peyronies diseasePosted by vangelis S on 3/05/04 at 02:04 (146060)
I have peyronies and i'dlike to know how Eswt help me,i live in greece,are doctors near to treat me?
Re: peyronies diseaseJan R. on 3/05/04 at 02:36 (146061)
Clinical data are weak to support ESWT for Peyronie´s disease. It cannot be recommended as primary treatment option.
Extracorporeal shock wave therapy for Peyronie's disease: exploratory meta-analysis of clinical trials.
Hauck EW, Mueller UO, Bschleipfer T, Schmelz HU, Diemer T, Weidner W.
J Urol. 2004 Feb;171(2 Pt 1):740-5
Department of Urology, Justus Leibig University, Giessen, Germany.
PURPOSE: Extracorporeal shock wave therapy (ESWT) for the treatment of Peyronie's disease is still controversial. This exploratory meta-analysis of published studies in the international literature investigates its therapeutic effects. MATERIALS AND METHODS: The treatment outcomes from 17 study groups identified by a computerized literature search were compared with natural history outcomes and data from control groups from 2 controlled ESWT studies. An exploratory meta-analysis was performed because a methodologically sound meta-analysis lege artis did not appear appropriate, since treated groups differ considerably in structure, the selection of outcome measures is inconsistent and measurement is not standardized. RESULTS: ESWT seems to have an effect on penile pain during erection and on the improvement of sexual function. Pain seems to resolve faster after ESWT than during the course of the natural history. The effect on plaque size and penile curvature is less impressive. CONCLUSIONS: ESWT in Peyronie's disease at least seems to be effective in regard to penile pain and sexual function compared to natural history. Deducing from these data the effect on plaque size and curvature remains questionable. However, ESWT is not an evidence based therapy at present. A controlled (preferably pairwise matched), single blind, multicenter study with careful, detailed documentation of disease symptoms before intervention and of outcomes is required to evaluate the real effect of ESWT.
Extracorporeal shockwave therapy for Peyronie's disease does not correct penile deformity.
Strebel RT, Suter S, Sautter T, Hauri D.
Int J Impot Res. 2004 Feb 19 [Epub ahead of print]
Department of Urology, University Hospital Zurich, Switzerland.
To evaluate whether extracorporeal shockwave therapy (ESWT) offers an effective treatment for the main complications of Peyronie's disease (PD), that is, penile deformity and angulation, painful erection and most importantly unsatisfied sexual intercourse. From September 1999 to January 2001, 52 patients with PD were treated with ESWT. Pain during erection was assessed with a visual analogue scale. Penile deviation was determined by photographs with a goniometer. Five treatment sessions were performed at weekly intervals. Each consisted of 3000 shockwaves with an emission frequency of 120 shockwaves/min and a mean intensity of 0.17 mJ/mm(2). A Storz Minilith SL 1 with integrated inline ultrasound probe was used. In all, 52 patients were evaluated 6 weeks after ESWT for early follow-up. Before ESWT intercourse was difficult or impossible for 40 men; 29 patients suffered mainly from penile deformity, 14 from painful erection and eight mainly from loss of distal rigidity. A total of 30 patients mentioned painful erection before treatment. In 28 patients (93%) pain reduction was achieved. A total relief of pain was observed in 19 patients (63%). Mean pain score dropped from 4.2 to 1.3 in patients who suffered predominantly from painful erections. Intercourse satisfaction improved in 11 patients after therapy. Mean angulation before (40 degrees ) and after (37 degrees ) ESWT did not change significantly. Late follow-up after 11.1 months (4-17 months) could be completed in 36 patients. In total, 19 men reported that ESWT improved their PD. Of these, 16 noted no change. Only one of the patients noticed a worsening of his disease during or after treatment. Complication rate was low with only minor side effects such as minimal skin bruising; one urethral bleeding occurred. ESWT did reduce pain during erection in patients suffering mainly from painful erection due to PD. However, penile angulation did not improve significantly in our setup and thus intercourse difficulties did improve only in 28% of the patients. Therefore, we do not recommend ESWT as a primary treatment for PD.International Journal of Impotence Research advance online publication, 19 February 2004; doi:10.1038/sj.ijir.3901192
Re: peyronies diseaseScott D. on 3/05/04 at 07:42 (146066)
With all due respect, you are not in the urological field and making your above statement based upon a few journal articles is, I feel, irresponsible.
If you read those two articles as a Peyronie's patient, and your primary motivation is pain relief, they are extremely encouraging!
To Vangelis, the answer to your question is that research is currently being done all over the world on this and that the procedure IS being done. Your best hope of finding some answers is to check with Urologists in Greece, more likely at major medical centers, and see who is doing this and what their results are.
Best of luck!
