outcomes following plication surgery for penile curvature: A retrospective

(1)

Disponibleenlignesur

ScienceDirect

www.sciencedirect.com

ORIGINAL ARTICLE

English / French

Patient-reported long-term sexual

outcomes following plication surgery for penile curvature: A retrospective

58-patient study

Évaluation fonctionnelle à distance d’une intervention chirurgicale pour courbure de verge : étude rétrospective d’une cohorte de 58 patients

A. Baldini , N. Morel-Journel , P. Paparel , A. Rufﬁon , J.-E. Terrier

^∗

Départementd’urologie,centrehosptalierLyonSud,cheminduGrand-Revoyet, 69495Pierre-Benitecedex,France

Received25November2015;accepted22August2016 Availableonline18November2016

KEYWORDS Peyronie’sdisease;

Penileinduration;

Questionnaire;

Penileplication surgery;

Functionalevaluation

Summary

Objective.—Toevaluatelong-termsexualfunctionresultsfollowingplicationsurgeryforthe correctionofpenilecurvatureusingpatientquestionnaires.

Methods.—Weperformedasingle-center,retrospectivestudyinacohortofpatientswithPey- ronie’sdiseaseorcongenital penilecurvature.Allpatients whounderwentplicationsurgery ontheconvexaspectusingtheNesbit,Yachiaordiamond-shapedtechniqueswereincluded.

Atamean34monthsaftertheinterventions,thepatientswereaskedtorespondtotheIIEF5 questionnaireanda19-itemquestionnaire.

Results.—Forty-sixpatientsoperatedfor Peyronie’sdisease and12for congenitalcurvature (total:58)wereincludedinthestudy.Thequestionnaireresponseratewas69%(40/58).The shortenedpenisbothered47.5%ofpatientsintheirsexualityatleastregularly.Involuntaryexit fromthevaginaoccurredfor35%ofthepatientsinatleastoneoutoftwosexualintercourse sessions.Postoperativesexuallifewasasgoodasorbetterthanpreoperativesexuallifefor 35%ofthepatients and95%statedthattheycouldachieveerectionatleastsometimes,in coherencewiththemeanIIEF5resultof19.3/25.

∗Correspondingauthor.

E-mailaddresses:abaldini@hotmail.fr(A.Baldini),nicolas.morel-journel@chu-lyon.fr(N.Morel-Journel),philippe.paparel@chu-lyon.fr (P.Paparel),alain.rufﬁon@chu-lyon.fr(A.Rufﬁon),jetterrier@yahoo.fr(J.-E.Terrier).

http://dx.doi.org/10.1016/j.purol.2016.08.018

(2)

Conclusion.—Ourstudysuggeststhatevenwhensuccessful,arelativelyhighrateofpatients may beunsatisﬁed withthe resultsofplicationsurgery,and theremay bearelatively low rateofmaintenanceorimprovementofpostoperativesexuallife.Furthermore,ourin-house questionnaire,althoughnotvalidated,shedlightonhowbothersomethelossofpenislengthis inpostoperativesexuality,anaspecttheIIEF5anditssoleevaluationoferectilequalitycannot detect.

Levelofevidence.— 4.

MOTSCLÉS Maladiede Lapeyronie;

Indurationpénienne; Questionnaire; Chirurgiedela convexité; Résultats fonctionnels

Résumé

Objectif.—Évaluerlesrésultatsfonctionnelssexuelsàdistanced’unechirurgiedelaconvexité pourmaladiedeLapeyronieetcourburecongénitaledeverge,aumoyend’unquestionnaire.

Matérieletméthodes.—Ils’agissaitd’uneétuderétrospective,monocentrique,àpartird’une cohortede72patients atteintsdela maladiedeLapeyronie,oud’unecourburecongénitale deverge.Touslespatientsontétéopérésparlemêmechirurgien,demai2008àfévrier2013.

Étaientincluslespatientsopérésd’unechirurgiedelaconvexitéparlatechniquedeNesbit, YachiaouDiamondshape.Unquestionnairepostopératoireaétésoumisàtouslespatientspar téléphoneouparcourrier,composéde19questions,ainsiquelequestionnaireIIEF5.

