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 ranging from 45-60° degrees. The demographic information is presented in Table 1.

Table 2 demonstrates the intra- and postoperative results. The average plaque area was 4.3 ± 2.6 cm². Two types of repair materials were adopted during the surgery: the tunica vaginalis of the testis and the bovine pericardium. The average surgical duration is around 4.5 h. After surgery, 9 (42.9%) patients experienced numbness at penile glans and self-resolved within an average of 3.2 months. The majority of patients (17 cases, 81%) reported total straightened penile, while the rest of which reported a <10° of curve. As for overall satisfaction, almost all the patients reported satisfaction.

In a typical example, a 54-year-old patient presented to the urology clinic with a penile deformity that had persisted for over 1 year. Physical examination revealed a painless, approximately 2 cm x 4 cm uneven plaque on the dorsal side of the penis. The patient reported that after achieving an erection, his penis bent backward at an angle greater than 60°, accompanied by complex deformity, making sexual intercourse impossible. Subsequently, the patient underwent a procedure involving microscopic electric rotary grinding of the plaque and an autologous tunica vaginalis graft to repair the defect of the tunica albuginea (Figure 1). No postoperative complications or severe adverse events were noted. The patient did not experience numbness at the penile glans and resumed sexual intercourse 3 months after surgery. At the 12-month follow-up, the penile morphology was completely straightened. The plaque disappeared. The hardness of penile erection was rated as 4. There is no loss of penile sensation and length, and the follow-up showed that the patient was very satisfied with the treatment results.

Figure 1: The main surgical steps and corrective effects of curvature deformity in patients with Peyronie's disease. (A) Artificial erection is induced to observe and record the degree and location of penile curvature and deformity. (B) Buck's fascia is isolated following routine foreskin degloving. Buck's fascia is meticulously separated from both sides towards the midline area on the dorsal surface. (C) The plaque area on the dorsal surface of the tunica albuginea is marked. (D) The fibrotic plaque is ablated using an electric grinding drill until a grid-like defect appears in the tunica albuginea, allowing full, normal stretching of the corpus cavernosum. (E) One side of the tunica vaginalis was excised completely. (F) The defect of the tunica albuginea and the edge of the tunica vaginalis are covered with the excised side of the tunica vaginalis, and the edge of the defect is tightly sutured using a 5-0 absorbable polyglactin thread. (G) Due to the large area of the defect on the dorsal side of the patient, the coverage of the defect with one side of the tunica vaginalis is not sufficient; the tunica vaginalis from the other side is taken to cover the remaining defect. (H) Both sides of the tunica vaginalis completely repair the defect in the tunica albuginea, ensuring adequate room for expansion. (I) Buck's fascia is meticulously repositioned and sutured using 5-0 absorbable polyglactin thread. (J) Artificial erection is induced again to observe the correction of penile curvature deformity. The original dorsal, lateral, and narrowing deformities disappear, and the penis returns to a normal straight state. Please click here to view a larger version of this figure.

Variables		n (%)	Mean ± SD	Median(minimum, maximum)
Age(y/s)		-	51.5 ± 9.4	55 (34, 68)
Smoking length(year)		-	20 ± 10	18 (0, 35)
Onset to surgery(month)		-	26.4 ± 24.0	15 (12, 84)
Diabetes		8 (38.1)	-	-
Hinge/sandglass deformity		5 (23.8)	-	-

Table 1: Demographic features of 21 patients. The patients with PD underwent microscopic electric rotary grinding of plaques combined with graft repairing of the defect of the tunica albuginea. PD: Peyronie's Disease; SD: standard deviation.

Variables		n (%)	Mean ± SD	Median (minimum, maximum)
Surgery time (min)		-	272 ± 69	268 (170, 385)
Surface area of plaque (cm3)		-	4.3 ± 2.6	4.0 (2.0, 12.0)
Graft type
Autologous unilateral Tunica Albuginea		12 (57.1)	-	-
Autologous bilateral Tunica Albuginea		3 (14.3)	-	-
Bovine pericardium		6 (28.6)	-	-
Slight plication		5 (23.8)	-	-
Follow-up time(month)		-	12.1 ± 7.2	12 (3, 24)
Numbness at glans		9 (42.9)	-	-
Persist time of numbness (month)		-	3.2 ± 1.9	3 (1, 6)
Shortening#		13 (61.9)
Shortening length (cm)		-	1.1 ± 0.7	0.5 (0.5, 2.0)
Completely Strengthening(%)		17 (81.0)	-	-
Curvature <10 degree(%)		4 (19.0)	-	-
Penile hardness after erection		-	3.8 ± 0.4	4 (3, 4)
Gap between surgery and sexual activity(month)		-	2.9 ± 1.4	3 (1, 12)
Self-reported overall satisfaction*		-	4.4 ± 0.7	4.5 (3, 5)

Table 2: Intraoperative information and follow-up results among 21 patients with PD. ^#Self-reported. ^*Score from 1-5, from very dissatisfactory, dissatisfactory, medium, satisfactory, to very satisfactory.

