Microscopic Electric Rotary Grinding of Plaques Combined with Graft Repair in the Management of Peyronie's Disease

Summary

The presented protocol describes a microscopic surgical method for the treatment of Peyronie's disease by using electric rotary grinding of the plaques followed by using the tunica vaginalis or bovine pericardium as a graft for the repairing of the defects of the tunica albuginea.

Abstract

Peyronie's Disease (PD) is clinically characterized by the development of localized fibrous plaques, primarily on the tunica albuginea, especially on the dorsal area of the penis. These plaques are the hallmark feature of this condition, resulting in penile curvature, deformity, and painful erections for affected individuals. Although various nonsurgical treatment options exist, their overall effectiveness is limited. As a result, surgical intervention has become the ultimate choice for patients with severe penile curvature deformities and associated erectile dysfunction. Our research team has successfully employed a combined approach involving microscopic electric rotary grinding of the fibrous plaques and the use of tunica vaginalis or bovine pericardium as graft materials for the repairing of the defects of tunica albuginea in the treatment of PD. This approach has consistently yielded highly satisfactory results regarding the restoration of penile shape, with excellent cosmetic results and significantly improved sexual satisfaction.

This protocol aims to present a comprehensive surgical management strategy utilizing electric rotary grinding of the plaques and repairing the defects of tunica albuginea by using the tunica vaginalis, which represents an optimal surgical strategy for treating PD.

Introduction

Peyronie's disease (PD) is a chronic fibrotic condition that contributes to penile deformity, curvature, pain, sexual disability, and even leading to psychological distress¹. PD likely represents a heterogeneous condition, with both heritable and environmentally-driven epigenetic factors contributing to its development and progression².

The reported epidemiology of PD varies and may be under-reported because of embarrassment and misconceptions about the available treatment options, with 0.4%-20.3% among different ethnicities and cohorts^2,3. The treatment for PD includes conservative therapy or surgical intervention, depending on symptom severity and stability. Conservative therapy is the most common recommendation during the active phase, while more invasive treatments are reserved for the passive phase⁴. A recent randomized, controlled trial evaluating the efficacy of Collagenase Clostridium Histolyticum (CCH) + RestoreX penile traction vs. Surgery + RestoreX penile traction in Peyronie's disease management demonstrated comparable results between these two strategies⁵.

Although penile traction therapy and intralesional injections result in modest improvements for many patients, surgical intervention remains the final solution for this disease, especially for those with severe curvature and hourglass or hinge deformities¹. Currently, penile straightening, such as penile plication and plaque incision or partial excision and grafting, represents the most reliable approach to correct penile curvature or deformity⁶. However, the reported methods have a high rate of sensory loss, erection function loss, or cosmetic dissatisfaction^5,7,8.

An electric grinder is commonly used in neurosurgery and orthopedics as an effective tool for bone shaping. It exhibits high efficiency in grinding hard tissues, like bones, while causing minimal damage to soft tissues. This characteristic gives it a unique advantage in the treatment of hard plaques.

In this study, we developed a new management strategy involving microscopic electric rotary grinding of the fibrous plaques and the use of tunica vaginalis or bovine pericardium as graft materials in the treatment of PD, which delivered high levels of patient satisfaction. This protocol is applicable for patients with severe curvature or other deformities that limit their ability to engage in satisfactory penetrative intercourse.

Protocol

The protocol was carried out in accordance with the principles of the Helsinki Declaration, and all the methods described here have been approved by the ethics committee of Daping Hospital (IRB: 2023168). Written consent was obtained from the patients.

1. Instruments for operation

1. Conduct all the procedures under a surgical microscope. Ensure the availability of sterilized instruments and other equipment mentioned in the Table of Materials. Set the magnification between 3x-6x during the surgery, which is enough for dissection.

2. Inclusion and exclusion criteria

1. Inclusion criteria: Include patients who are in a stable stage, have severe penile curvature and deformity, and are unable to finish sexual activity.
2. Exclusion criteria: Do not include patients during the active stage or having a slight curvature of the penis, erection dysfunction, or no sexual desire.

3. Preparation for surgery

1. Anesthetize before the procedure by combined spinal-epidural anesthesia (0.5% Ropivacaine, 2.5 mL) and then place the patient in a supine position.
2. Use a rubber band as a tourniquet to tie the base of the penis, and inject normal saline into the corpus cavernosum of the penis to induce artificial erection. Assess the localization and degree of penile curvature using the ruler and the protractor.

