Intracavernosal Plaque Excision Method

[solomon]

I'm new to the PDS forum and can one way or another relate to many posts.
I am 60 years of age but feel that I'm still in the game. I've done the urologist thing and
been all the way around the houses deciding on various treatment etc.
It seems the most proactive way of getting anywhere close to normalcy is to have some kind of surgery.
I'm not happy about that but I am prepared to go under the knife to get my life back.
Obviously the less invasive the surgery is the better the potential for recovery without complications.
Although my urologist recommended Nesbit plication I am not so happy about circumsion. Is that a fact of life for all surgery??
Like most people I have searched the net for alternatives and came across this Intracavernosal Plaque Excision Method.This sounds sort of simple and reasonably successful I thought. Is it used or mentioned in any of the forums?
Is this different to the grafting method I would like to know??
This was posted on the net on the European Urology website in 2004!

[BrooksBro]

I encourage you to read through the thousands of posts in the surgery section, perhaps starting here. 

https://www.peyroniesforum.net/index.php/topic,911.0.html

Patient satisfaction with excision and grafting is poor.  My memory is the satisfaction is something less than 50%.

[jackp]

Solomon

You did not mention if you also have Erectile Dysfunction. From most of the stories I have read about placation it does not work well, also one side effect is Erectile Dysfunction for a lot of guys. When that happens then the only option left is an implant.

That said. You need to go to a Male Sexual Function Specialist not a general practice urologist. There are very few of these doctors around and most major cities do not have one.

If you have peyronies with Erectile Dysfunction the "gold standard" is a length expanding implant. My thoughts are why go through surgery twice when the right doctor can correct the problem with an implant.

Any way I or others on this forum can help just let us know.

Jackp
http://jackp-penileimplant.blogspot.com/
Read my story "One Mans Journey"

[solomon]

I did not have erection problems prior to diagnosis of Peyronies Disease. My penis when erect is at a 90 degree right angle (useless for penetration) and veers off to my left as a result of Peyronies Disease.
I do find the number of options on the forum bewildering and it definitely appears as though there is not a cure-all.It's a minefield out there.
I'm prepared to travel and pay for the right answer, but evaluating the right treatment is going to be a matter of serious study and a consideration of the options. Unfortunately no body has been able to identify the treatment as mentioned on the European Urology website which claims 100% success! 

[jackp]

solomon

Can you give us the link to the European Urology web site that claims 100% success.

What I have found out over the years is it is sounds too good to be true then it is not.   My 2 cents worth.

Jackp

[LWillisjr]

I encourage you to read through the thousands of posts in the surgery section, perhaps starting here. 

https://www.peyroniesforum.net/index.php/topic,911.0.html

Patient satisfaction with excision and grafting is poor.  My memory is the satisfaction is something less than 50%.

I would be interested where you got your less than 50% data. My experience is just the opposite. That the satisfaction rate is greater than 50% with excision and grafting. There have been several here on the site who have had this. They just aren't all avid posters.

[solomon]

Jack sorry but unable to post links on this forum, so I just copied and pasted article. This is from 2004!

Abstract:

Objective: A new surgical method of treating Peyronie's disease consisting in intracavernosal excision of the plaque is presented.

Material and Methods: The operation was performed on 16 men aged from 34 to 65 years (mean 50.2 years). The angle of penile curvature was 30° to 60°. Thirteen (81.25%) had impaired intercourse because of penile deformity and in 3 (18.75%) patients it was prevented by marked penile curvature. The mean quality of life score (QoL) was evaluated as 4.8. The operation consists in incising the corpus cavernosum parallel to the plaque and through this incision removing the plaque from the inside without incising or replacing the underlaying tunica albuginea.

Results: Follow-up examinations made after 3, 6 and 12 months revealed normal, painless erection in all the patients. In 2 (12.5%) intercourse was impaired only by persistent penile curvature of over 20°. Mean QoL score −1.1.

Conclusions: In our opinion intracavernosal plaque excision is a simple method, easier to perform and less invasive than the operative methods applied to date. It eliminates the pain, does not result in a shortening of the penis, loss of sensation or erectile dysfunction. It ensures a considerable improvement in the QoL of the patients treated.

