Category: Article of the Week

Video: Combination of mpMRI and TTMB of the prostate to identify candidates for hemi-ablative FT

January 13, 2016/by admin Z.9

Combination of multi-parametric magnetic resonance imaging (mp-MRI) and transperineal template-guided mapping biopsy (TTMB) of the prostate to identify candidates for hemi-ablative focal therapy

Minh Tran*†‡, James Thompson*†§, Maret Bohm†, Marley Pulbrook†, Daniel Moses¶, Ron Shnier**, Phillip Brenner*†§, Warick Delprado††, Anne-Maree Haynes†, Richard Savdie§ and Phillip D. Stricker*†§

*St Vincent’s Prostate Cancer Centre, †Garvan Institute of Medical Research & The Kinghorn Cancer Centre, Darlinghurst, ‡School of Medicine, University of Sydney, §School of Medicine, University of New South Wales, Sydney, ¶Spectrum Medical Imaging , **Southern Radiology, Randwick, and†† Douglass Hanly Moir Pathology, Darlinghurst, NSW, Australia

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OBJECTIVE

To evaluate the accuracy of combined multiparametric magnetic resonance imaging (mpMRI) and transperineal template-guided mapping biopsy (TTMB) for identifying lobes with significant prostate cancer (PCa) for the application of hemi-ablative focal therapy (FT).

PATIENTS AND METHODS

From January 2012 to January 2014, 89 consecutive patients, aged ≥40 years, with a PSA level ≤15 ng/mL, underwent in sequential order: mpMRI, TTMB and radical prostatectomy (RP) at a single centre. Analysis was performed on 50 patients who met consensus guidelines for FT. Lobes were stratified into lobes with significant cancer (LSC), lobes with insignificant cancer and lobes with no cancer. Using histopathology at RP, the predictive performance of combined mpMRI + TTMB in identifying LSC was evaluated.

RESULTS

The sensitivity, specificity and positive predictive value for mpMRI + TTMB for LSC were 97, 61 and 83%, respectively. The negative predictive value (NPV), the primary variable of interest, for mpMRI + TTMB for LSC was 91%. Of the 50 patients, 21 had significant unilateral disease on mpMRI + TTMB. Two of these 21 patients had significant bilateral disease on RP not identified on mpMRI + TTMB.

CONCLUSIONS

In the selection of candidates for FT, a combination of mpMRI and TTMB provides a high NPV in the detection of LSC.

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Article of the Month: SRP for recurrent Prostate Cancer – Verification of EAU guideline criteria

January 6, 2016/by admin Z.9

Every Month the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Salvage Radical Prostatectomy for recurrent Prostate Cancer: Verification of EAU guideline criteria

Philipp Mandel*†, Thomas Steuber*†, Sascha Ahyai†, Maximilian Kriegmair‡, Jonas Schiffmann*, Katharina Boehm*, Hans Heinzer*, Uwe Michl*, Thorsten Schlomm*†, Alexander Haese*, Hartwig Huland*, Markus Graefen* and Derya Tilki*†

*Martini-Clinic Prostate Cancer Center, †Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg , and ‡Department of Urology, University Hospital Mannheim, Mannheim, Germany

Note: Figure 3 should be swapped with Figure 4. The legends for both figures stay the same and the referencing in the text is correct.

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OBJECTIVE

To analyse oncological and functional outcomes of salvage radical prostatectomy (SRP) in patients with recurrent prostate cancer and to compare outcomes of patients within and outside the European Association of Urology (EAU) guideline criteria (organ-confined prostate cancer ≤T2b, Gleason score ≤7 and preoperative PSA level <10 ng/mL) for SRP.

PATIENTS AND METHODS

In all, 55 patients who underwent SRP from January 2007 to December 2012 were retrospectively analysed. Kaplan–Meier curves assessed time to biochemical recurrence (BCR), metastasis-free survival (MFS) and cancer-specific survival. Cox regressions addressed factors influencing BCR and MFS. BCR was defined as a PSA level of >0.2 ng/mL and rising, continence as the use of 0–1 safety pad/day, and potency as a five-item version of the International Index of Erectile Function score of ≥18.

