Peyronie’s Disease Surgery: What Patients Should Know

26:42And if you think about stretching a muscle, right? Like I went through on this morning, my calf is tight. I'm going to stretch that calf out. If I don't do that every day and I stretch it for a while and it feels great and then I say, okay, good, I'm done. I'm going to stop. In a few days, my calf is going to be tight again. So it's kind of one of these things that you have to continue to do probably indefinitely to really maintain those benefits. That's not what traction is intended to do. By stretching scar tissue, the penis, i.e. the scar tissue, so you're pulling, you're putting pulling forces on the scar.

27:15There's actually good basic science evidence. So in the lab where people actually did experiments on human tissue, on scar tissue, and they put that tissue on stretch and looked at the chemical makeup of that in the milieu or in the, like the environment that would happen in the body. and they found that there's actually structural changes that happen to the tissue. So certain enzymes, which are sort of chemically active elements in the body, actually change the structural makeup of that scar tissue. And to me, the ultimate outcome is more stretch, more elasticity. The scar tissue has more give, it's more pliable.

27:55And when somebody has an erection and their tissue is less restricted, they have less curve. or if the whole area of scar tissue, which oftentimes much of the penis is involved in some degree in scar and loss of stretch, then you're going to get more length back. It's not going to necessarily create the penis you had before. Not even not necessarily. It will not create the penis you had before, but it can be a nice therapy. It's non-invasive. You wear this device at home, the device, Jesse, that you'd recommended or discussed, not recommended, that you referenced is the RestoreX, right? That's one traction system, but there's others available.

28:36But you wear them anywhere from 30 minutes a couple of times a day to several hours, depending on the device, for several months. And most men will get some mild but meaningful benefits from that. Yeah. Yeah, I've described too as if, you know, when we wear braces, the braces don't straighten the teeth. The tensile forces remodel the bone around the teeth and the teeth just kind of fall into place. And I think that kind of works a little bit for what's happening. I think you talked about, so there's the fibroblast cascade that kicks in and allows a little bit more elasticity back to the healthy tissue around.

29:12Sometimes that scar, unless you're doing something to the scar, which of course the combination of intralesional therapy, which we had a whole discussion on earlier as well with Zyaflex or some of the other non-FDA approved therapies. The idea is if you disrupt the scar, then you put a guy essentially in a splint, but it's, you know, you can't really walk around with a traction device on. Although I had a guy try to get through TSA once with this years ago, and that turns out that that, that went off, like the TSA works as much as a, yeah, so much, much as they say people are, are wasting their time.

29:47Here's a guy walking through a traction, with a traction device. He comes to my office, puts it on, and then goes back to wherever he comes from. And yeah, they actually pulled him out of line for that. So, so I don't recommend That's good to know. It's good to know that we are fast at work. Exactly right. But yeah, I mean, it is something that you can wear. But you can also overdo it too, just for everybody listening out there. An hour is recommended. There is something called neuropraxia, which we've talked about in relation to prostate nerves and erectile dysfunction. And neuropraxia can happen to the penis too.

30:19If you go to sleep with these devices on, for example, that's a little bit not recommended because if you wake up in the morning and you have stretched those nerves on the dorsum or the top aspect of the penis, you can get a little penile numbness. So sometimes too much is actually too much. And we always would put those guardrails on for our overly enthusiastic guys out there. They're going to run out and buy it. No, I think it's important because, you know, at least for the Restorix, like one of the main outcomes for the initial study, the randomized trial was safety. So patients say, can I wear this longer than 30 minutes at a time?

30:54And I say from an efficacy and safety standpoint, I think 30 minutes is the key. There's the max. And then you take it off for a little bit. You give your penis a rest. There you go. That's right. All right. So let's hit this. Let's talk about now what surgeries are out there. Who's a candidate for which one? And so kind of now pretend like I'm a 55-year-old guy in your office with penile curvature. And then talk me through what are my surgical options? And do I get to decide? Is it like a menu or is there one kind of form of Peyronie's that is better for one kind of surgery? So walk us through what my options are, Professor Siegelman.

31:33Do we have like two or three hours? Yes, exactly right. Our sponsors would love it. So generally, there are three kind of mainstay approaches to Peyronie's disease surgery. And I talk about these with all patients. There's various forms of penile plication. And the idea there is that you're essentially going to the opposite side of the curvature and you're using techniques, whether it's permanent or long-acting sutures or whether it's bringing tissue together. Regardless, you're using techniques to basically restrict the long side from stretching to mimic what's happening on the side where the scar tissue is.

32:18In essence, you're shortening the long side of the erect penis to account for the fact that scar tissue shortens the short side of the erect penis. It is a very reliable means. I mean, when we bring patients to the OR, we can get the penis within a few degrees of arrow straight in the operating room. And the studies suggest, and I would say my experience plays this out, that the long-term success rates are excellent as far as maintaining that level of straightness. Now, just having a straight penis is not patient satisfaction in the long term for everybody, but if that's the goal is to get the penis within a few degrees of straight as an arrow and maintain that level of straightness, it's an excellent option.