4. Procedure

1. Make a circular incision under the coronal sulcus, perform circumferential degloving of the foreskin along with the superficial fascia(dartos), and expose the Buck's fascia.
2. Make a longitudinal incision along both sides of the penis shaft by a small circular blade adjacent to the urethra, at the Buck's fascia level, with a length of approximately 4-6 cm. Ensure that it fully exposes the plaque area on the dorsal side of the penis without damaging the nerves and blood vessels on the dorsal side of the penis
3. Dissect Buck's fascia and meticulously separate it from either side toward the midline area on the dorsal side. Use precise dissection techniques, employing microscissors or a fine needle electrode (Disposable Radiofrequency Ablation Electrode) for cauterization to minimize possible injury to neurovascular bundles.
4. Mark the extent of the plaque after complete exposure of the plaques on the dorsal area of the tunica albuginea.
5. Utilize an electric grinding drill to ablate the fibrotic plaques.
   NOTE: There is no need to remove all the rigid plaque tissue; the endpoint is to fully release the fibrotic plaques, allowing the corpus cavernosum and tunica albuginea to extend normally.
6. Use unilateral or bilateral tunica vaginalis grafts or bovine pericardium to repair the defects of tunica albuginea based on the size of the defect.
   NOTE: Ensure that the size of the repair material is significantly larger than the defect area.
7. Make sure maximal penis stretching during suturing, allowing the tunica vaginalis or bovine pericardium loosely cover the defect without tension, providing adequate extension potential for erection.
8. Reposition the neurovascular bundles and Buck's fascia.
9. Re-induce artificial erection for the assessment of penile curvature. Make a minor plication of tunica albuginea to achieve complete rectification of curvature if needed.
   NOTE: The suture material is 2-0 non-absorbable thread.
10. Meticulously restore and suture the retracted dartos fascia and foreskin, respectively.

5. Postoperative care

1. Moderately compress and bandage the penis, keeping it in an upright position for at least 2 weeks to prevent early inflammatory swelling of the foreskin and penis.
2. Maintain postoperative intravenous antibiotic treatment every 12 h for 2-3 days and change to oral treatment for 5-7 days (Cefuroxime sodium, 1.5 g every 12 h).
3. Use the vacuum device to assist the functional recovery of the corpus cavernosum for at least 8 weeks from 4 weeks after surgery.
4. Advise the patient to take low-dose tadalafil (5 mg/day) orally once a day for 2-3 months 2 weeks after the surgery.
5. Advise the patient to attempt sexual intercourse from 8 weeks after surgery.

Results

A total of 21 patients were included from January 2021 to May 2023. The patient's age ranges from 34 to 68 years, with an average of 51.5 ± 9.4 years old. Of the total number of patients, 8 (38.1%) had diabetes. A total of 16 patients (76.2%) showed significant simple dorsal curvature of the penis, with a curvature angle of 60-90° and 5 patients (23.8%) presented with complex hourglass-like deformities with both dorsiflexion and lateral curvature, or accompanied by constriction like deformities, with bending angles ran...

Discussion

In this study, we developed a new surgical strategy combining microscopic electric rotary grinding of plaques with graft repair to manage PD. The preliminary results showed that the corrective effect is satisfactory. To the best of our knowledge, this is the first study on the combined application of microscopic technology and an electric grinding drill for the surgical correction of PD.

Currently, various treatment options are recommended for PD patients, ranging from oral medications and in...

Materials

Name	Company	Catalog Number	Comments
Bovine pericardium	Guanhao Biotech, Guangzhou, Co.	TB-S6050/TB-S3050
Cefuroxime sodium	Yiyi Saite, Co., Ltd	N/A	0.75 g
Disposable Radiofrequency Ablation Electrode (Multifunctional Surgical Dissector)	Chongqing Andiyingge Techology Developement Co.,Ltd	SZ02068
Operating microscope system	Carl Zeiss Co., Ltd	OPMI VARIO 700
Polyglactin thread	Ethicon, LLC	Vicryl, W9981
Ropivacaine	Yiyi Saite, Co., Ltd	N/A	0.5%,2.5 mL
Vacuum device	Shenzhen Chunyu Biotech Co.	CY078