Résultats.—Cinquante-huitpatientsontétéopérésd’unecorrectiondecourburedeverge, 46pourunemaladiedeLapeyronieet12pourunecourburecongénitale.L’âgemoyen était de 52 ans et la courbure initiale moyenne est de 72,4^◦ (45—120^◦). Le taux de réponseau questionnaireétaitde69%(40/58).Lespatientssedéclaraientsatisfaitsdans75%descas.La courburerésiduelleétaitde13,1^◦etleraccourcissementressortaitcommeunecausefréquente d’insatisfactiondans47,5%descas.Iloccasionnaitunesortienonvolontaireduvagindans35% descas.Laviesexuelledespatientsétaitidentiqueouamélioréepour35%despatientspar rapportàavantet95%despatientsdécrivaientuneérectionpermettantlesrapportscequiva danslesensdel’IIEF5moyenquiétaitde19,3/25.

Conclusion.—Letauxdesatisfactionglobaledeschirurgiesdelaconvexitépourcourburede verges’élevaità75%etl’améliorationdeleurviesexuelleétaitde35%.Notrequestionnaire permettaitdemettreenévidenceunegènedanslasexualitéenpostopératoire,dueauraccour- cissement,etquiétaitbeaucoupplusfréquentequenelelaissaitpenserl’IIEF5etlaqualitéde l’érectionseule.L’IIEFétantinsatisfaisant,ilfaututiliserdenouveauxquestionnairesprenant encomptelasexualité.

Niveaudepreuve.— 4.

Introduction

Penile curvature, mainly due to Peyronie’s disease, may resultinnotonlypainfulerectionsanddifﬁcultieswithintro- missionbutalsoadisturbedself-image,lossofpenilelength andpossiblyerectiledysfunction(ED)[1],whichcouldalso benotedforcongenitalcurvature.

ThecurrentincidenceofPeyronie’sdiseaserangesfrom 0.4 to 5% and the mean age of men with the disease is 53years[2—4].CollagenaseClostridiumhistolyticuminjec- tionsarecurrentlybeingevaluatedandother medications haveonlyshown moderateefﬁcacy,leavingsurgeryasthe onlyeffectivemeansoftreatingpenilecurvaturesthatare bothersome or that preventsexual relations. The Nesbit,

Yachiaanddiamond-shapedtechniques(groupedunderthe term‘‘plicationsurgery’’here)havebeendescribed since the 1990s. These involve an intervention on the tunica albuginea opposite the plaque; they shorten the convex aspect ofthe penile curvature andthus usuallythe penis itself.

Appraisalsoftheperceivedorrealshorteningofthepenis andthesexualsatisfactionofthepatientaftersurgeryvary intheliterature.

Theobjectiveofthepresentworkwastoassessthesex- ualoutcomesofpatientsafterplicationsurgerytocorrect penile curvature, whether congenital or in the setting of Peyronie’sdisease,asreportedbythepatientsthemselves usingaspeciﬁcallydevelopedquestionnaire.

(3)

Methods Population

Thepatientpopulationwasretrievedfromthedatabaseofa hospitalspecializedinpenilesurgery.Theevaluationperiod wasfromJanuary2008toFebruary2013.Wethusperformed aretrospective,monocentricdescriptivestudy.

Allpatientswhounderwentsurgeryforcongenitalcurva- tureorPeyronie’sdiseaseduringtheevaluationperiodwere retrieved.

Theemployedsurgicaltechniqueforanyonepatientwas chosenin accordancewithEuropean and Americanguide- lines as a function of curvature degree, penis size, any ED, photography or erection test during the visit andthe patient’spriorities[5,6].

The proposed interventions at the hospital included:

plication surgery, via Nesbit, Yachia or diamond-shaped techniques; grafting surgery, i.e., the lengthening of the concavepenileaspectvia theincisionofthetunicaatthe plaque site and the placement of a graft using porcine intestinalsubmucosa;andapproachescombiningaprosthe- sisandcurvaturecorrection(modeling).

For the present study, only patients with Peyronie’s diseasestableforatleastsixmonthsorwithcongenitalcur- vatureandwhohadundergoneplicationsurgeryalonewere included.Thus,patientswhounderwentgraftingsurgeryor prosthesisplacementwereexcluded.Asinglesurgeonhad performedalltheinterventionsfortheincludedpatients.