Re: peyronies diseaseEd Davis,DPM on 3/05/04 at 08:34 (146071)
Are you in touch with Sunny Jacob as he has some experience, I believe in that area? It may be an area requiring more studies at this time although I do like to give credence to experiental 'data' from practitioners who have performed significant numbers of such procedures. Let me know if you need his email address.
Re: peyronies diseaseDr. Z on 3/05/04 at 18:28 (146145)
Did you get my e-mail about your elbow. I have painful elbows waiting for the Scott D elbow protocol. Seriously I can't recall if you told me it was level 4 or 5 at 2500 total pulses. Please help me out again. thanks
Re: peyronies diseaseEd Davis,DPM on 3/05/04 at 21:37 (146181)
Things are looking good for lateral epicondylitis but not so good for medial epicondylitis stat wise. The attachment at the medial epicondyle is broader and one must probably aim a bit wide due to the proximity of the ulnar nerve -- just my assumption for the poorer stats on golfer's elbow (medial epicondylitis).
Re: peyronies diseaseelliott on 3/10/04 at 09:44 (146600)
Scott D, you do make some valid points. Of course, it's not surprising that
ESWT providers are predisposed to favor ESWT treatment,
ESWT researchers are predisposed to rely on preferably independent research, and
insurers are predisposed to reject new treatment modalities.
Not that it's anyone's fault, but on this board we don't get much balance from the three groups. We mainly see the ESWT providers. It is nice to have an ESWT researcher such as Jan R to give his perspective on things, and I hope he continues to post. We rarely if ever see the insurer's side of things. Here, for example, is a very recent paper by BCBS on the subject, concluding there is not sufficient evidence for ESWT efficacy for either PF or tendinitis of the shoulder/elbow:
(While some may scoff at its conclusion, it is a very interesting document for its specific comments on the Ossatron and Dornier studies):
If I were in desperate need of some type of treatment, I wouldn't necessarily wait for a consensus of several perfectly designed multi-center, double-blind, placebo-controlled studies. At the same time, the ESWT issue is still somewhat murky, the cost still high. A degree of balance, even if that includes what may appear to some as a knee-jerk response from a member of a specific group, may help a sufferer who comes to this board seeking advice to make a more informed decision.
Re: peyronies diseaseDr. Z on 3/10/04 at 10:10 (146601)
Would you be interested in reviewing this tech report and how valid their comparisons are that they are making. I would appreciate your imput since this report is a major road block for insurance coverage. Do you think that insurance companies are using this report as an excuse for ESWT coverage ?
I have one interesting finding. When I first started ESWT I would quote from ESWT European studies and show various medical directors literature with hopes of obtaining ESWT coverage for patients . The reponse was always that it is against policy to use European studies. We want USA peer reviewed literature. Now they are using European literature . Strange!!. From your view point is it valid to use results from the low energy study from the Austrialian study with either the dornier or ossatron FDA study.
Re: peyronies diseaseelliott on 3/10/04 at 10:51 (146605)
Dr. Z, how much is my review worth to you? :-) Have you read it carefully yet? Have you seen it before?
Re: peyronies diseaseEd Davis, DPM on 3/10/04 at 23:12 (146656)
When you use the term 'ESWT providers' you need to remember that there are those who for example, only do ESWT or have dedicated a large portion of their practice to that modality. That is not common in the US though.
Most of my colleagues who perform ESWT perform one or two cases per month and it makes up a very small percentage of their practice so there is little reason to assume a bias or favoritism. Dr. Z's situation or even mine is not typical nor representative of the 'average' ESWT provider in the US. Canada is different in that there are specific ESWT treatment clinics dedicated to that modality.
Re: peyronies diseaseEd Davis, DPM on 3/10/04 at 23:24 (146657)
Thank you for the paper as it is an interesting read. I read the first 3 and last 3 pages and scanned the rest, probably try to read the rest this weekend.
ESWT has a physiologic effect on tendon/ligaments which is not geographic/ anatomy dependent. As such, I am not in favor of the impetus to try to determine efficacy on a region by body region basis. I do think that we need to know the differentials; for example, the evdience that it is far more effective for lateral epicondylitis than medial epicondylitis.
The paper points out deficits in a number of pro-ESWT papers but does not (at least I did not get to that point) critically review the deeply flawed Buchbinder study. Sorry, but Dr. Buchbinder is an epidemiologist and in all likelihood has not diagnosed and treated a single case of PF in her career. Despite the flaws in some papers, the sheer volume of evidence is overwhelming considering the number of papers and the, now, vast experience of a number of practitioners. I have seen few treatments being held to this level of scrutiny and have to question the motives of third parties such as the tech committe of BC/BS that has relied so heavily on the Buchbinder study in the past. Certainly, a review of surgical procedures for PF should lead one to a conclusion that that surgery perhaps should not be covered by insurance or only covered under extenuating circumstances.