33:04I will tell you that many patients have a little bit of a hard time with the idea that we're intentionally going in and shortening the long side of the penis and leaving that scar tissue alone. But at the end of the day, from an efficacy standpoint, it's an excellent option. So from getting the penis straight, it's a great option. Trade-off there, right? Yeah. I was going to say Al Morey is another legend in our field. He had a great line that I use. I think with every patient, which is that what we're doing is we're expanding the functional length of your penis. Because if you have a severe curvature, you're unable to engage in penetrative intercourse, plication will allow you to engage in penetrative intercourse.

33:48So your functional and the functionality and the functional length is better. But there's no question that even if we do all kinds of relaxing incisions and techniques, which are reasonable to ask your surgeon if they do, at the end of the day, that's exactly right. I mean, the physics or the geometry of this is that you've got to shorten the long side in order to get a straight penis. That's just Pythagoras at work. Yeah. I think when I've talked about it with Landon Trost, another prominent member of our field, volume loss, right? From a physics perspective, we're decreasing the volume of the erect penis regardless of the – it's hard to measure an erection when it's curved.

34:32So the true length of the erection, I never quote patients how much they're going to perceive their penis to be shortened. Just because their reference point is also the straight erection they had before this all started. Mentally, that's where your mind is going to go. It's going to go back to the last time I saw my penis straight, and that's a different penis. Yep, setting expectations. All right, so placation. And the other thing to just throw out there is that there are some men who have mild curvature, but are bothered by narrowing. So they've got their hourglass where the essentially circumferentially the penis is narrowed or maybe one side is narrow.

35:14We call that indentation. And you can actually take a piece, oftentimes using cadaver tissue, either human or some type of animal product and actually molding it into those narrowed areas. So from a visual perspective, we can restore the more of a natural circumference of the erection. So we can do that placation surgery and then still make the penis look a bit more consistent and quote-unquote normal. So that's a nice option.

35:59Do you find yourself spending too much time on healthcare visits? In a small study, patients taking medications that had significant gene-drug interactions had nearly twice the number of total healthcare visits compared to those taking medications with zero to moderate gene-drug interactions. Time is precious. See how the GeneSight test may help you spend less time at your doctor's office. Visit genesight.com forward slash iHeart today. Hey, Donald, really flying on that treadmill. I'm trying to run as fast as T-Mobile 5G home internet, Zach. Well, you better pick it up, because now T-Mobile has the fastest 5G home internet, according to Ookla Speedtest.

36:38Really? How's this? T-Mobile's faster than that, bud, and it's still just$35 a month. Speed up! No! Plus, they've got a five-year price guarantee. Come on, faster! How can I go any faster? Channel the speed of T-Mobile 5G home internet. Think 100-meter dash fast. Think drag racing fast. Think speed skating fast. Now let's bump up your speed a notch. Hey, whoa, whoa, that's too fast! You'll be all right, just walk it off. Get on the fast track. T-Mobile now has the fastest 5G home internet. And it still starts at just$35 a month with auto pay and a voice line. Plus a five-year price guarantee. Plus taxes and fees.

37:18Fastest according to Oogler Speed Test Intelligence. Data second half, 2025. All rights reserved. Guaranteed for monthly price of 5G internet data on eligible plans. Find exclusions and details at T-Mobile.com. And now, another appliance triumph from our friends at Grand Appliance. With two dogs, every wash load came out covered in fur. I went into Grand Appliance looking for a fix, and they recommended the Maytag Top Load with Pet Pro Hair Removal System. They had it in stock and installed it days later. And you know what? It really works. Lint rollers are a thing of my past now. Great recommendations from the appliance experts.

37:52Shop GrandAppliance.com. GrandAppliance.com. This is Jacob Goldstein from What's Your Problem? Business software is expensive, and when you buy software from lots of different companies, it's not only expensive, it gets confusing, slow to use, hard to integrate. Odoo solves that because all Odoo software is connected on a single affordable platform. Save money without missing out on the features you need. Odoo has no hidden costs and no limit on features or data. Odoo has over 60 apps available for any needs your business might have, all at no additional charge. Everything from websites to sales to inventory to accounting, all linked and talking to each other.

38:35Check out Odoo at O-D-O-O dot com. That's O-D-O-O dot com. Hey, everyone. It's Cal Penn, host of Earsay, the Audible and iHeart Audiobook Club. This week on the podcast, I'm sitting down with divergent author Veronica Roth to talk about her sprawling new novel, Seek the Traitor's Son. It's a sci-fi fantasy epic about two protagonists on opposite sides of a war and a prophecy neither of them wanted. My first book was Divergent. And when that came out, like, because it was so popular, I think it attracted, like, mostly positivity, but the negativity I sucked in like a sponge. And I think it was, like, critiques of things I liked when I was, like, you know, I was 23 and I wrote this book and it had all my, like, dorky little cheesy or maybe unrealistic loves in it.