RESULTS

The median follow-up was 36 months. After SRP, 42.0% of the patients experienced BCR, 15.9% developed metastasis, and 5.5% died from prostate cancer. Patients fulfilling the EAU guideline criteria were less likely to have positive lymph nodes (LNs) and had significantly better BCR-free survival (5-year BCR-free survival 73.9% vs 11.6%; P = 0.001). In multivariate analysis, low-dose-rate brachytherapy as primary treatment (P = 0.03) and presence of positive LNs at SRP (P = 0.02) were significantly associated with worse BCR-free survival. The presence of positive LNs or Gleason score >7 at SRP were independently associated with metastasis. The urinary continence rate at 1 year after SRP was 74%. Seven patients (12.7%) had complications ≥III (Clavien grade).

CONCLUSION

SRP is a safe procedure providing good cancer control and reasonable urinary continence. Oncological outcomes are significantly better in patients who met the EAU guideline recommendations.

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Editorial: SRP – a few good men

January 6, 2016/by Chandrasekar Thenappan

The current management of recurrent disease after definitive treatment of a localized prostate cancer with radiation therapy (RT) or cryotherapy remains debatable. A substantial portion of patients treated with RT (20–50%) will experience biochemical recurrence. Androgen deprivation therapy has been the mainstay of therapy for this patient population, especially if there was concern about metastatic spread. As the initial experience with salvage radical prostatectomy (SRP) was highly morbid with poor functional outcomes, this did not gain strong acceptance as a recommended treatment method; however, with improved functional outcomes and fewer complications reported in recent series, SRP has once again become a viable alternative in select cases.

The rarity of the procedure makes it difficult to generate large-volume prospective studies on SRP, requiring us to depend on retrospective series. Chade et al. [1] published the largest series of patients undergoing SRP through a multicentre collaborative effort, and were able to identify 404 patients treated between 1985 and 2009; other large series were limited to 50–200 patients. In their systematic review of studies published between 1980 and 2011, Chade et al. [2] reported 5- and 10-year biochemical recurrence-free survival rates of 47–82% and 28–53%, respectively. This broad range of outcomes hints at the variable response of patients to SRP. Identifying the subset of patients who are most likely to benefit from SRP will therefore help tailor therapies for patients who have failed RT, cryotherapy or high-intensity focused ultrasonography.

As described by Mandel et al. [3], there are three sets of guidelines currently addressing patient selection for SRP. The NICE guidelines are the least specific, essentially mentioning SRP as an option for management without specifying specific criteria [4]. The European Association of Urology (EAU) and National Comprehensive Cancer Network guidelines are more specific, and help narrow the patient population to men with clinically localized recurrence (cT1–2), life expectancy of at least 10 years and a preoperative PSA level <10 ng/mL[5, 6]. The EAU guidelines are even more restrictive, limiting selection to men with Gleason ≤7 on prostate biopsy, although they do not specify whether that is before or after RT [5].

In their retrospective analysis of 55 patients treated with SRP between 2007 and 2012, Mandel et al. [3] compare the oncological outcomes of patients treated according to the EAU criteria (n = 32) and those treated without meeting the EAU criteria (n = 23). The 5-year biochemical recurrence-free survival rate was 48.7%, consistent with previous studies, as was the 5-year cancer-specific survival rate of 89%. Importantly, however, after stratification based on EAU criteria, the 5-year biochemical recurrence-free survival rates were drastically different: 73.9% in patients who met the EAU criteria and 11.6% in patients who did not. Patients who did not meet the EAU criteria were more likely to have Gleason score ≥8 (P = 0.08) tumours and pN1 (nodal metastatic) disease at the time of SRP (P = 0.04), which shows the ability of these criteria to select patients with localized disease recurrence. They also established that overall functional outcomes were acceptable after this procedure, with a postoperative urinary continence rate of 74%; none of the patients recovered potency, however, which is not surprising considering the high rate of preoperative erectile dysfunction and the non-nerve-sparing nature of the procedure [3].

In terms of complications, 12.7% of the patients had Clavien ≥ III complications requiring additional intervention. When complications do occur, they can be severe: three of the patients (5.5%) developed rectovesical fistulae and failed conservative management, progressing to fistula repair with omental flap, and two of the patients required permanent urinary diversion. There was no specification, however, regarding which subset of patients experienced these complications. The complication rate was acceptable, and consistent with recent reports of decreased complication rates with SRP [3].