Re: peyronies diseaseDr. Z on 3/10/04 at 23:39 (146661)
Very good points. If is very strange that ESWT was considered, before the
Dr. Buchbinder study, a procedure that met that quality of health standard dictated by this Blue Shield Company TEC report.
My question to Elliott is how can the TEC committee use and compare studies that had two different protocols,duration of pathology, etc.
In my opinion the most important aspect of ESWT technology is the low risk and very high benefits. We can talk about cost when cost of how the insurance companies doing business is regulated and controlled.
Re: peyronies diseaseDr. Z on 3/10/04 at 23:47 (146664)
After you read this TEC report I think you will discover one important aspect of the report. Before the Australian Buchbinder Study and the Dornier PMA approval ESWT was endorsed in the previous TEC report. So in my mind the only reason that it failed to meet the TEC approval was ONLY due to the Buchbinder study. This is the study that was reported in every major newpaper, TV in the USA. Ok . Very strange
Re: peyronies diseaseelliott on 3/11/04 at 10:00 (146688)
Dr. Ed: Yes, good point, there are different types of providers (just as there are different types of researchers, e.g., independent ones vs. those working for the very company promoting a machine). On these boards, for the most part we are not seeing the 'average' ESWT provider who treats one or two people a month, which contributes to the different perceptions as to treatment we get here.
Re: peyronies diseaseelliott on 3/11/04 at 11:47 (146700)
You say, 'After you read this TEC report.' Good line, that. Take that advice for yourself. I gather from this thread that you are and have been well aware of these two TEC reports for some time, as the second one has been a thorn in your side, preventing much insurance coverage for ESWT. Had you read its executive summary appearing at the top (it's just 4 pages and took me about 5 minutes), you would have seen instantly that the Ossatron success criteria were completely different from Dornier's and that the success rates you used for so long were not directly comparable, something stated explicitly in that summary. You never read the Buchbinder study you love to criticize either, even when it was placed in front of your eyes by me well over a year ago. Had you done so, you again would have realized the success criteria for Ossatron were different. Not only that, but one of your criticisms (and that of others) of Buchbinder was that in order to promote proper blinding without anaesthesia, it used a real dose on the sham group, albeit a very low one. I find it hypocritical that one who claims high energy is far superior to low energy is going to be concerned that a low dose more akin to turning on a light bulb is going to have a dramatic effect on the placebo results. Regardless, had you read Buchbinder, you would have seen that another respected researcher did the very same thing: his name was Rompe.
It has become popular for the ESWT providers here to badmouth the Buchbinder report, but here is my take on it: what it showed is that when Dornier is set on low energy similar to that of other low-energy studies, it does not seem to help patients with the mean and minimum duration of PF symptoms as stated (which were quite lower than those for the FDA studies), and possibly even for the subgroup having longer duration. I happen to find that useful information. This is not changed by the fact that the press or whoever distorted the conclusion to encompass far more than that.
To answer your question, no, the TEC did not base its change just on Buchbinder. It based it also on Dornier; its reservations on Dornier are given on page 2. That is not to say everyone must agree with the TEC's overall conclusion or their motivation for reaching it.
You asked if there are any obvious weaknesses in the TEC report, which overall I happen to think is written very well. The main one I see is that they make a big deal of requiring approval from governmental regulatory bodies (FDA), suggesting that the protocols used in that gov't-approved study should be followed, and then cites the Buchbinder study, which did not follow them. While it is true, as the TEC report says, that 'there are no controlled clinical trials that test the relative efficacy of various techniques for shock wave dosage and delivery', you can scream that if you change the setting to a low one and point it instead at the patient's tush and it doesn't work, that doesn't negate your positive findings.
Dr. Z, just a little advice: slow down a little, and FIRST READ THE MATERIAL YOU ARE KNOCKING. I have asked you to do that on many an occasion. Please do so for your own good. Honestly, I don't want to keep pointing out what you missed in material you should have read.
Re: peyronies diseaseDr. Z on 3/11/04 at 17:26 (146740)
You are real positive today.
I have a piece of advice. Keep an open mind. I am not knocking materials I have given you my opinion. I am not missing items in these reports and I have no idea where or what you are talking about. Why do you think no one comments on your posts. Believe me there are alot of people there that are engineers, doctors etc. Think about it no comment.
Re: peyronies diseaseEd Davis, DPM on 3/11/04 at 19:30 (146746)
Yes, it is just 'another treatment' to most. Unfortunately, those individuals are not as motivated to post. Considering the outcomes of plantar fascial release surgery, this alternative should be very welcome though.
