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Objective:
Peyronie disease (PD) is characterized by penile pain, penile deformation and curvature, sexual dysfunction, and psychological implications. Calcified plaque develops in at least 20% of these patients, excluding them from medical therapy with collagenase injection and often requiring more extensive surgery?for treatment (plaque excision and grafting, inflatable penile prosthesis placement, or plaque incision and grafting)[1-5]. Penile ultrasound with Doppler (PUS) is used to exclude erectile dysfunction and identify plaques; however, plaque extent and distribution can be obscured by acoustic shadowing, limiting complete plaque characterization. Non-contrast pelvis computed tomography (CT) provides a noninvasive method to identify plaques in 3 dimensions and quantify plaque calcification burden. Agatston calcium scoring (ACS) has potential to measure calcium (Ca) burden more consistently as 3 plane plaque measurement can be affected by penile curvature or positioning, and PUS may underestimate burden due to plaque shadowing and location.

Materials and Methods:
IRB approved retrospective database review from 1/1/2017 - 6/30/2021 identified 25 patients with calcified plaques on CT after PUS performed by a single urologist. Two abdominal radiologists reviewed CT in consensus to measure calcified plaque size and distribution on PACS. Penile calcification was marked with a semiautomated software package (syngo.via Client 5.1, Siemens Healthcare, Erlangen, Germany) designed for quantifying coronary artery calcium using a threshold of 130 Hounsfield units or higher to calculate ACS. Total Ca volume/mm^3 and total ACS were correlated with hourglass deformity on clinical exam, plaque complexity on CT (>2 discrete calcified plaques, >50% corpus cavernosum involvement, or septal involvement), plaque complexity on clinical exam & PUS, and surgical management using descriptive statistics and t-test.

Results:
Mean Ca volume=1417 mm^3 (range 1.4-5425.7, standard deviation (SD) 1570); mean ACS=1691 (range 1.6-6048; SD 1862). Patients with complex plaque on CT (n=13) had significantly higher ACS (2834 vs 449, p<0.05). Patients with complex plaque by clinical exam & PUS (n=9) had significantly higher ACS (3088 vs 905 p<0.05). The longest plaque dimension in any plane was significantly longer on CT than US (31 mm vs 22 mm, p<0.05). There was no significant difference in ACS for nonsurgical (n=10) vs surgical management (n=15)(1844 vs 1462, p=0.29) or for no hourglass (n=16) vs hourglass deformity (n=9) (1261 vs 2455, p=0.19).

Conclusion:
Significantly higher ACS is seen in patients with complex plaques by PDU combined with clinical exam or by CT features. CT plaque measurements are larger than PUS measurements, which may have implications for surgical planning. Although there was no difference in ACS for nonsurgical vs surgical patients, nearly all patients (24 of 25) were offered a surgical management plan but only 15 underwent surgery. Semiautomated ACS may help noninvasively identify complex calcified penile plaques to guide medical and surgical therapy for PD.