39:24And I started to feel a lot of shame about those things. And so for the rest of my career, I steered away from those little things that like make you feel pleasure when you read. But I also was like saying no to these parts of myself that I then was like, screw it. So that's this book. Listen to Earsay, the Audible and iHeart Audiobook Club on the iHeartRadio app or wherever you get your podcasts.

39:59yeah i've been doing a lot of those too i think in here over the last few years especially now that they're a little more cost-effective options surgically to do what we call extra tunical grafting and and the durability i'm always surprised at how durable it is but you know i think what happens even after the graft is somewhat reabsorbed it you just get this you still maintain a lot of that cylindrical shape and help with that volume loss it's not correct volume loss, but it is cosmetically volume lost. And yeah, it looks, it's so much a nicer, more elegant outcome than the classic kind of puckering you get with a placating suture.

40:35So yeah, I'm a big believer in extratunicle grafting, placation as well. Yeah. The other, sort of the next line as far as surgical intervention is either, we call it plaque incision or partial plaque excision, but it's basically going directly to the scar tissue and either making a full thickness cut through the scar or in some instances, for example, if you have calcium, some people actually have chunks of essentially bone in their penis, we'll cut out a segment of the scar. I usually always tell patients it's partial excision. We're not going in with the intention of removing all of the scar that you feel necessarily, we're going in to straighten the penis.

41:17But the idea there is you're releasing that restricted area as opposed to going to the opposite side and restricting it. So you're actually going to the point of the problem, which on paper always sounds like the nice option to do. The challenge comes in one, the intricacy of the surgery, and that goes back all the way to the start of our conversation. I mean, that is a case where, you know, there's not that many of us, you and I and a few others, who do a lot of these. And even then, I mean, what defines a lot is somewhat variable, but it's a challenging operation as far as just carrying out.

42:01But I think the more challenging part is just mitigating the side effects. And the side effects with that surgery are neuropraxia. So it changes in penile sensation long-term. And that's because, especially for upward and side-to-side curves, there's a tissue layer called the neurovascular bundle, which essentially has the sensory nerves that supply sensation predominantly to the head of the penis. And to get to the scar tissue, which sits several layers deep, which you have to dissect, tedious dissection, lift those nerves up and off of the scar, which can be very challenging, especially if they've had other treatments like Zyaflex, for example.

42:45And even in very experienced hands, when you're manipulating those nerves, there's going to be some tension on the tissue, et cetera. And so not everybody recovers full sensation or there's a risk of some sensation loss. Now, in longer term studies, which I would say are defined as a year or greater, that risk is generally low. Like most studies, it's less than 10%. I think in experienced hands, it's probably less than 5%, but it's not zero. It's not zero. And certainly we have patients who experience that. So that's one side effect. To me, the bigger concern is erectile dysfunction after surgery.

43:26So there's a mechanism that allows your penis to trap blood during an erection. It's called the veno-occlusive mechanism. I describe it as these microscopic veins that sit at the interface between where that scar tissue is and the blood-filled, the cavernosal body underneath, the space that fills with blood during an erection. And those veins, as the penis fills with blood, get compressed and they basically block the outflow. That allows the penis to maintain blood. And when you cut that scar or maintain the rigidity as the blood stays in the penis, when you cut that scar, I mean, we're violating that mechanism.

44:02There's no way around that, right? We are injuring that mechanism where the scar tissue is located. And we do so in a piece of material, again, usually a cadaver tissue into that area, which is supposed to be a scaffolding to allow the body's normal tissue to grow in and recover that mechanism. But it doesn't always do that. And so there is a risk of erectile dysfunction after that. Surgery meaning soft erections, meaning I didn't need pills before like migraine, cialis, and now I do. or meaning I didn't need pills before and now Viagra and CLS don't work. And I'm needing injections to help induce an erection or I'm needing a surgery called a penile implant to allow my penis enough rigidity for intimacy.

44:49And so we've had patients where they've had excellent rigidity before surgery and unfortunately needed a penile implant after surgery. So we get their penis nice and straight and optimize the size, but again, they're not maintaining rigidity at home, even with pills, then we have to bring them on to the next step. So that's a really tough outcome. And it's one that thankfully is not the norm if we select the right patient for the right surgery, but it's one that I want all my patients to know as a possibility. And so I would talk through these options with them to say, what if that happens to you?

45:24What would you do? If pills didn't work, Would you think about injections? Would you think about an implant? If the answer is no, no, no, that's not for me, that's not for me, I'm going to try to encourage them to think strongly about a plication because, yeah, they may perceive their penis to be a bit shorter, but the surgery didn't, in most instances, cause them to be non-functional. Yeah. That's the way I think of it. No, I think that's a key point. And there's a little bit of longitudinal data. Jerry Brock, I think, has a really long study since he's a couple years older than we are. And looking at the long-term durability of plaque excision and grafting, and it always is the thing that kind of puts guys over the edge is when they lose erectile function.