Indications for surgery were signiﬁcant discom- fort/pain/nuisance or the inability to have sexual intercourse.

The degreeof preoperativecurvature wasmeasured in the operating room during the initial erection test. All interventions were successful with only minimal residual curvatureattheendoftheintervention,asassessedwitha newerectiontest.

Evaluation method: questionnaire

At a meanof 34 months after their surgeries(range 6 to 62months), we sent two questionnairesby mail toall of thepatients:thesimpliﬁed InternationalIndexofErectile Function (IIEF5) and another postoperative self-reported questionnaire developed in-house toevaluate penile curvature corrective surgery and the effects of the surgery as perceived by the patient. This second questionnaire comprised19 items exploring ﬁvepostoperative domains:

deformation, pain, sensation, erection, sexual relations.

Each item had ﬁve or six possible responses (Supporting questionnaire).

Results Population

During the evaluation period, there were 72 surgical interventionsforPeyronie’sdiseaseorthecorrectionofcon- genitalcurvature.Fourteenofthesecasesinvolvedgrafting surgery or prostheses and were thus excluded from the study.Therefore,therewere58casesofplicationsurgery

Figure1. Flowchart.

(i.e.,thoseemployingtheNesbit,Yachiaordiamond-shaped techniques) included in the study (Fig. 1). The employed techniquewasdecideduponbythesurgeonpreoperatively andadjustedintraoperativelyaftertheerectiontest.

Patient and clinical characteristics

Twelvepatients(21%)withameanageof25years(19—36) were operated for congenital curvature and 46 patients (79%) withameanage of 58years(31—83) for Peyronie’s disease.

Twenty-fourpatients(41.3%)hadapreoperative curvature>60^◦.Fortypatients respondedtothequestionnaires, i.e.,aresponserateof69%.

Sevenpatients(17.5%)werenothavingsexualrelations andthuscouldnotrespondtosomeofthequestionsinthe IIEF5orinourquestionnaire.

Deformation

Thenmean curvaturemeasured postoperativelywas13.1^◦ (0—60^◦).For26ofthem(65%)residualcurvaturewasabsent orminimal(<10^◦)andfor three(7.9%)itwasgreaterthan 50^◦.Nonehasexpressedthewishtobeoperatedagain.

Twenty-nine(72.5%) of the40 respondentsdescribed a

‘‘clear’’orgreaterlossofpenilelengthduetotheoperation (Fig.2).Themeanlossoflengthwasabout2.4centimeters (0,3cminthecongenitalcurvaturegroup).

Theshortenedpostoperativepeniswasconsideredtobe atleastregularlybothersomeforthepatient’ssexualityby 19(47.5%)patients(Fig.3).

Erection

The abilitytoachievean erectionat leastsometimeswas reported by 95% of the sexually active respondents. The meanpostoperativeIIEF5scorewas19.3/25(23/25in the

(4)

Figure2. Postoperativefunctionalresults(Q3:Haveyounoticed alossoflengthforyourpenissincetheoperation?).

Figure3. Postoperativefunctionalresults(Q5:Doestheshorter penisbotheryouinyoursexuality?).

congenital curvature group). As determined by the IIEF5, erectilefunctionwasnormal(scorefrom22to25)in32.5%

ofthecases.TherewasmildED(score17—21)in30%ofthe cases,mildtomoderateED(score11—16)in15%,andsevere ED(score6—10)in5%.

Sexual activity with penetration

Fourteen(35%)patientsreportedthatinvoluntaryexitfrom thevaginaduringsexualintercourseoccurredinatleastone outoftwosexualintercourseepisodes(Fig.4).

Sexual life afterthe surgery wasjudged asgood asor betterthanbeforethesurgeryby37.5%ofthepatients(100%

inthecongenitalcurvaturegroup).

Satisfaction

Twenty-threeresponders(57.5%)wereatleastsatisfiedwith the intervention, 10 (25%) were at least unsatisfied, and seven(17.5%)hadnoopinion(100%satisfiedinthecongen- italcurvaturegroup).

Thecorrelationcoefﬁcientbetweenthedegreeofsatis- factionwiththesurgeryandtheinitialcurvaturewasweak (r:0.2).Thus,inourstudytheinitialcurvatureappearedto playnorealroleinpostoperativesatisfaction.