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 intralesional injection to surgical intervention, depending on the stages and the severity of the deformity⁹. However, the overall effectiveness of nonsurgical therapies remains limited, especially for those with severe deformity^1,10,11. Under such conditions, surgical intervention becomes the ultimate way, with three main approaches existing: convex side shortening (plication or tunical shortening procedures), concave side lengthening(grafting or tunical lengthening techniques), and penile prosthesis implantation^3,10.

The choice of specific surgical procedures is based on both penile morphology and patient preference¹⁰. However, current surgical methods are challenged by penile shortening^12,13, postoperatively irregular plaque indurations⁷, and sensory or rigidity loss¹⁴. Additionally, techniques involving rectangular or elliptical incisions to remove sections of plaque tissue are challenging in terms of controlling depth and scope during excision, which can potentially lead to excessive damage to the corpus cavernosum⁷.

In light of these challenges, we have explored the use of electric rotary grinding in plaque management under microscopy. This approach offers a significant advantage: it not only prevents the large-scale defects associated with traditional excision methods but also minimizes the extent of the hardened plaque, thereby improving local tactile satisfaction. Besides, surgery under microscopy can provide accuracy and reliability during the process of neurovascular bundle mobilization, which can prevent postoperative sensory loss and erectile dysfunction (ED).

Currently, the complete or partial plaque excision method is not widely accepted and is rarely employed because the larger defect could result in higher postoperative ED risk^7,8. The general consensus is that it is sufficient to excise only the most severely affected area of plaque tissue responsible for penile deformity without the need for complete plaque removal. Alternatively, some advocate for loosening the tunica albuginea in the plaque region to correct the curvature.

In the literature, several techniques have been employed worldwide for plaque management^15,16. In a recent systematic analysis encompassing various surgical methods, the overall incidence of ED can reach as high as 24.1%, loss of sensation can be as pronounced as 36%, and satisfaction levels can dip as low as 62%³. In contrast, our method's initial results demonstrate optimal outcomes compared to the reported data.

In this study, we described the surgical procedure for treating Peyronie's Disease (PD) using electric rotary grinding of plaques and repairing tunica albuginea or bovine pericardium grafts and discussed its promising outcomes. Compared to previous surgical methods, this protocol has been refined and improved in various clinical aspects. Precise microscopic techniques are employed throughout the entire surgical procedure with 3x-6x magnification. When addressing Buck's fascia, the emphasis is on initiating the lifting and sharp separation at locations as distant as possible from the dorsal neurovascular bundle. This minimizes the risk of damaging the neurovascular system and avoids excessive tension on the Buck's fascia and its neurovascular bundle. An electric grinding drill and a combination of "moving" and "scattered point" grinding techniques are used to transform the plaque area into a grid-like pattern. This enables normal expansion and stretching of the corpus cavernosum. The testicular tunica vaginalis is completely removed and loosely overlaid on the grid-like defect area, followed by tight suturing using 5-0 absorbable Polyglactin thread. Buck's fascia is replaced and sutured using 5-0 absorbable Polyglactin thread to prevent excessive expansion of the repaired testicular tunica vaginalis during erection. After the full restoration and suturing of Buck's fascia, an artificial erection is induced to assess penile straightness recovery. If necessary, limited plication of the tunica albuginea may be performed. To facilitate penile erection function recovery and reduce the risk of penile shortening due to scar healing, patients are routinely prescribed 5 mg of tadalafil for oral administration once daily after surgery. Additionally, vacuum devices are used for rehabilitation training, involving daily sessions of 15-20 min each, starting 4 weeks after surgery and continuing for 2-3 months.

Despite the strengths mentioned above, the limitations should also be noted. The small number of cases is the main limitation of this study. A long-term follow-up is required to achieve definitive conclusions. A direct comparison with other surgical techniques is required for further study. The use of a tourniquet may, to some extent, affect the accurate measurement of penile erection abnormalities in PD patients. The application of vasoactive drugs to induce erections may be more beneficial for accurate evaluation of penile deformities. Due to the limited number of cases, this study did not observe the differences in efficacy between tunica vaginalis and bovine pericardium as graft materials. More cases and longer follow-ups are still needed to reach a conclusive result. The histological types and characteristics of the tunica vaginalis and the tunica albuginea are different. Therefore, as a repair material, the tunica vaginalis still needs long-term follow-up observation to evaluate its impact on penile erection and the effectiveness of correcting deformities. Nevertheless, this study is the first to visually demonstrate technical details using microscopic electric rotary grinding combined with tunica albuginea or bovine pericardium graft repairing for the management of PD. In conclusion, microscopic electric rotary grinding combined with graft repairing is an effective and safe method for patients with severe PD in terms of overall satisfaction, cosmetic shape, and sexual ability.

Materials

List of materials used in this article

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