46:14And most of the time, thankfully, in good hands, you're not talking about year one or year two. But by year five, year 10, almost 100 % of guys after a plaque excision graft, they've got 10 years under their belt. Maybe they've developed worse cholesterol. Maybe they develop worse diabetes, worse blood pressure. But also, as you say, just the anatomy we fundamentally alter, at some point, these guys are going to need that secondary surgery, which will be what you're probably going to talk about next. And I think that's critical. I love how you couch that. And I want people to think about that when they're having a consultation with a peroneal surgeon is what are you willing to do if this doesn't work?

46:50And I think that's brilliant what you just said, Matt, because I'm going to use that. I think it's fantastic because I think we, you know, we're doing this three, sometimes it can take up to four hours to do one of these plaque excision and graft surgeries. And you put all of this in it, your heart and soul goes into it as a surgeon and you're only want the best outcome from your patient. And, you know, six months, a year from now, if they still are having issues, you've got to go back to the conversation you had before you both went down that road together. And there's an old saying in surgery, the last two people that want a second operation are the surgeon and the patient.

47:24You know, we're not any more or any less invested in your outcomes, especially if you go to a really good high volume conscientious surgeon. We want as good an outcome as the patient and sometimes a PEG or a plaque incision graft or incision graft. No matter what we do, we still are going to have work to do at the end of that three or four hours. Yeah, I totally agree on that. And I mean, you develop a real relationship with these patients and it's a longitudinal relationship. Like I tell them we're in this together, but you're right. I mean, when we get that great outcome, which thankfully we get great outcomes with these surgeries.

48:04I certainly don't want to overemphasize the potential side effects. We get great outcomes. Otherwise we wouldn't be doing these. but it is you know it's one we're all invested in and the whole team is invested and I think if your surgeon isn't invested in that way then it's probably you know a scenario where you want to find someone who is. Yeah you do and I think that's the other thing is that you mentioned it but there aren't a lot of us doing a high volume number of plaque incision or plaque excision and grafting and it is because it's something you really have to either have incredible experience early in your career or have a fellowship train background to do it.

48:49And then to just keep up your reps to make sure you're able to elevate the neurovascular bundle well every time reliably. And then also what to do when you put that graft in and you still may have some other vascular work to do to get the guy perfect. I like how you put that, is that you want that high volume. So talk to me then, you mentioned it earlier, but I would say, first of all, to kind of sum up plaque excision graft is high, good velocities or good pre-surgical erectile function is one of the things that you need. Maybe severely calcified graft where you can excise as much of that calcium, but leave as much healthy tunic, what we call tunical sparing, plaque incision, excision, grafting, all good candidates.

49:38And And if a guy comes to you, has a calcified plaque, is only getting some degree of an erection with injection, has a curvature, say, of 50 degrees, 60 degrees, and he already has some baseline erectile dysfunction, talk to me about what you would do for that guy. And I don't mean to lead the surgeon here, but give me the scenario. No leading necessary. Talk to me about what you're going to do with a guy with already baseline erectile dysfunction, severe calcification deformity. Let's walk through those scenarios. Yeah. Yeah. And also, I mean, that's, you know, 50 degrees is, and that's measured, assuming we measure that in the office is probably a bit of an underestimation too, right?

50:21Many of these patients don't get quite, quite the rigidity that they see at home or that they would with a full erection. So that's a challenging scenario because what we're going to be talking about here is potentially a very definitive but also invasive surgery that's going to kind of be a big step. And the idea here is that this patient has a calcified scar, which we can go ahead and excise. We can cut that scar out. But he also has baseline erectile dysfunction. And that patient has no wiggle room, meaning if his erections are a little bit affected rigidity-wise by the surgery to remove the scar, he's going to have complete ED.

51:13He's going to have a lot less wiggle. Correct, correct. So he's already on max dose PD5 inhibitors, Cialis, Viagra. I mean, we don't have any opportunity to try those non-invasive options. So then we're moving on to something more invasive right from the get-go. There's a high likelihood that we're going to need something more. And so that's a man I'm going to talk about, something called a penile implant as part of the surgical treatment. A penile implant is a device that we place inside the erectile bodies that has the ability to essentially expand that space in the same way that blood would fill the space.

51:51and create a strong, rigid erection that men can maintain as long as they want, whenever they want, without impacting their ability to urinate, still should be able to achieve climax and ejaculation, etc. So it's really designed to provide on-demand rigidity. There's another component called a pump, which you place in the scrotum, and then a third component called a reservoir, which you can think of like a balloon, and that usually gets tucked behind the pubic bone or under the abdominal muscle. And the whole idea is that you put fluid in the system and that fluid gets transferred into the penile tissues or into the penile cylinders, creates that rigid erection.

52:30Obviously, these guys don't want to be walking around with an erection all day, most of them at least. It's Santa Monica, man. Come on. I was going to say, maybe it's not North Dakota.

52:44But for those guys here, yeah, there's a way to move that fluid into the water, the sac, the reservoir, so that they can have more of a flaccid appearance. So that treats erectile dysfunction very reliably. But if we're doing that surgery, we also will address the curvature, we'll address the narrowing, we'll adjust the calcified scar. And then all those things that we were going to introduce as side or that the main thing that we're going to introduce as a side effect, i.e. erectile dysfunction, we're now addressing. So you can do both of those at the same time. You can do that grafting surgery and know that I'm treating the ED that this surgery is likely exacerbating.