Figure4. Postoperativefunctionalresults(Q16:Howoftendoyou experienceinvoluntaryexitsfromthevaginaduringsexualinter- course?).

Discussion

Ourcohortshed lighton numerous aspectsof thesexual- ityofpatients withpenilecurvature, either congenitalor duetoPeyronie’sdisease.Plicationsurgerycancorrectthe excessivecurvatureinthevast majorityofcases(13.1^◦ of residualcurvatureinourcohort)butatthepriceofashort- ened penis. Indeed72.5% of ourpatients self-reported at least a ‘‘clear’’ loss of penile length. This loss of length wasconsideredbothersomeforthesexualityof47.5%ofour patientsandinvoluntaryvaginalexitwasreportedby35%of them.

Surgical technique

In their guidelines, the American Urological Association (AUA) recommends surgery for the correction of penile curvature in the setting of Peyronie’s disease when the curvaturepreventsthepursuitof anormalsexuallife.No randomizedstudies have been done tocompare plication andgraftingsurgery,butcertainstudiesdogivepreference toplicationsurgerywhenpenissizeisnormal,penilecurva- tureis<60^◦ andED isabsent.Incontrast,graftingsurgery orpenileprosthesesarerecommendedinthepresenceofa smallpenis,curvature>60^◦ and/orED[6].TheAUAguide- linealgorithm(Fig.5)isonlymoderatelyusefulhowever,as itdoes notcover thefull rangeof situations thatmaybe encounteredinclinicalpractice,for examplealong penis with>60^◦ curvature.

Inourstudy,41%of thepatients(24 of58)hada >60^◦ penilecurvatureatthetimeofsurgery,andthemeanpreop- erativecurvaturewas74.2^◦.Thesenumbersfallatorbeyond the limitsfor plication surgeries asrecommended by the AUA.Inourcenter,wecarefullyexplaintheadvantagesand disadvantagesofthevarioustechniquestothepatientsand letthemmaketheﬁnaldecision.Thepatientswhooptedfor plicationsurgeryandwhowereincludedinourstudyhadan acceptablemeanresidualcurvatureof13.1^◦.

Loss of penis length

Intheliterature,thelossofpenislengthasaresultofpli- cationsurgery varies widely,from5to80%. Savocaetal.

(5)

reported loss of penis length for 17.4% of their patients whounderwenta Nesbitprocedurewithpenetrationdiffi- cultiesin 2.5% of thecases [7]. Their patients hadmean initialpenilecurvaturesof65^◦ (30—110^◦),andtheauthors considered that the loss of penis length was significant when ≥1.5cm. However, defining loss of length in that way does not allow for an assessment of the patient’s subjective impressions after the surgery, an aspect influenced greatly by the size of the patient’s penis before thesurgery.Recently,Kueronya andal.described patient- reportedoutcomedataaftersurgeryofPeyronie’sdisease, byplicationsurgeryorgraftingsurgery[8].Asthispresent study, they showed that penile length loss was the most bothersomesymptomaftersurgeryinthosepatients.Around 78%ofpatientstreatedbyplicationsurgeryreportedasub- jective loss of penile length with 86% being bothered by that,morethanourstudyexplainedbythefactthattheir questionnairehadtobeansweredby‘‘yes’’or‘‘no’’.Never- theless,itshowedthatpenilelengthlossisbadlyestimated after penile curvature surgery and surgeons misinform patients.

Questionnaires

Theself-administeredIIEF5questionnaireisvalidatedinthe setting of EDscreening [9].The mean postoperativeIIEF5 scorewas19.3/25inourstudy,correspondingtomildED.

Versionsofthe InternationalIndexofErectile Function arefrequentlyusedtoassesstheefficacyofpenilecurvature correction surgery. Forexample,Zucchi etal. observed a significantpostoperativeimprovementinIIEF5scores(from 15to23 of25possible points)inpatientswhounderwent corporoplastywithbuccalmucosagrafting[10],andIacono etal.reportedsignificantpostoperativeimprovementusing the IIEF15 (from25 to38 of 75 possible points, P<0.01) inpatientswhounderwentplicationsurgeryfor Peyronie’s disease[11].