[Kaj]

16 is a really small sample size. I would also be interested in whether there have been other studies. One study 7 years ago is not what I would call empirically proven "best practices"  data. Also, I see no indication of 100% satisfaction outcome in the abstract quoted. Was the abstract cut and pasted in its entirety? Not to throw cold water on your hopes/excitement since I am not in the medical field; I just tend to give much less credence to minimally supported information. To quote Sci-fi writer, Robt. Heinlein: ~ "What are the facts? Again and again and again --- what are the facts? Shun wishful thinking, ignore divine revelation, forget what "the stars foretell", avoid opinion, Care not what the neighbors think, never mind the unguessable "verdict of history" --- what are the facts, and to how many decimal places? You pilot always in to an unknown future; facts are your only chance. Get the facts!
-- Lazarus Long" ~

Kaj

[solomon]

Kaj, I agree with you, I would like to know if there was futher studies done? And I will look more in depth if I'm able.
When you discover you have Peyronies Disease as I did about a year ago and with all my years of unblinkered existence I'd never heard of this disease before! Well anyway as I'm sure you and others will agree it's initially a bit like clutching at straws trying to find a solution.
Maybe if Peyronies Disease was more life threatening their would be more research done.You'd think there would have been considerably more advancement since initial discovery in 1743.
Imagine if every time you injured yourself somewhere on the body you developed internal scarring like Peyronies Disease?!

[BrooksBro]

Here are two studies on long term patient (dis)satisfaction.



http://www.urotoday.org/careers--training/educational-opportunities/fiveyear-followup-of-peyronies-graft-surgery-outcomes-and-patient-satisfaction-abstract-2233337.html

Five-year follow-up of Peyronie's graft surgery: Outcomes and patient satisfaction - Abstract
Friday, 10 December 2010

St Joseph Health Care-Urology, London, Ontario, Canada.
University of Western Ontario, London, Ontario, Canada.

Graft surgery for Peyronie's disease (Peyronies Disease) is associated with significant long-term risks.

To evaluate the clinical and functional outcomes of graft repairs with a minimum of 5-year follow-up.

A retrospective review of database and third party telephone survey was undertaken in all men who underwent reconstructive graft procedures for Peyronies Disease between May 1999 and May 2005.

Patient demographics, International Index of Erectile Function (IIEF-5) scores, and penile Doppler ultrasonography were performed preoperative. Follow-up assessments included surgical outcomes and overall patient satisfactions.

A total of 86 patients with an average age of 54.6 (34 to 73) years underwent Peyronie's graft repair. The average follow-up was 98 (61 to 120) months. Twenty patients received dermal graft whereas 33 patients underwent Tutoplast graft and 33 patients had Stratasis small intestinal submucosa graft. Penile curvature greater than 60 degrees was more common in the Tutoplast and Stratasis groups. Twelve patients used phosphodiesterase type 5 inhibitors or intracavenous agents preoperatively. At the time of review, only 46 (53%) patients were able to be contacted and consented for telephone interview. Although 6 months of postoperative follow-up showed excellent resolution, or significantly less, penile curvature, this figures decreased to 50% in dermal, 87% in Tutoplast, and 76% in Stratasis patients. Further penile length shortening was also reported on patient self-assessment at the recent follow-up. Worsening of IIEF-5 scores were noted with the development of erectile dysfunction was more pronounced in the diabetic cohort (P<0.01). The overall satisfaction on a 5-point scale was 2.6 with more than 65% of patients dissatisfied with the outcomes of the Peyronie's graft surgery.

The recurrence of penile curvature, penile length loss, and the new-onset of Erectile Dysfunction are not uncommon sequelae and are associated with a significant patient dissatisfaction rate when a 5-year follow-up is achieved.





http://www.ncbi.nlm.nih.gov/pubmed/18387398

Urology. 2008 Apr;71(4):698-702.

Subjective patient-reported experiences after surgery for Peyronie's disease: corporeal plication versus plaque incision with vein graft.

Kim DH, Lesser TF, Aboseif SR.

Department of Urology, Kaiser Permanente Medical Center, Los Angeles, California 90027, USA.