53:27It is a definitive treatment for erectile dysfunction and Peyronie's disease, which many patients have simultaneously. seriously. Even for those men with less severe curves or non-calcified scar and you're not anticipating needing to do that plaque incision or excision, you can do the plication where you put the suture in. You can do something else called modeling, which is basically putting the device in and aggressively bending the penis opposite the direction of the curve, which can actually stretch and release some of those fibrous bands in the scar and correct the curvature. So there are opportunities.

54:09And if you have somebody, a surgeon who does a lot of Peyronie's disease, they're going to have all of those tools in their tool belt to address the curvature during the penile implant surgery if needed to get you a great outcome with respect to both the erectile dysfunction and the Peyronie's disease. Yeah. Yeah, there's a great abstract. I can't remember. Maybe you remember at our last meeting just a couple of months ago in DC on over dilation to help address that. You know, so most of the time, and this is super technical Jordan here, jargon Jordan, but essentially the idea is that when we put in penile implants, we have to stretch out that tissue with something called dilators.

54:49And there's a bunch of different ones. And we typically, most of us that do a lot of penile implants go up to maybe 12, a number 12 dilator. But if you go up a little bit more, you can actually manually manipulate that scar tissue and break up some of those bands. So it's almost like pre-modeling because the cylinders themselves act as I-beams if you put in a rigid enough cylinder that can really hydraulically fill up to the 25 plus to 30 PSI, even if you really, really pump. But I think that's interesting too, is this aggressive dilation, because you're right. And if you do a plaque excision and graft and an implant in the same day, first of all, it's a long surgery.

55:27We know that the complications are cumulative with that. But man, man, what a home run operation if you can do it in the right candidate that's super healthy. Definitely, I would never consider anybody that has uncontrolled diabetes, hypertension, anything that could affect wound healing, history of radiation therapy to the pelvis. But the ideal candidate that has just isolated severe Peyronie's and erectile dysfunction, but otherwise is healthy, that is your perfect candidate to try to do both at once. But yeah, there's so many other maneuvers that we can do short of doing that, that plaque excision graft plus IPP at the same time.

56:04But, but, but yeah, that is kind of like, oof, that's, you know, that's our, that's our 12 point buck in the order to be able to do that on the, on the same day. It is a, I mean, that it is a significant recovery. Like for graft, I mean, just the plaque incision or plaque excision and graft and those guys from, I mean, there's a lot of healing that happens in the penis during the first several months, but impact on their day-to-day life, usually by a couple of weeks, they're like rocking and rolling. Yeah, good point. Yeah. And a penile implant, yeah, some of those guys can be extremely sore for two to four weeks and there's definitely a lot of swelling and there's a recovery there.

56:46But if you combine those two, I just always emphasize that it's going to be a rough six weeks. We're going to get you there, but it's a big, much bigger recovery to do the two together. It's oftentimes the right thing to do in the right patient. But it's also a reason that if somebody is saying, I really want to do the grafting surgery, and I understand that I may not be the ideal candidate, but I want to see if I'm in that 50 % who's going to maintain my erectile function for several more years. And I'll think about it down the line or if in six months I need it. I mean, that's two surgeries, but the recovery cumulative is probably still easier on that person than the two together.

57:41And so I certainly, I've done that and have had conversations with patients about that. Larry Levine had a paper, I don't know if it's out yet, but it was accepted for discussing. No, no, this one's a couple years old now. But it was describing patients who he recommended do an implant, but they decided to go with a graft after appropriate counseling. And it was about a 50 % risk of erectile dysfunction that was essentially refractory to oral medication. So higher than we would expect in a standard population of men with good erectile function. But 50-50, some guys who are really trying to avoid that implant, they may still be willing to take those odds.

58:40Do you find yourself spending too much time on healthcare visits? In a small study, patients taking medications that had significant gene-drug interactions had nearly twice the number of total healthcare visits compared to those taking medications with zero to moderate gene-drug interactions. Time is precious. See how the GeneSight test may help you spend less time at your doctor's office. Visit genesight.com forward slash iHeart today. Hey, Donald. Really flying on that treadmill. I'm trying to run as fast as T-Mobile 5G home internet, Zach. Well, you better pick it up because now T-Mobile has the fastest 5G home internet according to Ookla Speedtest.

59:18Really? How's this? T-Mobile's faster than that bud and it's still just 35 bucks a month. Speed up! No! Plus, they've got a five-year price guarantee. Come on! Faster! How can I go any faster? Channel the speed of T-Mobile 5G home internet. Think 100 meter dash fast. Think drag racing fast. Think speed skating fast. Now let's bump up your speed a notch. Hey, whoa, whoa, that's too far! You'll be all right, just walk it off. Get on the fast track. T-Mobile now has the fastest 5G home internet. And it still starts at just$35 a month with auto pay and a voice line. Plus a five-year price guarantee.