Administered preoperatively, the IIEF5 is difficult to interpret because questions 3 to5 areheavily influenced bythepenilecurvature,which,whensignificant,canmake sexualintercourseimpossible,thusbiasingtheresponsesto thosequestions.Indeed,theIIEF5exploresonlythepossi- bilityofpenetrationandnotthequalityoftheerectionorof

Figure5. AUAguidelinesforpenilecurvature.

(6)

thesexualintercourse.InastudyassessingtheIIEF5andthe Luescore,Muyshondtetal.determinedthatonlythefirst twoquestionsof theIIEF5wereof useforevaluatingPey- ronie’sdiseaseseveritypreoperatively[12,13],illustrating thenon-pertinenceoftheIIEF5inthissetting.Inourstudy, we had a very low rate of patients reporting insufficient or impossible erections(5%).Nonetheless,despite scoring well on the IIEF5,a patient couldbe unsatisfied withhis sexuallifebecauseoffunctionaldifficultiescaused bythe curvature,painencountered byhispartner, lossof length followingtheoperationorundesiredexitfromthevaginafor example.Thus,theIIEF5doesnotreallylenditselftoeval- uatingsexualsatisfaction. Some teams, Levineand Natali forexample,usethemodifiedErectileDysfunctionIndexof Treatment Satisfaction(EDITS) questionnaire, validatedin 1999.TheadvantagesofthemodifiedEDITSarethatitcan beadaptedtoanytreatmentofED,medicalorsurgical,and thatit hasa sub-section for thesexual partner.Itsdisad- vantagesarethatit hasnotbeen validated forPeyronie’s diseaseand itdoes not evaluaterigidity or thequalityof sexualintercourse[14].

Thereareotherquestionnairescurrentlyavailable.The Peyronie’s Disease Index(PDI) was ﬁrstdescribed in 2002 byShabsighthen in2003 byLevine.It comprises35ques- tions covering penile curvature as well as the notions of sexualactivity,desireandsatisfaction.However,thePDIhas notbeenvalidatedinalarge-scalestudyasofthiswriting.

Itsquestionsarelargelyorientedtowardthehistoryofthe Peyronie’sdiseaseandthequalityoferections[15].

TheLuescore[13]isusefulfororientingsurgeryandcal- culating Peyronie’sdiseaseseverity butnotfor evaluating postoperativefollow-uporthepatient’simpressions.Iteval- uatespain,curvaturedegreeandplaquesize,eachona5 pointscale.Ithastheadvantageofprovidingobjectiveand precise responses forthese domainsandthus goodrepro- ducibility.It is often usedin studies for the preoperative evaluationofpatients.

ThePeyronie’sdiseasequestionnaire(PDQ)wasrecently validated in patients receiving collagenase treatment for Peyronie’sdisease[16].ThePDQexploresproblemsandpain insexualitycausedbythePeyronie’sdiseaseandhowboth- ersomecertainaspectsmaybe.Itnecessitatesanevaluation bothbeforeandafterplicationsurgery.

Finally, the Self-Esteem and Relationship (SEAR) ques- tionnaireexplores fourdomainsof self-esteem.Tal et al.

showedthattherewassigniﬁcantimprovementinthreeof thefourSEARdomainsfollowingplicationsurgeryfor Pey- ronie’sdisease,whereasthewaslittlechangeinIIEF5results [17].

Satisfaction

In our study,37.5% of the patients reported a sexual life after the surgery as good as or better than before and 75% reportedthatthey wereat least notunsatisﬁed with the surgery. This suggests that patient satisfaction with thesurgeryseemstobenotnecessarilycorrelatedwithan improvementinsexuallifeorwiththeinitialpenilecurva- ture.

To our knowledge, our study is the ﬁrst to illustrate this.Theseresultsmaybeexplainedinseveralways.First, the criteria used to judge surgical efﬁcacy are residual

deformationandIIEF5results.The IIEF5reﬂects thepost- operativesexualactivityofpatientsbadly,asdemonstrated inourstudy,wherethemeanresidualcurvaturewas13.1^◦ andthemeanIIEF5scorewas19.3/25,‘‘successful’’results coherent with those in the literature [10,11]. However, these criteria cannot give a complete picture of postop- erativepatientsexualityin thattheydonot evaluatethe feasibilityofsexualintercourse.

