Urology Journal UNRC/IUA Vol. 2, 36-39 Spring 2004 Printed in IRAN 36 Management of Peyronie's Disease by Dermal Grafting NIKOOBAKHT MR, MEHRSAI A, POURMAND GH, JALADAT H, NASSEH HR Department of Urology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran ABSTRACT Purpose: To evaluate the results of plaque excision and dermal grafting in Peyronie's disease. Materials and Methods: Twenty seven patients were scheduled to undergo plaque excision and dermal grafting for Peyronie's disease. Potency, bending of erected penis, and having painful erection were evaluated in patients before and after operation. To evaluate erectile dysfunction, we used International Index of Erectile Function (IIEF) by interviewing the patients and filling questionnaires by their partners. Doppler ultra- sonography was used to determine the vascular competence of penis before and after operation in 15 patients. Results: The disease was more prevalent between the ages of 40 and 60 years. Plaques were located as follows: dorsal in 18, right lateral in 6 and left lateral in 3. Mean plaque size was 11 (range 5 to 18) mm. After plaque excision and dermal graft- ing, penile deformity, erectile dysfunction, and painful erection had remained yet in 4 (15%) out of 27, 3 (16%) out of 19, and 3 (14%) out of 22, respectively. Doppler ultra- sonographic study in 15 patients revealed improvement in peak systolic velocity (p<0.01). In addition, a decrease in end diastolic velocity was noted also that was not significant statistically (p=0.26). Resistive index did not improve after operation. Conclusion: This procedure showed significant improvement in penile deformity (85% of cases), erectile dysfunction (84% of cases) and painful erection (86% of cases). We recommend plaque excision and dermal grafting as an effective procedure in treat- ing Peyronie's disease. KEY WORDS: impotence, dermal grafting, Peyronie's disease Introduction The incidence of symptomatic Peyronie's disease is estimated to be 1% and its asymptomatic preva- lence is between 0.4% and 1%. In 100 autopsies from previously asymptomatic individuals, 22 cases of Peyronie's like lesions were found. Moreover, it seems that the incidence of the dis- ease is in progress.(1) Thus, finding an appropriate therapy is getting more crucial. It is suggested that trauma is the trigger event.(2) The result is a plaque formation, which impede dilation of tunica albuginea during the erection.(1) Changes in the appearance and the tis- sue of tunica albuginea is the characteristic pathology. Induration may occur within the tunica albuginea with or without lymphocyte infiltra- tion.(3) This disease can lead to painful erection, bending of erected penis, and in advanced stages, erectile dysfunction (43%).(4) According to various studies, improvement occurs spontaneously in 13% of the patients. In 47%, complications persist and in 40% progress gradually.(5) Several therapeutic options are available: medical treatments such as Orgotein (an anti-inflammatory drug)(6), vitamin E(7), Tamoxifen(8), Verapamil(9), Cholchicine(10), and intralesional Triamcinolone(11) and even radiother- apy or surgical approaches. Various surgical procedures have been used to date. One of the increasingly accepted methods is dermal grafting.(1) In a study of 20 patients who underwent plaque excision and dermal grafting, ample erection for satisfactory intercourse was achieved postoperatively in 4 of 4 patients (100%) with erectile dysfunction.(12) Considering the high prevalence of Peyronie's disease and its impact on Accepted for publication in July 2003 MANAGEMENT OF PEYRONIE'S DISEASE BY DERMAL GRAFTING patients' quality of life, and regarding the out- comes of the studies on dermal grafting in other countries, we decided to investigate the results of plaque excision and dermal grafting in Iranian patients. Materials and Methods Thirty five patients were evaluated between September 1992 and February 1998 at Sina hospi- tal. Twenty-four of them had the indication for sur- gery and underwent plaque excision with dermal grafting by a single surgeon. We used a hairless area in the superio-lateral side of iliac crest of the