59:57Plus taxes and fees. Fastest according to Uglo Speed Test Intelligence data. Second half, 2025. All rights reserved. Guaranteed for monthly price of 5G internet data on eligible plans. Find exclusions and details at T-Mobile.com. And now another appliance triumph from our friends at Grand Appliance. With two dogs, every wash load came out covered in fur. I went into Grand Appliance looking for a fix, and they recommended the Maytag Top Load with Pet Pro Hair Removal System. They had it in stock and installed it days later. And you know what? It really works. Lint rollers are a thing of my past now.

1:00:30Great recommendations from the appliance experts. Shop GrandAppliance.com. GrandAppliance.com. This is Jacob Goldstein from What's Your Problem? Business software is expensive. And when you buy software from lots of different companies, it's not only expensive, it gets confusing, slow to use, hard to integrate. Odoo solves that because all Odoo software is connected on a single affordable platform. Save money without missing out on the features you need. Odoo has no hidden costs and no limit on features or data. Odoo has over 60 apps available for any needs your business might have, all at no additional charge.

1:01:09Everything from websites to sales to inventory to accounting, all linked and talking to each other. Check out Odoo at O-D-O-O dot com. That's O-D-O-O dot com. Hey everyone, it's Cal Penn, host of Earsay, the Audible and iHeart Audiobook Club. This week on the podcast, I'm sitting down with Will Wheaton, who played Gordy Lachance in Stand By Me 40 years ago and now narrates Stephen King's The Body, the novella that inspired it all. We talk about what it's like to return to a story that shaped his life, channeling his memories of River Phoenix in the recording booth, and why the friendships you have at 12 might be the most important ones you'll ever have.

1:01:53I know Gordy Lachance. I am Gordy Lachance. Like, I mean, even when I was a little kid, I was Gordy Lachance when I didn't know it. Listen to Earsay, the Audible and iHeart Audiobook Club on the iHeartRadio app or wherever you get your podcasts.

1:02:14Yeah, I think that stage procedure, it also gives guys a chance to do traction and potentially end up if you stage it, even if it's staging by one to two years. there's like you said, if 50 % of those guys are able to get erections with maybe injections, pills, traction, that you might be able to come back and put in a better implant than you could at the same time. So I think that's a really nice stutter step and another very nuanced aspect of our counseling. So we have this section, Professor Ziegleman, we do pretty much every time called You're Probably Gonna Be Okay. And once somebody is going to actually say, actually, no, you're not going to be okay.

1:02:49But to date, maybe it's because I phrased the question with the case scenario where we leave our audience with hope and a future of a better day. But let me go through this case scenario. A 55-year-old guy, because you're probably going to see this in your office this week, maybe two or three times, comes into you. He had Xyflex, which is the intralesional collagenase we had a whole episode on, about maybe he started with a 70-degree curvature, dorsal meaning up so towards his belly button curve really difficult having intercourse he had some calcifications within the plaque but but still was able to get about a 50 well 20 degree improvement so he's left with 50 degree dorsal has really good rigid erections otherwise super healthy he's a triathlete and in fantastic shape no diabetes good blood pressure still has 50 degrees after this, he also noticed some length loss.

1:03:43And maybe his eye flex and traction helped get him back a centimeter or so, but he's very, very conscious about his length and his penile dysmorphism where he just never could look at his penis the same way again. So he's so bothered by this that it's very difficult for him to even think about intercourse again, even though he had you know, a reasonable expected or inspection, uh, improvement with Zyaflex. He still has a curvature. What are you gonna do for this guy? And is he going to be okay? Are you going to like, Hey, let's do some more Zyaflex. You got a little bit of an improvement. Maybe I have a better technique than where you came from.

1:04:21Tell them, tell me about this guy. Now he's been, been at this for now for almost two years in this journey. And, you know, almost six months of that was an active therapy with Zyaflex. He wants an answer. He's coming all the way to Rochester for you to take care of him. Yeah, I would say I'm not going to buck the trend here. Yes, you are going to be okay. Yeah, there we go. No, I still think this is, yeah, we see patients with a similar experience all the time. Severe curvature to start, wanting to try something non-surgical up front, which I think is very appropriate and had some response to that treatment, but still bothered by the residual curve.

1:05:01And that's actually challenging in some ways because you're going, you prove to us that you're a responder to Zyaflex. So there's nothing, you've had your eight injections, but there's nothing to say that, no data that I know of that says you're not going to continue to have some incremental response if we, and in fact, I think there is data, I think even your experience, Jesse, right? Yeah, we have that probably. Yeah, that says you can continue to have an incremental response with additional Zyaflex. So if somebody is looking to, you know, minimize the potential side effect risk of surgical interventions, was okay, did fine in the recovery, it wasn't too impactful on his life as far as the coming in and back and forth to the clinic, doing the stretching, et cetera, I would absolutely consider that person a candidate to continue on with another cycle series, full treatment course of Zyaflex, knowing that at any point we can cut bait.