The questionnaire that we developed has the advan- tageoffocusingspeciﬁcallyonthepostoperativeresultsof plicationsurgery for penile curvature and analyzing their consequences on erection quality, sexual relations quality,andpatientperceptionsasconcernstheresultsofthe surgery.Ourresultsunderlinetheneedfora‘‘realitycheck’’

whenprovidingpatientswithpreoperativeinformation.Pey- ronie’s disease progresses over months and signiﬁcantly alters the sexual life of the patient and his self-image.

Ourhighdissatisfactionrate(25%)mayﬁnditsrootsinthe patient’s hope of recovering his former sexual life com- pletely.

Theresultsofourquestionnaireillustratehowimportant itistoprovidepatientswithclearandhonestinformationas towhatthesurgerycanandcannotdo.Itmustbemadeclear topatientsthatacompleterecoveryoftheirformersexual lifewillnothappen,thatthepeniswillbeshorterdueinpart totheremainingplaque,andthattheymayencounterprob- lemsduringintercourse,includinginvoluntaryexitsfromthe vagina.

Nevertheless,thepresentstudyhadsomelimitssuchas theretrospectivenatureofthestudyortherelativelysmall population sample evenif this wasone of the biggest in theliteratureonlyonplicationsurgery.Theamountofnon- responders(31%), of patients whodidn’t have any sexual activities,andthelackofapreoperativequestionnairewere alsolimitsofourstudy.

Finally, it does not consider patient psychological aspects. Depression, sometimes necessitating treatment, can occur in patients with Peyronie’s disease. For example,Smithetal.illustratedahighprevalenceofemotional (81%)andrelationship (54%)difﬁcultiesin apopulation of 254patientswithPeyronie’sdisease.Theyreportedthatloss ofpenislengthandtheinabilitytohavesexualintercourse werehighlypredictive(P<0.05)ofthesepsychologicaldif- ﬁculties[18].

Conclusion

In the present study, patients who underwent plication surgery to correct penile curvature had good objective resultsfor residualcurvature and erectilefunction. How- ever,therateofdissatisfactionforthesepatientswashigh (25%)andthatofmaintainedorimprovedqualityofsexual liferatherlow(35%),possiblyduetolossofpenilelengthand resultinginvoluntaryexitsfrom thevagina.New pre-and postoperativequestionnairesintegratingpsychologicaland sexualrelationsaspectsneedtobedeveloped,assessedand validatedtoprovidepertinentevaluationtoolsinthissur- gicalsetting.Preoperativepenilelengthmustbecarefully measured andcarefully considered whendeciding upon a surgicaltechnique.Surgeryshouldbeavoidedifsexualinter- courseisstillpossible.Whenitisneeded,thepatientmust

(7)

beclearlyinformedontheprobablelossofpenislengthand theriskofinvoluntaryexitsfromthevagina.Thepsycholog- icalimpactofpenilecurvatureanditscorrectionshouldnot beneglected.

Acknowledgments

SupportedbyagrantfromtheBibliothèquescientiﬁquede l’InternatdeLyonandlesHospicesCivilsdeLyon.

Disclosure of interest

Theauthorsdeclarethattheyhavenocompetinginterest.

Appendix A. Supplementary data

Supplementary data associated with this article can be found,intheonlineversion,athttp://dx.doi.org/10.1016/

j.purol.2016.08.018.

References

[1]Mulhall JP, Schiff J, Guhring P. An analysis of the natu- ral history of Peyronie’s disease. J Urol 2006;175:2115—8, http://dx.doi.org/10.1016/S0022-5347(06)00270-9[discussion 2118].

[2]Morel-Journel N, Paparel P, Rufﬁon A, Courtois F, Leriche A. Maladie de La Peyronie : prise en charge en 2009.

ProgUrolFMC2009;19:F98—103,http://dx.doi.org/10.1016/

j.fpurol.2009.02.002.

[3]PryorJ,AkkusE,AlterG,JordanG,LebretT,LevineL,etal.

Peyronie’sdisease.JSexMed2004;1:110—5.

[4]Greenﬁeld JM, Levine LA. Peyronie’s disease: etiology, epidemiology and medical treatment. Urol Clin North Am 2005;32:469—78, http://dx.doi.org/10.1016/j.ucl.2005.