Re: peyronies diseaseEd Davis, DPM on 3/11/04 at 20:23 (146749)
My guess is that there are very few people involved in ESWT who have not read the Buchbinder study (including Dr. Z). That study has gained quite a bit of notoriety due to its flaws but more so since a flawed study was published in a reputable journal with what appeared to be a minimum of critical review and had become the item most often used by third parties as the reason for adverse coverage decisions. It is surprising to see third parties still hanging their hats on that study.
I knew about the most obvious flaws, that is, that 50% of patients in the study did not have PF long enough to be eligible for most studies (this is a fatal flaw in the study unto itself), issues concerning amount of energy used. I learned of 3 additional valid criticisms during a hearing I was at a couple of weeks ago but was not in a position to take notes. Perhaps one of the research oriented people like Dr. Rompe may come forth to discuss the study.
Re: peyronies diseaseDr. Z on 3/11/04 at 20:31 (146753)
What is most sad about the buchbinder report is that alot of patients were prevented from ESWT treatment and some may have suffered from plantar fascia surgeon. We are talking about people not stats, numbers or comparisons.
Ed as you know unless you are a patient with plantar fascia pain or a doctor trying to help a patient that is suffering then this will be just stats to someone who works for an insurance company. I still remember an insurance representative telling hey doctor don't gets so upset its only pain no one dies from plantar fasciitis.
Re: Another day in court...Ed Davis, DPM on 3/12/04 at 22:52 (146835)
I just got back from another day in court. This case was about a fellow who developed PF, did not recieve any reasonable treatment from a very restrictive HMO, got worse, could not work, got fired from his job -- now he is uninsured, unemployed and cannot afford treatment. He had filed his case as a worker's comp case so he was not informed that he could have actually broken free from his HMO and gotten appropriate treatment.
I testified on his behalf, basically explaining what appropriate PF treatment is. I had his attorney read ScottR 's Heel Pain Book so she would have a good understanding of the various treatments.
I had performed an IME (independent medical exam) in April, 2002 on this patient and, at that time, provided a complete treatment plan consistent with what most of us would agree upon. That plan was never carried out by his HMO. He got worse, could no longer work as a schoolteacher, was fired, hired an attorney. His attorney noted that he did not get the treatment I had outlined and asked that I do a new IME which I did in December 2002. I stated in the latter IME, that his PF had become recalcitrant and that while surgery was an option, a newer and better option, ESWT, had come forth. The AG's attorney went ballistic on me for that opinion since our state's workers comp system won't cover ESWT. I would not back down (being the resident hard head has some advantages).
I was on the stand for about 2 1/2 hours and the case is still ongoing. I have been sending the plaintif's attorney studies to back up some of the issues involved since.
Re: Another day in court...Dr. Z on 3/13/04 at 08:15 (146853)
I would have loved to have my popcorn and soda and watched you on the stand. Your testifying could have a VERY important influence on ESWT coverage at least in the work compensation area.
The only time I was ever involved something similiar was a case ( WC) where the patient in New York State came to me for ESWT. WC refused to
cover ESWT. With only a report from me there was a bench hearing and the patient won with a set fee that matched my UCR for ESWT.
IT was nothing like you are going thru. Maybe because it was NY state.
This was five years ago. I still can't find the hearing results but if you think it would help with this case I will start running reports and going thru files. It shows the verdict, diagnosis. fee payment. It might have Big O on it I can remember. One more thing I don't know if this is important but the patient was a NY City Police Detective retired, very strong union power !!
Re: Another day in court...Ed Davis, DPM on 3/13/04 at 11:08 (146870)
I think that the state (WA) realizes that whenever this issue arises, as it has in a number of WC cases, their policies are being challenged.
I really had to work hard on this case as the plaintiff's attorney had to be educated. Unfortunately, we may not win this case because the patient/plaintiff was not without fault. As a WC patient he could have walked away from his HMO at any time and procured most of the necessary treatment (except maybe ESWT) from an independent provider -- I had informed him of that in April 2002 -- unfortunately he did not 'take the ball and run with it.' He took a very passive approach. Unfortunately, many patients are too passive , not taking responsibility for their own health issues. That issue is one of my 'hot buttons' and is the main reason why I support this site -- it gives patients the information they need to make informed decisions. We literally need a site like this for a lot of health problems out there in which patients are not getting adequate treatment for a variety of reasons.
Re: Another day in court...Ed Davis, DPM on 3/13/04 at 16:06 (146886)
I did have to behave myself (it wasn't easy :D ) as I did not want to aggravate the judge. There is no jury in the WC hearings so the judges don't appreaciate antics or tolerate any shenanigans. My snide remarks about 'stifling medical progress' to the attorney for the AG were off the record after the judge left the room.