1:06:05One of the challenges is just making sure that we get insurance approval for that, but all the things created equal, that'd be very appropriate. That being said, if they've gone through the Zyaflex, they're ready to move on to a surgical treatment. And this is where that expectation setting comes in. Those patients who are really bothered by their loss of penile length, just emphasizing what is the goal with surgery, right? It's function over fashion. It's restoring the, I should say, improving intimacy by enhancing sexual function by straightening the penis. And so, yes, with, for example, plaque incision in a setting like this, in theory, we're releasing the restricted area.

1:06:50The reason that men perceive and actually lose length on their erection is a lot more complicated than just that one area where the scar tissue is causing the curvature. So I really spent a lot of time with these in this setting, emphasizing what the goals of surgery are and that most men, at least in my experience, are not perceiving their penis to be longer after that surgery. they may actually still perceive their penis to be shorter again because of that perception versus reality you know what was the baseline erectile length or when before this all started versus you know after we're done etc but ultimately that patient may be a good candidate he's healthy he's got still residual moderate to severe curvature if he understands the risk benefits and alternatives, I'd be, I would consider him a candidate for incision and grafting.

1:07:44That being said, I would also talk about plication and really emphasize the, you know, functional improvements that can be had with straightening the penis and the trade-offs as far as side effect profile and the, you know, potential ED risk, et cetera. Because this is a guy where, you know, if you do, if he is, you know, if he does develop BD, like that could be a lot more devastating than perceiving a little bit of extra size loss. So it's just setting expectations. But ultimately, this is shared decision making, right? I'm not going to talk this patient and this is a great candidate for any of those treatment options.

1:08:20And I'm not going to try to talk him in and I don't want him to perceive that I'm talking him into any therapy. I'm going to offer you the best outcome we can with any of these options. Yeah, I love that. Yeah, no. Long-winded answers. Sorry for that. No, it's beautiful. And I gave that to you for the reason that, you know, you could, he would be a candidate for all of that with excellent decision making. And to wrap up, what you were saying is that we looked at this years ago, I think it was around 2019, we published this, but it's, you know, guys that do well with the eight injections, about 80 % of guys, at least in our experience, had a very satisfactory outcome with that.

1:08:59So the 20 % of guys that we looked at for second round, and that number has actually migrated up, is around 23 % now. But still, you know, 20, say, percent of guys had about a 20-degree improvement, which is lower than what the impressed trials would say, which was what got FDA approval for Zyaflex, about 34 % to 35%. So we had some recalcitrant plaques, I call them, that would go on to a second round. So of those 20 % that didn't get a great outcome with that first round of Zyaflex, by the time we did two rounds or a fraction of two rounds, so somewhere between 12 and 16 injections, they developed about a 50 % improvement.

1:09:37And so you're right. This guy, if we went from 70 down to 50, but then if we went 50 to 25, he all of a sudden has a curvature that most guys would be easily able to have penetrator intercourse. And so that's why we did this whole thing on surgery. And then I had you come up with a case scenario where he might be okay with just perseverance and another potential another round of zyphalics. But yeah, if a guy's also like, look, you know what? I don't have the time for this. Then you could start talking. Because I've certainly had guys that you're just like, I don't love getting injections. And, you know, it's cumbersome and it's uncomfortable.

1:10:11And if you can do a surgery where I can get in and out of your OR in an hour or three, then let's talk about that now, Professor Siegelman. And so that's exactly why I said, you're going to be okay. I mean, that's the most important thing with anything Peyronie's related is we're going to find a way to get back your functionality. So we have to close always with this question that I ask all of my guys. And you already mentioned it today already. It's a couple hours later in Minnesota than it is in Santa Monica. So you already went up for your run for the day. But without leading you again, what is it that you do every day?

1:10:44Because you're a dad, you're a husband. I mean, you have so many things in your life to make you show up every day as well as you can. Tell me the hit list to make Professor Ziegleman the dude he is. Yeah, so wonderful question. Actually, you prompted me about this a couple of days ago, so I had some time to think too. Sorry if I'm giving away. Spoiler alert. No, it's all spontaneous on the cuff. No, it's, yeah, so every morning, you know, unless there's some very extenuating circumstances, I try to get up and do self-care. And for me, that's usually cardio. I do either run or bike. And being in Minnesota, you can imagine in the winter, a lot of that is indoors.

1:11:30Yeah. But you know what? One of my other loves is TV and movies. And so I can get through a TV show and or a couple of movies a week, doing some indoor, you know, running and cycling, which is great. So that gets me ready for the day. Yeah, yeah, exactly. I do the same thing. I love, yeah, I love on a treadmill watching a series and it makes the pain and the tedium so much better. Totally, yeah. I get to run outside all the time here, but I don't get that same level of habit stacking. Although I listen to books on tape when I run. So it kind of helps. But yeah, I just said books on tape. Jordan, help me.

1:12:09Can you fix that? It's audio books. I still call them books on tape. Well, if we all talk about Austin Powers, we're meant to be a third generation. I still have a CD player, you know, I still. Jordan and I swap eight tracks. It's pretty cool. Real, real. Jordan, you've been so quiet. I want to get Dr. Ziegleman off of his days since he delivered so famously on the mailroom. But any closing thoughts about questions? You maintain your color throughout an entire surgical discussion about disassembling and reassembling penises. So congratulations on that. Thank you. We have pictures. We have pictures.