abdominal skin for obtaining dermis. Epidermis was removed and derma was grafted. Mean follow- up was 12 (range 9 to 72) months. Each patient who met these criteria was included: a minimum of 1-year unsuccessful medical treatment, age of less than 65, and the location of plaque on the inferior or lateral surface of penis. A written con- sent was signed by the patients preceded with explaining the procedure and its complications. Patients who were over 65, had no plaque, were not interested in surgical therapy, or were given medical treatment less than one year were exclud- ed. Data were collected through interview, ques- tionaires filled out by the patient and his sexual partner, and physical examination before and after the procedure. Erectile dysfunction, painful erec- tion, and bending erected penis were evaluated using International Index of Erectile Function (IIEF). In order to quantify postoperative symptoms, we graded the patients based on the surgeon and patient's point of view as follows: Grade 1: only one symptom resolved or all the symptoms remained. Grade 2: two symptoms were relieved. Grade 3: no symptom remained. Statistical analysis was performed by SPSS soft- ware, using Paired t test. The P value of less than 0.05 was regarded significant. Results Twenty seven out of 35 were selected to under- go the operation. They were classified by age (table 1). Mean age was 56 (range 36 to 64) years. Similar to the results of other studies, Peyronie's disease was more prevalent in the patients between 40 and 60 years old. All the patients underwent plaque excision with dermal grafting. Plaque was located right-laterally in 6, posteriorly in 18, and left laterally in 34. Mean plaque size was 11 (range 5 to 18) mm. Nineteen patients had erectile dysfunction (70%), based on the IIEF scoring, 22 (81%) had painful erection, and all of the cases (100%) suffered from bending erected penis. Postoperatively, penile deformity, erectile dysfunction, and painful erec- tion were found in 4 (15%) out of 27, 3 (16%) out of 19, and 3 (14%) out of 22, respectively (tables 2,3). The remainder were improved (p<0.001). Doppler ultrasonography was performed in 15 cases; Peak Systolic Velocity increased significant- ly (p<0.01) and End Diastolic Velocity had slight decrease which was not statistically significant (p=0.26). Resistive index did not improve after the surgery (table 4). According to our grading, 23 patients had no unresolved symptom (grade 3). One case of bending erected penis remained unre- solved (grade 2) and 3 patients still had painful erection, erectile dysfunction, and bending erected penis (grade 1). Discussion Peyronie's disease is not a rare condition. Despite of its self-limiting nature and the availabil- ity of a series of non-invasive treatments, in some cases with failure of conservative therapies and 37 TABLE 1. Patients' age distribution Age Number (percent) <40 years 3 (11.3%) 40-60 years 18 (66.4%) >60 years 6 (22.3%) Total 27 (100%) TABLE 2. IIEF results before and after dermal grafting in 27 patients underwent the surgery Mild: 5-7 scores, Moderate: 8-16 scores, Severe: 17- 21 scores TABLE 3. The effect of plaque excision and dermal grafting on painful erection, erectile dysfunction, and erected penis bending Before the Operation After the Operation Erectile Dysfunction intensity Number (percent) Number (percent) Mild 3 (16%) 0 (0%) Moderate 7 (37%) 2 (66.7%) Severe 9 (47%) 1 (33.3%) Painful Erection Erectile Dysfunction Erected Penis Bending Before the Operation 22 (87%) 19 (70%) 27 (100%) After the Operation 3 (11%) 3 (11%) 4 (15%) P value <0.001 <0.001 <0.001 MANAGEMENT OF PEYRONIE'S DISEASE BY DERMAL GRAFTING severe deformity and erectile dysfunction, surgical correction would be warranted. The most common surgical methods are Nesbit's Tucking technique, its excision-plication type, and Free Dermal Grafting introduced by Devine and Horton.(13) In this study, 27 patients needed surgical interven- tion and dermal grafting of whom 70% had erec- tile dysfunction, similar to those in previous reports.(14-16) The rate of erectile dysfunction was reduced to 11% (3 cases) after the procedure (p