While the study has its limitations as a retrospective review of a relatively small cohort, it is the first to analyse outcomes based on published guidelines criteria, and thereby helps to validate the subset of patients that will benefit from surgical intervention. Based on their findings, appropriately selected patients, those with evidence of truly localized recurrent disease after RT or high-intensity focused ultrasonography, can have significant oncological benefit with acceptable functional outcomes and without significant morbidity. The goal is not to perform SRP indiscriminately, rather to wait for a few good men.

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Thenappan Chandrasekar , and Christopher P. Evans

Department of Urology, University of California, Sacramento, CA, USA

References

1 Chade DC, Shariat SF, Cronin AM et al. Salvage radical prostatectomy for radiation-recurrent prostate cancer: a multi-institutional collaboration. Eur Urol 2011; 60: 205–10

2 Chade DC, Eastham J, Graefen M et al. Cancer control and functional outcomes of salvage radical prostatectomy for radiation-recurrent prostate cancer: a systematic review of the literature. Eur Urol 2012; 61: 961–71

3 MandelP, Steuber T, Ahyai S et al. Salvage radical prostatectomy for recurrent prostate cancer: veriﬁcation of European Association of Urology guideline criteria. BJU Int 2015; 117: 55–61

4 Prostate cancer: diagnosis and treatment. NICE clinical guideline 175: Hearing before the National Institute for Health and Care Excellence (January 2014).

5 Heidenreich A, Bastian PJ, Bellmunt J et al. EAU guidelines on prostate cancer. Part II: treatment of advanced, relapsing, and castration-resistant prostate cancer. Eur Urol 2014; 65: 467–79

6 Mohler JL, Kantoff PW, Armstrong AJ et al. Prostate cancer, version 2.2014. JNCCN 2014; 12: 686–718.

Article of the Week: Frozen Section During Partial Nephrectomy: Does it Predict Positive Margins?

December 30, 2015/by admin Z.9

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

If you only have time to read one article this week, it should be this one.

Frozen Section During Partial Nephrectomy: Does it Predict Positive Margins?

Jennifer Gordetsky, Michael A. Gorin*, Joe Canner†, Mark W. Ball*, Phillip M. Pierorazio*, Mohamad E. Allaf* and Jonathan I. Epstein*

‡Departments of Pathology and Urology, The University of Alabama, Birmingham, AL , *Department of Urology, †Department of Surgery, Center for Surgical Trials and Outcomes Research, and ‡Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD, USA

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OBJECTIVE

To investigate the clinical utility of frozen section (FS) analysis performed during partial nephrectomy (PN) and its influence on intra-operative management.

PATIENTS AND METHODS

We performed a retrospective analysis of consecutive PN cases from 2010 to 2013. We evaluated the concordance between the intra-operative FS diagnosis and the FS control diagnosis, a postoperative quality assurance measure performed on all FS diagnoses after formalin fixation of the tissue. We also evaluated the concordance between the intra-operative FS diagnosis and the final specimen margin. Operating reports were reviewed for change in intra-operative management for cases with a positive or atypia FS diagnosis, or if the mass was sent for FS.

RESULTS

A total of 576 intra-operative FSs were performed in 351 cases to assess the PN tumour bed margin, 19 (5.4%) of which also had a mass sent for FS to assess the tumour type. The concordance rate between the FS diagnosis and the FS control diagnosis was 98.3%. There were 30 (8.5%) final positive specimen margins, of which four (13.3%) were classified as atypia, 17 (56.7%) as negative and nine (30%) as positive on FS diagnosis. Intra-operative management was influenced in six of nine cases with a positive FS diagnosis and in one of nine cases with an FS diagnosis of atypia.

CONCLUSIONS

The relatively high false-negative rate, controversy over the prognosis of a positive margin, and inconsistency in influencing intra-operative management are arguments against the routine use of FS in PN cases.

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Editorial: Frozen section during partial nephrectomy: an unreliable test that changes nothing

December 30, 2015/by Grenville Oades

A core goal of oncological surgery is complete removal of the neoplastic mass. Conventional wisdom with regards to partial nephrectomy (PN) is that a minimal tumour-free margin is sufficient to achieve adequate cancer clearance, minimises loss of normal renal parenchyma and avoids local tumour recurrence [1]. Does this maximisation of nephron preservation and reported positive surgical margin rates after PN ranging from 0% to 7% [2] make intraoperative frozen sections a prerequisite? The results of the paper by Gordetsky et al. [3] in this month’s issue of BJU International suggest that frozen section results from the tumour bed of patients undergoing a PN may be both unreliable and result in subsequent inconsistent management decisions by the operating surgeon.

