In recent reviews, the use of buccal mucosa as autologous material in the surgical treatment of Peyronie Disease (PD) is considered as a second option to commercially available biocompatible tissue, and probably the major reason is that reports of clinical series using buccal mucosa are limited (1,2). With our study we aim to demonstrate that, on the basis of the achieved results, this technique is useful and, in selected patient, it can be considered the first option in the treatment of PD.
The reasons lye on several points that should be taken in consideration. The patient perspectives in terms of patient’s and partner satisfaction are obviously the first outcomes to be achieved. In clinical setting also the surgeons expectations are important so the reproducibility of surgical technique, the availability of the graft, the time of resumption of erectile function, the surgical complications and finally the cost of the procedure should be considered in the final surgical choice. These issues will be more deeply discussed.
Corporoplasty with the buccal mucosa graft is not time consuming if 2 surgical equipes are contemporary available allowing the operating time to significantly decrease with a mean operating time of 75 minutes. The technique is easily reproducible after a relatively short learning curve (2) and following these surgical steps: surgery is carried out under general anesthesia, positioning the tracheal tube, where possible, passing through the nose, in order to be able to harvest the buccal mucosa easily. After sub-coronal incision and degloving, a hydraulic erection is performed positioning a 19 G butterfly needle at the level of the glans of the penis and injecting saline solution inside corpora cavernosa. The Buck’s fascia is than open bilaterally, at the para-urethral level and, in this way, the isolation of the neuro-vascular bundles or the urethra is carried out according to the position of the fibrous plaque to be treated. Once the site of the plaque is identified, an “I” or “H” incision is performed (dovetail incision) at the site of maximum curvature. The margins of the incision are carefully prepared on all sides, preserving the underlying erectile tissue, and the dimension of the area to be covered with the buccal mucosa is measured. At the same time a second surgical team harvests the buccal mucosa from the cheek and prepares the patch removing the fat. The patch is then sutured, covering the cavernous tissue, using 3/0 reabsorbable sutures with the submucosa surface in contact with the cavernous tissue in order to obtain a quick blood supply. A hydraulic erection is than performed to control residual curvature and the straightened of the penis.
The intrinsic properties of buccal mucosa allow rapid integration with subsequent more rapid spontaneous erection resumption (spontaneous erections return 3-5 days after surgery). It avoids the need of post-operative rehabilitation which is generally requested after corporoplasty with other grafts. Biocompatible materials such as pericardium, SIS (Swine Intestinal Submucosa), porcine dermis, etc. need an integration times varying from 4-6 weeks; buccal mucosa, on the other hand is immediately supplied with blood from the cavernous tissue and tends to heal rapidly, immediately integrating with the surrounding albuginea tissue. Furthermore the thickness of the buccal mucosa is nearly the same of the tunica albuginea favoring easy adaptation to all sides of albuginea’s incision ensuring a perfect seal. These characteristics reduce the risk of curvature relapse and erectile dysfunction (ED) after surgery.
The results with buccal mucosal graft overlap and in our experience are better than reported in literature using other biocompatible grafts. Our first experience (2)demonstrated excellent results (0% ED - 100% satisfaction rate) but it had as major bias the limited number of patients (15 patients). In this study we confirm excellent results on 32 patients with only 3,5% ED and 85% satisfaction rate. We were able to demonstrated the results are stable over time as shown by our 2-year follow-up in 16 patients. Furthermore good results were also reported by the partners, which referred to be particularly satisfied when patients PGI-I scores were 1 and 2 confirming the results in terms of couple satisfaction.
The complication rate is low with buccal mucosal graft. A rare complication is represented by seroma formation above the patch that usually needs a short re-operation and removal, at a distance of few months. In our series it happened in one patient and it wasn’t reported in the paper because it appears afterwards.
As final consideration today, in the era of spending review, the cost of the procedure is an important element to be considered although difficult to demonstrate outside of a well designed cost/analysis study. We only briefly evaluated the main costs: the operative time and the hospital stay were not different with autologous or eterologous graft, on the other hand the costs of the biocompatible materials and of the “stretching therapy” with vacuum device, necessary with other grafts, make cheaper the use of the buccal mucosa. If we sum the average cost of most bio-compatible materials usually used in Europe (ranges from 500 - 1,000 euros) and the cost of buying or renting a vacuum device the total costs are about 1,500/2,000 euro per patient using other grafts.
In conclusion corporoplasty with buccal mucosal graft can be considered the best technique in the surgical reconstruction of PD because it is easy, reproducible with an adequate surgical training, efficacious from the functional and aesthetic point of view with optimal results in terms of patients’ and couple’s satisfaction and finally less expensive than the corporoplasty using other autologous or eterologous grafts.
Alessandro Zucchi, MD and Elisabetta Costantini, MD.
Urology and Andrology Department, University of Perugia, Italy.
Abstract: Corporoplasty using buccal mucosa graft in peyronie disease: is it a first choice?
1.Levine LA and Larsen SM. Surgery for Peyronie’s disease. AJA 2013; 15: 27–34
2. Cormio L, Zucchi A, Lorusso F, Selvaggio O, Fioretti F, Porena M, Carrieri G. Surgical treatment of Peyronie's disease by plaque incision and grafting with buccal mucosa. Eur Urol. 2009; 55:1469-75.