08.011[vii].

[5]Hatzimouratidis K, Eardley I, Giuliano F, Hatzichristou D, Moncada I, Salonia A, et al. EAU guidelines on penile curvature.EurUrol2012;62:543—52,http://dx.doi.org/10.1016/

j.eururo.2012.05.040.

[6]NehraA,AlterowitzR,CulkinDJ,FaradayMM,HakimLS,Hei- delbaughJJ,etal.Peyronie’sdisease:AUAGuideline.JUrol 2015,http://dx.doi.org/10.1016/j.juro.2015.05.098.

[7]Savoca G, Scieri F, Pietropaolo F, Garaffa G, Belgrano E.

Straightening corporoplastyfor Peyronie’s disease: areview of218patientswithmedianfollow-upof89months.EurUrol

2004;46, http://dx.doi.org/10.1016/j.eururo.2004.04.027 [610—614—614].

[8]KueronyaV,MiernikA,StuparS,KojovicV,Hatzichristodoulou G, EgydioPH,et al.International multicentrepsychometric evaluationofpatient-reportedoutcomedataforthetreatment ofPeyronie’sdisease:psychometricevaluationofPROdatafor thetreatmentofPeyronie’sdisease.BJUInt2015;115:822—8, http://dx.doi.org/10.1111/bju.12968.

[9]RosenRC,RileyA,WagnerG,OsterlohIH,KirkpatrickJ,Mishra A.Theinternationalindexoferectilefunction(IIEF):amultidi- mensionalscaleforassessmentoferectiledysfunction.Urology 1997;49:822—30.

[10]ZucchiA,SilvaniM,PastoreAL,FiorettiF,FabianiA,Villirillo T,etal.CorporoplastyusingbuccalmucosagraftinPeyronie disease:isitaﬁrstchoice?Urology2014,http://dx.doi.org/

10.1016/j.urology.2014.10.026.

[11]Iacono F, Prezioso D, Ruffo A, Illiano E, Romeo G, Amato B. Tunical plication in the management of penile curva- turedueLaPeyronie’sdisease. Ourexperienceon47cases.

BMCSurg 2012;12(Suppl.1):S25,http://dx.doi.org/10.1186/

1471-2482-12-S1-S25.

[12]MuyshondtC,FaixA, Costa P,Droupy S.[Clinical and para- clinicalassessmentofPeyronie’s disease: placeofquestion- nairesandpenileduplexultrasound].ProgUrol2012;22:113—9, http://dx.doi.org/10.1016/j.purol.2011.06.009.

[13]LueTF,GiulianoF,MontorsiF,RosenRC,AnderssonK-E,Althof S, et al. Summary of the recommendations on sexual dys- functionsinmen.JSexMed2004;1:6—23,http://dx.doi.org/

10.1111/j.1743-6109.2004.10104.x.

[14]NataliA, OlianasR,FischM. Penileimplantation inEurope:

successesandcomplicationswith253implantsinItalyandGer- many.JSexMed2008;5:1503—12,http://dx.doi.org/10.1111/

j.1743-6109.2008.00819.x.

[15]Levine LA, Benson J, Hoover C. Inﬂatable penile pros- thesis placement in men with Peyronie’s disease and drug-resistant erectiledysfunction: a single-center study. J SexMed2010;7:3775—83,http://dx.doi.org/10.1111/j.1743- 6109.2010.01971.x.

[16]Hellstrom WJG, Feldman R, Rosen RC, Smith T, Kaufman G, Tursi J. Bother and distress associated with Peyronie’s disease: validation of the Peyronie’s disease questionnaire.

J Urol 2013;190:627—34, http://dx.doi.org/10.1016/j.juro.

2013.01.090.

[17]TalR,NabulsiO,NelsonCJ,MulhallJP.Thepsychosocialimpact of penile reconstructive surgery for congenital penile devi- ation.J SexMed 2010;7:121—8, http://dx.doi.org/10.1111/

j.1743-6109.2009.01574.x.

[18]Smith JF, Walsh TJ, Conti SL, Turek P, Lue T. Risk factors for emotional and relationship problems in Peyronie’s disease.JSexMed2008;5:2179—84,http://dx.doi.org/10.1111/

j.1743-6109.2008.00949.x.