A recent survey of 197 American urologists revealed that up to 69% (‘always’ or ‘sometimes’) undertake a frozen section during PN [4]. In view of such high penetrance of this test with a resulting high workload for the uro-pathologist, it is critical that the test is reliable and the results are positively and consistently acted upon by the operating urologist.

Gordetsky et al. [3] present interesting data from an expert uro-pathology service, on a consecutive cohort of patients undergoing PN. Reassuringly the pathologist’s skill at making the correct call on the frozen-section specimen was extremely high with a 98% concordance between the actual frozen section and the subsequently created formalin-fixed paraffin-embedded tissue block from the very same piece of tissue. However, despite this high level of accuracy, the sensitivity of the tumour bed frozen section in predicting the actual presence of a positive surgical margin in the resected tumour was only 30% (in other words, of all the patients who actually had positive surgical margins only 30% were identified by frozen section analysis of the tumour bed). As tumour bed biopsies only represent a small fraction of the resection margin this is perhaps unsurprising.

The second issue addressed by Gordetsky et al. [3] is the matter of an inconsistent response of the surgeon to a positive frozen section. In five cases no action was taken, in three cases the tumour bed was re-resected and in a single case a subsequent radical nephrectomy was performed. These results can be compared with those of Sidana et al. [4], where there was a similar inconsistency of management strategies. This inconsistency can be explained by the controversy surrounding the oncological importance of a positive surgical. There is evidence that a positive margin may be associated with an increased risk of recurrence; however, it does not appear to infer a poorer long-term oncological outcome for the patient [5]. It is intriguing that at the time of a completion nephrectomy following a positive surgical margin, residual malignant cells were not found in any of the patients who underwent a re-resection or nephrectomy in this and other studies [3, 6]. It should, however, be noted that published series of conservative management of positive margins are few with only medium-term follow-up. As we know that the natural history of the small renal mass is one of slow growth, any microscopic residual disease may take several years to become clinically apparent and these studies are therefore underpowered.

We think there are several practical arguments against routine use of frozen section. Whilst waiting for the frozen section result some surgeons have been known to keep the kidney ischaemic (16%) resulting in consequent loss of renal function [4]. To avoid this many urologists will undertake the renorrhaphy whilst waiting for the result, a practice becoming increasingly more common with the move towards laparoscopic and robot-assisted PN, where tumour extraction is usually the final step. This practice inevitably influences the subsequent enthusiasm of the surgeon to go back and perform a re-resection and re-do renorrhaphy. It is known that the surgeons’ gross interpretation of the surgical margin approaches the sensitivity of the permanent section and has low false-negative rates, apparently superior to tumour bed frozen section [7]. Routine cautery of the resection bed may also provide an additional safety margin and render any microscopic positive margin clinically insignificant.

It is our opinion that this work by Gordetsky et al. [3] adds credence to the stand that there is no need for a routine tumour bed frozen section in PN and that careful examination of the resected tumour with selected frozen section analysis of suspicious areas is a safe strategy, saves time and provides adequate information for intraoperative decision making.

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Grant D. Stewart, *† and Grenville Oades, ‡

*Clinical Senior Lecturer, Edinburgh Urological Cancer Group, University of Edinburgh,†Honorary Consultant in Urological Surgery, Department of Urology, NHS Lothian, Edinburgh, and ‡Consultant Urological Surgeon, Department of Urology, NHS Greater Glasgow and Clyde, Glasgow, UK

References

1 Sutherland SE, Resnick MI, Maclennan GT, Goldman HB. Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter? J Urol 2002; 167: 61–4

2 Marszalek M, Carini M , Chlosta P et al. Positive surgical margins after nephron-sparing surgery. Eur Urol 2012; 61: 757–63

3 Gordetsky J, Gorin M, Canner J et al. Frozen section during partial nephrectomy: does it predict positive margins? BJU Int 2015; 116: 868–72

4 Sidana A, Donovan JF, Gaitonde K. Surgeons’ preferences and practice patterns regarding intraoperative frozen section during partial nephrectomy. Urol Oncol 2014; 32: 864–8

5 Bensalah K, Pantuck AJ, Rioux-Leclercq N et al. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. Eur Urol 2010; 57: 466–71

6 Raz O, Mendlovic S, Shilo Y et al. Positive surgical margins with renal cell carcinoma have a limited inﬂuence on long-term oncological outcomes of nephron sparing surgery. Urology 2010; 75: 277–80

7 Timsit MO, Bazin JP, Thiounn N et al. Prospective study of safety margins in partial nephrectomy: intraoperative assessment and contribution of frozen section analysis. Urology 2006; 67: 923–6

Article of the Week: Recourse to RP and associated short-term outcomes in Italy

December 23, 2015/by admin Z.9

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Mr. Julian Hanske, discussing his editorial.