1:12:47Exactly right. Send me the deck through the email. Yeah, yeah, yeah. I mean, I think the only question I had, and this was – you answered a lot of my physiological questions, and I had a couple psychological questions that maybe we could save for another day. But just this kept popping back into my head. The implant, you said was, I think the phrase you used was sort of on-demand rigidity that would fill with saline or whatever the fluid is. How is that triggered? Yeah, yeah, yeah. I wish it was on an app on your phone or up here. Someday. Someday, someday. That's what we've been hearing. It's called a pump, and it's put in your scrotum.

1:13:27So your scrotum is like your sac, right? And we put it between the testicles, either in front or behind, depending on. And you actually, the guy learns to squeeze the pump. So it's like it kind of almost feels in some men like a firm third testicle. Not really. But I mean, and then you squeeze that. And that actually generates the fluid transfer from that reservoir, the water balloon behind the pubic bone, up into the penis. Wow. It's magic. we're going to have a whole series on penile implants. So this is good foreshadowing for that, but it is truly a revolutionary device. It's relatively new.

1:14:08It's only been out since about 1972. So we got some learning to do there, young Jordan. I don't know anything past vinyl. So any technology past 1970, I'm excited. We got you, brother. We got you. Well, Matt, thank you so much for coming on The Mailroom. This has been great. You've definitely entertained as well as educated our audience. And I hope you continue to do the amazing work you're doing for guys everywhere with your career, which, again, to achieve professor level at your young age is truly an accomplishment. So I want to shout that out, that that's truly remarkable work and dedication to your craft.

1:14:49So congrats. And then maintaining your cardio through the whole thing. I appreciate it. Well, thank you. This has been great. nerding out on Peyronie surgery. Hell yeah. There's nothing better on a Monday, let me tell you. That's right. We're doing it. All right. All right. Well, we'll see you at the next meeting. Have a great summer. And thanks again for dedicating an hour of your time to help guys everywhere. All right. Thank you. Jordan, we nailed it. Another one for the books. We got it. You delivered on the mailroom, my friends. Thank you. Cool.

1:15:53The Mail Room with Dr. Jesse Mills was a production of iHeartRadio. It was executive produced by Jordan Runtog. It was edited, mixed, and mastered by Bahid Frazier, and the theme was provided by Long Transit. If you liked what you heard, please subscribe and leave a review. For more podcasts from iHeartRadio, check out the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows. This program is intended for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Consult your health care provider for any medical or other related questions or concerns.

1:16:32The views and discussions aired on this podcast are those of Dr. Mills and do not represent the official positions of UCLA or UCLA Health.

1:16:48I tell myself, it's not about comparing. But then I start wondering, what can they lift? Are they adding more weight to their barbell than I am? And suddenly, I'm not training. Then I realize, my journey is not theirs. I've earned every step. So I smile. My smile is the shape resilience takes to keep me moving. To put more smiles out into the world, Colgate has supported female athletes for over 50 years with the Colgate Women's Games, the nation's longest-running indoor track and field series for girls and women. Colgate, your smile is your strength. And now, another appliance triumph from our friends at Grand Appliance.

1:17:24I want to eat healthier, but get frustrated when produce spoils before I can eat it. So I went to Grand Appliance looking for a fridge that would help. They recommended a Frigidaire Gallery French door with crispers that block dry air and excess moisture to extend the life of fresh food. And wow, it really works. No more wasted food in my house. Expert appliance recommendations for the win. Shop GrandAppliance.com This is Jacob Goldstein from What's Your Problem? When you buy business software from lots of vendors, the costs add up and it gets complicated and confusing. Odoo solves this. It's a single company that sells a suite of enterprise apps that handles everything from accounting to inventory to sales.

1:18:07Odoo is all connected on a single platform in a simple and affordable way. You can save money without missing out on the features you need. Check out Odoo at odoo.com. That's odoo.com. Hey everyone, it's Kel Penn. I'm inviting you to join the best sounding book club you've ever heard with my podcast, Earsay, the Audible and iHeart Audiobook Club. Every episode, I nerd out with amazing guests and dive into the best new audio books available on Audible. It's the book club for your ears. Listen to Earsay, the Audible and iHeart audiobook club on the iHeartRadio app or wherever you get your podcasts.

1:18:52Summer is here, which means we all want to look and feel our best. A GLP-1 may be right for you. Visit orderlymeds.com to learn more about which GLP-1 you could be eligible for. Getting started is fast, easy, and happens virtually through telemedicine from licensed professionals. Check it out for yourself. Go to orderlymeds.com slash podcast. That's orderlymeds.com slash podcast. Taking care of yourself feels great. Compat and medications are not FDA approved. Deligibility required and determined by a licensed provider. Individual results may vary. See website for details. This is an iHeart Podcast.

1:19:25Guaranteed human.