Abstract

OBJECTIVES: To compare patient-perceived outcomes of corporeal plication to plaque incision with saphenous vein grafting for the correction of Peyronie's disease.

METHODS: Patients with stable Peyronie's disease deemed to be good operative candidates for both tunical plication and plaque incision with saphenous vein graft were counseled on both procedures and chose which operation they would undergo. At 1 year, the records were reviewed and the patients were contacted. The variables included age, operative time, and outcome ("satisfactorily straight," loss of rigidity, loss of sensation, new use of erectile aids, ability to have intercourse, palpable nodules, erectile pain, penile shortening, and being "completely satisfied").

RESULTS: Of the 67 patients, 35 underwent tunical plication and 32 underwent plaque incision with vein grafting. No differences were present in patient age between the two groups. The average operative time was shorter for the plication group (P = 0.0001). No differences were found regarding satisfactory straightness (P = 0.13), satisfaction with the operation (P = 0.71), new use of erectile aids (P = 0.06), erectile pain (P = 0.12), or subjective penile shortening (P = 0.41). Patients who underwent plaque incision with grafting were more likely to experience loss of rigidity (P = 0.03), inability to have intercourse (P = 0.05), and loss of sensation (P = 0.0045). Patients who underwent plication were more likely to experience palpable nodules (P = 0.03).

CONCLUSIONS: The results of our study have shown that both procedures are effective surgical options for the correction of Peyronie's disease. Plication is a simple procedure with less morbidity. Shortening is a common complaint, regardless of the type of operation done.

[Luciano]

solomon

Can you give us the link to the European Urology web site that claims 100% success.

What I have found out over the years is it is sounds too good to be true then it is not.   My 2 cents worth.

Jackp

Well I have been looking at that European website (I am myself in Europe) for quite a while.
I do not know what to think of them. They are in germany. The cost is around 12.000 € that is about $17.000 (that is come in for operation and stay at hotel)
Double the price if you stay in the clinic there.
They have a page in english:

www.the-european-institute-ugrs.com/usa/


The problem is, in germany, austria, switzerland NO urologist knows them or has even heard of them!! (I asked 3)
The doctor is Greek, they have no contract with insurances.

The only 2 testemonies that can be found in german forums are visibly written by people working for them.
In some forums users speak of rippoff, but on the other hand, as in germany laws are very strict, nobody filed any complaint. So they must have some results.

what they mainly do, is they remove the plaque, (they give it to you after the operation in a little glass tube) and then use some graft tissue to replace the plaque.

After some research I found following:

It seems that the greek doctor was working with another Serb doctor who had a clinic in belgrade. both are using the same methods.

the serb doctor sava perovic seems to have died.
www.savaperovic.com
but the clinic in belgrade still is working and they try to make money
www.peyronies-surgery.com

here pics about the method:
www.peyronies-surgery.com/peyronies-disease-treatment.htm
(websites look very commercial also)

(If I was going to be ripped off, i'd prefer the german rippoff (because legal system is better. In Serbia I have no idea if they have any legal way to get the hold of them if it is a ripoff)

But what is more interesting, is a third doctor working with the serb guy :
He was head of the urology department in a german public hospital. But he retired this month  
What he did looks very promising:
Penile disassembly (taking the penis apart) Method devellopped by Perovic
Removing the plaque with a "water pressure scalpell"
grafting
and then putting the penis together again.

here is a video of the operation (its in german though):
www.urosource.com/content/video-library/view/browse/13/article/surgical-treatment-of-morbus-peyronie-using-penile-disassembly-technique-accomplished-by-water-jet-d/
(hope the link works)

There are also a couple of videos on youtube of the operation. (horrible to look at)

So basically all three are using the same method, one using water-jet to "shave" the plaque, but its basically the same.
What I also read is that this method does NOT work with ALL kinds of plaque.. (but circular plaque seems to give relatively good results)

thats my 2 cents (makes 4 )

Luc

[solomon]

Very interesting. My research has the authors emanating from Poland.
These are the authors:
Janusz S. Darewicz, Barbara A. Darewicz, Lech M. Gałek, J. Kudelski, B.M.A. Badri.
www.europeanurology.com/article/S0302-2838%2803%2900435-4/abstract
I suppose reading their conclusion is the thing which caught my eye.