If you only have time to read one article this week, it should be this one.

Recourse to radical prostatectomy and associated short-term outcomes in Italy: a country-wide study over the last decade

Giacomo Novara, Vincenzo Ficarra*, Filiberto Zattoni and Ugo Fedeli†

Department of Surgery, Oncology, and Gastroenterology, Urology Clinic, University of Padova, Padova, *Department of Experimental and Clinical Medical Sciences, Urologic Clinic, University of Udine, Udine, and †Epidemiological Department, Veneto Region, Italy

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OBJECTIVE

To estimate time trends in the recourse to radical prostatectomy (RP) and associated short-term outcomes after RP in Italy, as population-based data on RP adoption and outcomes are available mainly from Northern America and Northern Europe.

PATIENTS AND METHODS

All RPs for prostate cancer performed between 2001 and 2010 were extracted from the Italian national archive of hospital discharge records. Age-specific and age-standardised RP rates were computed. The effect of procedural volume on in-hospital mortality, complications, and length of stay (LOS) was estimated by multilevel regression models.

RESULTS

In all, 144 432 RPs were analysed. Country-wide RP rates increased between 2001 and 2004, and thereafter remained stable, with large differences between geographical areas. The mean hospital volume increased in the first study years, without centralisation but due to increasing RP numbers at the population level. The median LOS declined from 10 to 8 days over the study period (mean from 11.7 to 9.2 days). In-hospital mortality declined from 0.16% in 2001 to 0.07% in 2010. In-hospital mortality, LOS, and the prevalence of complications increased with age, and decreased with year of surgery. Compared with very low-volume hospitals, procedures performed in high-volume hospitals were associated with decreased in-hospital mortality, in-hospital complications, and LOS.

CONCLUSIONS

The study adds evidence on rapidly changing trends in RP rates in Italy, on improving in-hospital outcomes, and on their association with procedural volume.

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Editorial: How Can We Improve Surgical Outcomes?

December 23, 2015/by Quoc-Dien Trinh

How to improve surgical outcomes for all is a long-standing health policy/services research question. There are generally two perspectives to the debate. One reasonable approach would be to regionalise, or centralise, the performance of a procedure, in this case radical prostatectomy (RP), to ‘specialised’ surgeons or institutions. Data from the USA show that regionalisation of prostate cancer care initially occurred in the late 1990s and even further more recently after the introduction of robotic surgery. The improvement of surgical outcomes after RP in the USA has been partially attributed to such phenomena [1]. Conversely, it may be impossible to centralise a common procedure, such as RP, to a small number of hospitals, concerns that were raised in an review on improving surgical care by Hollenbeck et al. [2]. Alternatively, large state or national quality improvement initiatives, with incremental advances in process-of-care adoption/compliance, may improve the care of prostate cancer for all. This collaborative and inclusive approach is, for example, employed by the Michigan Urological Surgery Improvement Collaborative (MUSIC). However, one has to factor in that this type of approach demands funding, collaboration and patience. Regardless, there is little doubt that both approaches, enforced by health policy or not, are needed in large and diverse countries such as the USA.

