and a reduced morbidity. I have used it systematically for 4 years but uniquely intraoperatively, which allows one to reduce the plicatures in the albuginea. Laceration allows a gain of 1 and sometimes 2 cm in length, and to reduce the plaque. Nevertheless, the precise technique of laceration needs to be improved. The first which I did resulted in a doubling of the volume of the plaque, which led me to be more prudent, and to look to improve the technique with 2 precautions: a controlled technique for laceration and prevention of a recurrence or post-operative fibrous aggravation by an accompanying corticoid injection, the prescription of tadalafil each evening in the absence of spontaneous erections, and recommendations for repetitive extensions of the cavernous tissue by traction on the glans for 2 weeks. Actually, on an erect penis, I avoid making an extensive laceration, but uniquely longitudinal and transverse grooves if the plaque is extensive and a prudent section of the plaque’s fibrous attachments.
Click on Table below to see the table referred to in the paper
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