5. Conclusions
Intracavernosal plaque excision in patients with
Peyronie's disease is a procedure which gives good
results; it eliminates pain, does not result in penile
shortening, disturbance of sensation within the glans
penis or erectile dysfunction. In our opinion it is easier
and simpler to perform than the methods used to date
and thanks to its efficacy ensures a marked subjective
improvement in the patients' quality of life.

[Luciano]

@solomon
the pdf is quite impressive
I would want to have it done immediately, but how to find an urologist that has some experience with this??
I dont want to be his/her first operation with this method....

L.

[solomon]

It does sound positive, but there is always the element that if it sounds to good to be true it probably is. However, I also think if this was such a positive result why is it not being more widely publicised?
The origin seems to be Poland. Any Polish speaking people on the forum?
This is the address which was in the article.
Department of Urology, Medical Academy of Bialystok, M. Skłodowskiej-Curie 24A Str., 15-276 Bialystok, Poland

* Corresponding author. Tel. +48-85-746-8624; Fax: +48-85-746-8624.

I will write to them.

[Luciano]

After your post i checked a little...
actually its more or less husband and wife..
they have an urology cabinet together in that polish town.

But she, Dr. Barbara Darewicz, seems the important one..
as she is head of the local urology clinic. She also participated in the operation of a guy that had cut off his penis with an ax 
http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ArtikelNr=282912&Ausgabe=251947&ProduktNr=224282&filename=282912.pdf
so she probalby is not that bad.

you can check what she looks like, here the link to her hospital:
http://spskam.bialystok.pl/urologia/index_e.htm
(somehow you have to refresh the page after having clicked the link)

(she probably is the one in the middle)
The hospital reminds me of one i've seen here in the sixties....
but part of the page is in english...

good luck.. and keep us updated...
(I will try and give them a call.. but not before next week..  - got a polish maid.. she could give the call in polish, but i dont know how to explain her what the problem is... looool)

PS: the phone number you have is the number of the clinic.

[solomon]

You would have to have a reasonable amount of faith in a surgeon who can successfully reattach a penis.
I imagine that they would have a good level of English so you don't have to ask your Polish maid.

I'm still interested to know the significance in the invasiveness of this type of treatment for Peyronies Disease as opposed to the grafting technique.
Is this something they are still doing? Is it a treatment that is also dependent on the amount of curvature for example or other factors?

[Luciano]

You would have to have a reasonable amount of faith in a surgeon who can successfully reattach a penis.
I imagine that they would have a good level of English so you don't have to ask your Polish maid.

I'm still interested to know the significance in the invasiveness of this type of treatment for Peyronies Disease as opposed to the grafting technique.
Is this something they are still doing? Is it a treatment that is also dependent on the amount of curvature for example or other factors?

well there are allways 2 sides...
1. the penis was reattached but there was a necrose and they dont know why....
   (I can see the situation: "Oh we removed your plaque, but your penis is more curved than before.. we dont know why..)

2. I reread the pdf of the method and 1 thing drew my attention:

Further experience with this technique may indeed
determine whether it is useful for more severe defomity
such as bottle neck deformity or where there is full
thickness plaque involvement of the tunica.

So I think I will do following (as a serious doctor will not give a diagnosis on the phone. Going there just so they tell me.. Oh sorry, we cant do it because..... is a no go.):

I will first find an urologist that will make ultrasound an localise the plaque and give me the results (images) to be able to send her.
(the first they all do - even the critisized german clinic - is to make an ultrasound.)
I will then send picts and ultrasound so she can at least determine if feasable or not.

Luc

[solomon]

That makes sense.
I have emailed Dr. Barbara Darewicz via the hospital (the link email: (urolamb@cksr.ac.bialystok.pl) didn't work).

I have already had a diagnosis from a urologist; I was thinking of getting a second opinion from another urologist (although I don't anticipate any other further good news).This would be an opportunity to get an ultra sound. Likewise I would send photos and images.
The other thing is the reference to the amount of deformity. I wonder how they cope with right angles? This sounds a bit of a grey area?
Are they only treating milder forms of Peyronies Disease?