In this issue of BJU International, Novara et al. [3] examine the trends in RP utilisation within Italy. The authors have to be commended for their efforts to raise awareness of the need for concerted cancer registries and centralised treatments. They corroborated previous studies on the relationship between hospital volume and perioperative outcomes, such as in-hospital mortality, complications and length of stay [4]. They also found an improvement in perioperative outcomes over time. Although their study design may only allow us to speculate on the reasons for these improvements, they are likely to be the result of many factors, such as improved surgical technique, improved perioperative medical/anaesthetic care and regionalisation of care. For surgical technique, the only significant advance over the past decade was the introduction of robot-assisted RP. Given the late adoption of robotic surgery in Italy and the controversy about its benefits, this is unlikely to be the major driver behind the recorded trends. On perioperative medical/anaesthetic care, the past decade has seen major advances and standardisation of thromboembolic prevention, perioperative care of patients with pre-existing heart conditions and significant comorbidities. Finally, centralisation of care may have played an important role in the decreasing rates of adverse outcomes after RP. Although the authors specify that there was no policy-driven regionalisation of RP care in Italy (relative to the UK, for example), the increase in average hospital volume should translate into better outcomes, as discussed above [4]. Further regionalisation should be expected in Italy with the adoption of robotic surgery, as only a few centres have the means and logistics to support a da Vinci system [5].

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Julian Hanske *†, Christian P. Meyer†‡ and Quoc-Dien Trinh†

*Department of Urology, Marien Hospital, Ruhr-University Bochum, Herne, Germany, †Division of Urologic Surgery and Center for Surgery and Public Health, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA and ‡Department of Urology, University Medical Centre Hamburg–Eppendorf, Hamburg, Germany

References

1 Kowalczyk KJ, Levy JM, Caplan CF et al. Temporal national trends of minimally invasive and retropubic radical prostatectomy outcomes from 2003 to 2007: results from the 100% Medicare sample. Eur Urol 2012; 61: 803–9

2 Hollenbeck BK, Miller DC, Wei JT, Montie JE. Regionalization of care:centralizing complex surgical procedures. Nat Clin Pract Urol 2005; 2: 461

3 Novara G, Ficarra V, Zattoni F, Fedeli U. Recourse to radical prostatectomy and associated short-term outcomes in Italy: a country- wide study over the last decade. BJU Int 2015; 116: 862–7

4 Trinh QD, Bjartell A, Freedland SJ et al. A systematic review of the volume–outcome relationship for radical prostatectomy. Eur Urol 2013; 64: 786–98

5 Makarov DV, Yu JB, Desai RA, Penson DF, Gross CP. The association between diffusion of the surgical robot and radical prostatectomy rates. Med Care 2011; 49: 333–9

Video: How Can We Improve Surgical Outcomes?

December 23, 2015/by admin Z.9

Recourse to radical prostatectomy and associated short-term outcomes in Italy: a country-wide study over the last decade

Giacomo Novara, Vincenzo Ficarra*, Filiberto Zattoni and Ugo Fedeli†

Read the full article

OBJECTIVE

PATIENTS AND METHODS

RESULTS

CONCLUSIONS

The study adds evidence on rapidly changing trends in RP rates in Italy, on improving in-hospital outcomes, and on their association with procedural volume.

Read more articles of the week

Article of the Week: Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

December 16, 2015/by admin Z.9

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Franklin Kuehhas, discussing his paper.

If you only have time to read one article this week, it should be this one.

Penile lengthening and widening without grafting according to a modified ‘sliding’ technique

Paulo H. Egydio and Franklin E. Kuehhas*

Centre for Peyronie’s Disease Reconstruction, Sao Paulo, Brazil, and *London Andrology Institute, Suite 7 Exhibition House, Addison Bridge Place, London, UK

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OBJECTIVE

To present the feasibility and safety of penile length and girth restoration based on a modified ‘sliding’ technique for patients with severe erectile dysfunction (ED) and significant penile shortening, with or without Peyronie’s disease (PD).

PATIENTS AND METHODS

Between January 2013 and January 2014, 143 patients underwent our modified ‘sliding’ technique for penile length and girth restoration and concomitant penile prosthesis implantation. It is based on three key elements: (i) the sliding manoeuvre for penile length restoration; (ii) potential complementary longitudinal ventral and/or dorsal tunical incisions for girth restoration; and (iii) closure of the newly created rectangular bow-shaped tunical defects with Buck’s fascia only.

RESULTS

In all, 143 patients underwent the procedure. The causes of penile shortening and narrowing were: PD in 53.8%; severe ED with unsuccessful intracavernosal injection therapy in 21%; post-radical prostatectomy 14.7%; androgen-deprivation therapy, with or without brachytherapy or external radiotherapy, for prostate cancer in 7%; post-penile fracture in 2.1%; post-redo-hypospadias repair in 0.7%; and post-priapism in 0.7%. In patients with ED and PD, the mean (range) deviation of the penile axis was 45 (0‒100)°. The mean (range) subjective penile shortening reported by patients was 3.4 (1‒7) cm and shaft constriction was present in 53.8%. Malleable penile prostheses were used in 133 patients and inflatable penile prostheses were inserted in 10 patients. The median (range) follow-up was 9.7 (6‒18) months. The mean (range) penile length gain was 3.1 (2‒7) cm. No penile prosthesis infection caused device explantation. The average International Index of Erectile Function (IIEF) score increased from 24 points at baseline to 60 points at the 6-month follow-up.

