Male Sexual Dysfunction Lingual Mucosal Graft in Treatment of Peyronie Disease Emad A. Salem, Ehab H. Elkady, Ahmed Sakr, Aref M. Maarouf, Lotfy Bendary, Salem Khalil, Ashraf Shahin, and Hussein Kamel OBJECTIVE PATIENTS AND METHODS
RESULTS
CONCLUSION
To evaluate the use of lingual mucosal graft (LMG) as a substitute for tunica albuginea in the treatment of Peyronie disease (PD). Seventeen patients, reporting normal erectile function, with PD interfering with sexual function were operated on by plaque excision and grafting with LMG. Preoperative assessment included: the International Index of Erectile Function-5 score, penile duplex, and penile curvature angle measurement. Postoperative erectile function and penile deformity were assessed every 3 months for 9-18 months. Mean age of the patients was 52 (4.7) years and mean angle of deformity was 60 (5.1). Donor site complications occurred in the form of mild transient swelling, numbness, and pain. Postoperative assessment showed complete penile straightening in 15 patients with mild curvature recurrence (1 year) shows pain resolution, stability of the plaque formation, and the resulting penile curvature.7 Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Faculty of Medicine, Zagazig University, Zagazig, Egypt Address correspondence to: Aref M. Maarouf, M.D., Department of Urology, Faculty of Medicine, Zagazig University, 34 Elshiekh Gouda Khalil Street, Tasqeem Al-moalemen, Zagazig, Egypt. E-mail: [email protected] Submitted: April 8, 2014, accepted (with revisions): July 24, 2014
1374
ª 2014 Elsevier Inc. All Rights Reserved
Surgical treatment is indicated for patients with a penile curvature interfering with penetration. The type of surgery depends on the angle of the curvature and the presence of associated ED.8 The 3 main categories of surgical management of PD include: shortening of the convex side of the tunica, lengthening of the concave side by using grafts, or penile implant surgery with or without modeling in patients with associated ED.9 There is no agreement on the ideal graft. Various materials have been used including dermis,10 vein,11-14 cadaveric and bovine pericardium,15,16 dura mater,17 synthetic materials,18 and porcine small intestine (jejunal) submucosal extracellular matrix (Surgisis; Cook Urological, Spencer, IN).19 Synthetic grafts showed poor results due to marked inflammatory reaction, leading to fibrosis around the graft with increased the risk of infection.20 Tissue-engineered grafts21,22 avoid the additional time and morbidity associated with harvesting but is associated with extra cost, which may not be affordable by all patients or health authorities in all countries. Additionally, there were no data to support better results in terms of reduced scarring and de novo ED.20 Buccal mucosal grafting (BMG) has been proposed by Shioshvili and Kakonashivili23; they reported that such tissue showed better elasticity, higher graft take than conventional autologous grafts. Considering our encouraging results with lingual mucosal grafts (LMG) as an alternative to BMG in cases of complex hypospadias,24 we tried LMG as a tunica-lengthening http://dx.doi.org/10.1016/j.urology.2014.07.042 0090-4295/14
Figure 2. The tongue after closure of the graft defect. (Color version available online.) Figure 1. Dissection of the lingual mucosa from the undersurface of the tongue. (Color version available online.)
procedure in PD. To our knowledge, this is the first study to evaluate the use of LMG for correction of penile curvature resulting from PD.
PATIENTS AND METHODS After approval from our institutional ethics and review board, 17 patients were enrolled in this prospective study. All patients were informed about the nature of their disease, various surgical treatment options, expected results, and possible side effects, then signed a detailed consent for using their LMG to replace the fibrotic PD plaque. All patients gave a history of painless, stable penile curvature interfering with intercourse for >1 year duration, with normal erections. Patients with penile curvature angles of
RESULTS
CONCLUSION
To evaluate the use of lingual mucosal graft (LMG) as a substitute for tunica albuginea in the treatment of Peyronie disease (PD). Seventeen patients, reporting normal erectile function, with PD interfering with sexual function were operated on by plaque excision and grafting with LMG. Preoperative assessment included: the International Index of Erectile Function-5 score, penile duplex, and penile curvature angle measurement. Postoperative erectile function and penile deformity were assessed every 3 months for 9-18 months. Mean age of the patients was 52 (4.7) years and mean angle of deformity was 60 (5.1). Donor site complications occurred in the form of mild transient swelling, numbness, and pain. Postoperative assessment showed complete penile straightening in 15 patients with mild curvature recurrence (1 year) shows pain resolution, stability of the plaque formation, and the resulting penile curvature.7 Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Faculty of Medicine, Zagazig University, Zagazig, Egypt Address correspondence to: Aref M. Maarouf, M.D., Department of Urology, Faculty of Medicine, Zagazig University, 34 Elshiekh Gouda Khalil Street, Tasqeem Al-moalemen, Zagazig, Egypt. E-mail: [email protected] Submitted: April 8, 2014, accepted (with revisions): July 24, 2014
1374
ª 2014 Elsevier Inc. All Rights Reserved
Surgical treatment is indicated for patients with a penile curvature interfering with penetration. The type of surgery depends on the angle of the curvature and the presence of associated ED.8 The 3 main categories of surgical management of PD include: shortening of the convex side of the tunica, lengthening of the concave side by using grafts, or penile implant surgery with or without modeling in patients with associated ED.9 There is no agreement on the ideal graft. Various materials have been used including dermis,10 vein,11-14 cadaveric and bovine pericardium,15,16 dura mater,17 synthetic materials,18 and porcine small intestine (jejunal) submucosal extracellular matrix (Surgisis; Cook Urological, Spencer, IN).19 Synthetic grafts showed poor results due to marked inflammatory reaction, leading to fibrosis around the graft with increased the risk of infection.20 Tissue-engineered grafts21,22 avoid the additional time and morbidity associated with harvesting but is associated with extra cost, which may not be affordable by all patients or health authorities in all countries. Additionally, there were no data to support better results in terms of reduced scarring and de novo ED.20 Buccal mucosal grafting (BMG) has been proposed by Shioshvili and Kakonashivili23; they reported that such tissue showed better elasticity, higher graft take than conventional autologous grafts. Considering our encouraging results with lingual mucosal grafts (LMG) as an alternative to BMG in cases of complex hypospadias,24 we tried LMG as a tunica-lengthening http://dx.doi.org/10.1016/j.urology.2014.07.042 0090-4295/14
Figure 2. The tongue after closure of the graft defect. (Color version available online.) Figure 1. Dissection of the lingual mucosa from the undersurface of the tongue. (Color version available online.)
procedure in PD. To our knowledge, this is the first study to evaluate the use of LMG for correction of penile curvature resulting from PD.
PATIENTS AND METHODS After approval from our institutional ethics and review board, 17 patients were enrolled in this prospective study. All patients were informed about the nature of their disease, various surgical treatment options, expected results, and possible side effects, then signed a detailed consent for using their LMG to replace the fibrotic PD plaque. All patients gave a history of painless, stable penile curvature interfering with intercourse for >1 year duration, with normal erections. Patients with penile curvature angles of