It's a long way to travel atleast for me here in Australia, so you would want to have as many bases as possible covered, that's IF they thought that it was worth the effort.
I'd go to the moon if it meant I was back to normal!

[Luciano]

I have emailed Dr. Barbara Darewicz via the hospital (the link email: (urolamb@cksr.ac.bialystok.pl) didn't work).

Strange.. thats the same email on the hospital page...

[Luciano]

@Solomon...
Did she ever answer?
L.

[solomon]

I did not receive any answer from the email I sent to Dr. Barbara Darewicz. I sent a snail mail letter about a week ago to her practise in Bialystok Poland.
My GP put me touch with a penile dysfunction surgeon in Sydney and I sent him info on the Intracavernosal plaque excision method.Haven't heard back from him yet either.He also does other body part surgery for various improvements/enhancements, I wonder if that dilutes or increases his skills with the scalpel. He's supposedly been doing it for 37 years?
Ironically my wife is not pro me having any surgery because of the risks involved.

[Luciano]

Well i think he should be able to handle the operation, because when you look at the end of the study,
You have an Editorial Comment by F. Montorsi, Milan, Italy
He is the one who published the first verapamil studies some years ago.
(so I assume he is a Peyronies Disease specialist)

This is a new and interesting technique which shows
how to approach the Peyronie's disease plaque from
inside the tunica albuginea. The technique seems easy
to perform and reproducible and I believe that many of
us Urologists will use it in the future.

So it seems its not such a sophisticated operation, just another way of removing plaque whitout taking the penis apart.
The question is: will he want to do it.

L.

PS: there is good and bad news.
i found a critical analysis of operations,
http://pt.wkhealth.com/pt/re/merck/fulltext.00042307-200411000-00015.htm

where the guy says:

In an alternative approach, Darewicz et al. [35•]  reported on a new intracavernous excisional correction technique for dorsal Peyronie's plaque. After an intraoperative artificial erection is obtained, the authors enter the tunica albuginea with a 3 cm incision parallel to the plaque at a distance of approximately 5 mm from the edge of the lesion and away from the neurovascular bundles. After carefully separating the plaque from the corpus cavernosum by finger dissection, the authors cut the plaque from the underside and closed the tunica. Sixteen patients (mean age 50.2 years) with only dorsal plaques (0.5×2 to 1.5×4 cm) and penile angles between 30 and 60° underwent this procedure 81.25% of the patients complained of impaired sexual activity preoperatively, with a mean International Index of Erectile Function (IIEF)-5 score of 15.1]. At the 12-month evaluation, apart from two patients who had impaired intercourse because of the recurrence of curvature greater than 20°, there was no evidence of residual plaque, no pain with erections, no loss of sensation, no reduction in penile length, and all had significant improvements in IIEF-5 scores. The investigators concluded that because this procedure does not require mobilization of the neurovascular bundles, the chances of sensory loss are substantially diminished. Application of this procedure for lateral and ventral curvature is speculative at this time.

So it seems that no one will want to test it if its not a dorsal plaque.

[solomon]

I received a letter back today from the specialist in Sydney. He said he had heard of the Janusz technique. He says the technique can be performed in suitable circumstances, with quite good results. Further he says,'my post op treatment requires the use of a penis pump to prevent the corpus from shrinking at the excision site just as occurs with the incision and graft technique.The pump largely overcomes this problem.It is also necessary to suppress erections post op to prevent the possibility of an aneurismal deformity at the excision site'. He's got me a bit confused there, I thought the penis pump was for creating an erection?
Essentially it's down to the plaque. Curse the plaque!
So I have to have an ultra sound to view the plaque.He says that this type of treatment is not suitable for all Peyronie's plaques.
I have a feeling that Peyronie's specialists have a preferred technique which seems to work for them and they probably lean towards whatever that may be.

[Old Man]

Solomon:

Penis pumps - AKA VEDs (vacuum erection devices) have uses other than for erections. This forum has many threads and posts concerning the use of VEDs. There are protocols listed in the VED board section of the home page explaining the regimen used for the treatment of Peyronies Disease. There no protocols for Erectile Dysfunction therapy since it is obvious the result of pumping up ones penis and installing the restrictor ring, if necessary, to hold up the erection.