CONCLUSION

Penile length and girth restoration based on our modified sliding technique is a safe and effective procedure. The elimination of grafting saves operative time and, consequently, decreases the infection risk and costs associated with surgery.

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Editorial: Is the modified sliding technique the way forward in Peyronie’s surgery?

December 16, 2015/by Giulio Garaffa

The old goal of prosthetic surgery, which aimed to guarantee a hard and straight penis good enough for penetrative intercourse, is likely to have now become obsolete. Various authors have reported that patients with Peyronie’s disease (PD) and severe corporal fibrosis who undergo penile prosthesis implantation tend to report the lowest satisfaction rates, mainly because of significant penile length loss [1, 2]. In particular, according to Kueronya et al. [3], ~80% of patients affected by PD perceive a degree of penile shortening before surgery, and any further loss of length attributable to the surgical correction leads to bother among all the affected patients. All attempts at penile length restoration during prosthetic surgery should therefore be welcomed in order to achieve higher patient satisfaction.

Initial attempts at penile length restoration involved a full disassembly of the penis and the use of a circumferential graft [4]. Then, in 2012, Rolle et al. [5] described the sliding technique, a modification of the circumferential graft that consists of a double dorsal-ventral patch and should therefore provide more stability to the corpora cavernosa than a circumferential graft.

The present series by Egydio et al. [6] describes a modified sliding technique without grafting the defect of the tunica albuginea. This reduces the operating time and theoretically infection rates should therefore be reduced.

Although leaving a defect in the tunica albuginea should, in theory, lead to a haematoma formation and potentially infection of the device, in the present series, no penile prosthesis infections were reported.

Although we believe that cutting corners in surgery is not the way forward, the authors of the present paper should be congratulated because the postoperative results in their series are very encouraging. In fact, the mean penile length gain in their series was 3.1 cm, with no reported infections requiring the explantation of the penile prosthesis and with an average increase in International Index of Erectile Function score of 36.

Certainly, if the results of the present series can be confirmed in the future, this technique will revolutionize the concept that any tunical defect >1 cm in size needs to be grafted to prevent aneurysmal dilatation of the cylinders of an inflatable penile prosthesis [7], as none of the inflatable cylinders in the series developed aneurysms.

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Giulio Garaffa, and David J. Ralph

St Peter’s Andrology and the Institute of Urology, University College London Hospitals, London, UK

References

1 Akin-Olugbade O, Parker M, Guhring P, Mulhall J. Determinants of patients satisfaction following penile prosthesis surgery. J Sex Med 2006; 3: 743–8

2 Zacharakis E, Garaffa G, Raheem AA, Christopher AN, Muneer A, Ralph DJ. Penile prosthesis insertion in patients with refractory ischemic priapism: early versus delayed insertion. BJU Int 2014; 114: 576–81

3 Kueronya V, Miernik A, Stupar S et al. International multicenter psychometric evaluation of patient reported outcome data for the treatment of Peyronie’s disease. BJU Int 2015; 115: 822–8

4 Sansalone S , Garaffa G, Djinovic R et al. Simultaneous penile lengthening and penile prosthesis implantation in patients with Peyronie’s Disease, refractory erectile dysfunction and severe penile shortening. J Sex Med 2012; 9: 316–21

5 Rolle L, Ceruti C, Timpano M et al. A new, innovative, lengthening surgical procedure for Peyronie’s Disease by penile prosthesis implantation with double dorsal-ventral patch: the sliding technique. J Sex Med 2012; 9: 2389–95

6 Egydio P, Kuehhas F. Penile lengthening and widening without grafting according to a modiﬁed sliding technique. BJU Int 2015; 116: 965–72

7 Ralph D, Gonzalez-Cadavid N, Mirone V et al. The management of Peyronie’s Disease: 2010 guidelines. J Sex Med 2010; 7: 2359–74