VEDs are used for erectile dysfunction as well where they are needed to produce erections suitable for penetrative sexual activity. You should read up on the VED usage on the above mentioned above to understand more about their use.

There are many members of this forum that used the VED protocol with success in helping with their Erectile Dysfunction and Peyronies Disease symptoms.

Old Man

[Luciano]

[Full quote removed by admin, please edit down quotes]

Yup, thats what heard also, only suitable for dorsal plaques, and / or plaques that are along the lenght of penis... (mine diagonal, causing the indent so it seems its not for me)
The VED is for softening the tissue.
There is a video interview of dr.Lue posted in one of the xiaflex threads.

Latest Videos

He says in it, that the main problem is the loss of elasticity. "Desolving (Removing) the scar tissue doesnt give you back the elasticity" . Even if xiaflex resolves the plaque, the tissue lost its elasticity like after excision. It has to be mobilised with a device. So use of VED seems logic to me.
Actually the VED is not for getting erections. Even without surgery it allows you to loose some curvature. Because the way you do it. creating an erection for only 15 seconds. this pulls on the scar tissue and extends it and makes it softer. You gain length and girth. that is why you should stick to the 26 weeks protocol using the technique described in the ved section.

[EDIT]oops old man was quicker  [/edit]

[Arkibald]

This looks promising.


A new paper, 2016, supports the conclusions made by Darewich in 2004.
The study is made with 35 patients.


The Therapeutic Effects of Intracavernosal Plaque Excision in Peyronie's Disease: A None Grafting or Tunical Excising Procedure


Has anyone here tried this kind of surgery - or identified more EU/US doctors who perform this technique?


Regards,
Arkibald

[scola]

Arkibald

This is a very interesting paper. Thanks for posting it. I will ask my urologist to investigate it further. I'm surprised that people aren't jumping up and down about it although I do understand that it is a small sample of only 35. Still, 86% complete straightening! Do you have any further information on this about anyone else performing the procedure outside of Iran?

[Jonbinspain]

My Andrologist prefers to avoid excision unless necessary. The incidence of post surgical Erectile Dysfunction is far higher than that for plaque incision.

[Arkibald]

Jonbinspain,


I read about your surgery and recommendation of Dr Kuehhas some time ago, so I visited him in Vienna last month. He is excellent! I thank you for the advice, and I left Dr Kuehhas with both a relief, a better understanding of my condition, and a feel that he can solve my problem. I am 95% likely to let him staigthen out things by means of the Egydio-technique later this year.

[/size][size=78%]However - before signing up for surgery - I want to be sure, that Egydio is superior to this Intracavernosal Plaque Excision method, which to me seems both efficient and somewhat less invasive. [/size]


Regarding Erectile Dysfunction: Neither in the Darewich study 2004, nor in the Ahmadnia study 2016, are any surgery induced cases of Erectile Dysfunction observed. Further, no disorder of sensation and no shortening is reported, and the recovery time is relatively short. Note, that the incision is longitudinal, without excising any tunica, and that no grafting material is used - which may be the reason why this specific plaque excision method results in fewer complications.


It would be great, if you have the time to read and comment the article. I will appreciate all input, pros, cons and feedback, since I strongly consider to get the same surgery done as you.


All good,
Arkibald

[Arkibald]

Scola,


The only other I have found, are the Dr Janusz Darewich and Dr Barbara Darewich in Bialostok, Poland. I have however not called them yet, as I would first hear, if someone in this forum has a more recent lead than the 2004 article. Here is a link to the hospital: Klinika Urologii


Regards,
Arkibald

[Jumper49]

I am new here, but I too have researched this technique. My Urologist at Mayo said he had never heard of it, but said it looked "interesting".  As the other options presented to me are not very promising, I have been desperately looking for more info on this surgery, and any clinics which are currently performing it.

If anyone has any news regarding this, I would be eternally grateful to hear from you, either on this thread or via a private message.

Currently the only info I was able to obtain were the Polish study done in 2004, the study from Iran in 2016, and a variation of this surgery done at Univ. of Cal S.F. from 2010.