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SINGLE AND MULTIPLE DERMAL GRAFTS FOR THE MANAGEMENT OF SEVERE PENILE CURVATURE
0022-5347/98/1603-1128$03.M)/0 THE JOURNAL OF UROLOGY
Vol. 160,1128-1130, September 1998 Printed in U.S.A.
Copyright 8 1998 by AMERICAN UROLOGICAL AMTION, INC
SINGLE AND MULTIPLE DERMAL GRAFTS FOR THE MANAGEMENT OF SEVERE PENILE CURVATURE BRUCE W. LINDGREN, EDWARD F. REDA, SELWYN B. LEVITT, WILLIAM A. BROCK AND ISRAEL FRANC0 From the Long Island Jewish Medical Center, Schneider Children's Hospital, New Hyde Park and Westchester County Medical Center, Valhalla, New York
ABSTRACT
Purpose: Conventional techniques result in chordee correction in the majority of patients. However, some with extensive chordee require further treatment to correct persistent extraordinary penile curvature. Our practice has been to treat this condition with interpositional dermal grafting. We review our experience with this procedure. Materials and Methods: During a 5-year period dermal grafts harvested from the nonhairbearing inguinal skin fold were placed in 51 patients with a mean age of 29 months. The primary diagnosis was penoscrotal or perineal hypospadias in 36 patients (hypospadias cripple in 41, the exstrophy-epispadias complex in 3, mid shaft or distal hypospadias with severe chordee in 10 and chordee without hypospadias in 2. A total of 49 patients (96%) underwent staged urethroplasty. Results: One graft was placed in 29 patients (57%),9 (18%)received 1 graft and underwent a Nesbit plication, (14%) received 2 grafts, 5 (10%) received 2 grafts and underwent dorsal plication, and 1 (2%) received 3 grafts. Second stage urethral reconstruction was done using a Thiersch-Duplay tube in the majority of cases. In 5 patients mild residual chordee was easily corrected a t the time of second stage repair. Conclusions: In a staged repair the first priority of the initial stage is to achieve a straight phallus. While our experience indicates that a single dermal graft is sufficient in approximately 57% of cases, when it does not result in complete straightening, we have had success with placing additional graft(s) and/or performing dorsal plication. We believe that the additional penile length achieved with dermal grafting results in a dependent phallus and cosmesis preferable to that of plication only. KEYWORDS:penis, hypospadias, abnormalities Penile curvature may develop as an isolated malformation, or in association with hypospadias or epispadias. Conventional techniques for correcting penile curvature involve the release of all tethering skin attachments followed by sharp resection of the fibrous chordee tissue. When residual curvature exists, the urethral plate is divided, the urethra is mobilized and any remaining fibrous tissue is excised sharply, resulting in the correction of penile curvature in the majority of patients. When curvature persists despite these conventional techniques, the cause most often appears to be a discrepancy in corporeal body dorsal-to-ventral length. The procedure that we use to correct this condition is determined by the remaining degree of curvature. In mild cases dorsal plication is performed with excellent success. However, when severe chordee of approximately 30 degrees or more persists, especially when the penis is short, we prefer to interpose a dermal graft, as previously reported.' We present our recent experience with this procedure. METHODS
Using computerized office records we identified all patients in whom dermal graft placement was performed in a 5-year period. We retrospectively reviewed their office charts and hospital records, including preoperative and postoperative visits, and operative reports. Included in this study were 51 patients 6 months to 14 years old (mean age 29 months) at graft placement on whom sufficient information was available. The primary diagnosis was penoscrotal or perineal hypospadias in 36 patients (hypospadias cripple in 4), the
exstrophy-epispadias complex in 3, mid shaft or distal hypospadias with severe chordee in 10 and chordee without hypospadias in 2. The penile shaft skin is first mobilized and all residual chordee tissue is sharply excised. The urethral plate is divided and the urethra is mobilized. As described by Gittes and McLaughlin,' an artificial erection is then initiated. If the remaining curvature is less than approximately 30 degrees, dorsal plication is performed, similar to that described by N e ~ b i t When .~ more severe chordee persists, the tourniquet is released and the penis is wrapped in a moist antibiotic soaked gauze pad while the dermal graft is harvested. The nonhair bearing inguinal skin fold is the site of graft harvest. The graft placement site is measured with calipers. The elliptical graft outlined with the skin marking pen is larger in anticipation of the possibility that a second graft may be needed. The whole epithelial surface of the graft site is then colored with ink. The skin is pulled taut and the epithelium is incised along the previous outline using a number 15 scalpel blade. The epithelium is elevated from the dermis via sharp dissection using several new scalpel blades as needed. The epithelial ink marking aids in identifying the proper depth of resection, so that all epithelium is removed. The dermis is incised along the periphery and removed from the underlying fat with dissecting scissors. The dermal graft is defatted and placed in Ringer's lactate solution until needed. The donor site is inspected for hemostasis, packed with a moist gauze pad and closed in 2 layers after penile reconstruction is completed. The artificial erection test is repeated, and a t the point of
1128
SINGLE AND MULTIPLE DERMAL GRAFTS FOR SEVERE PENILE CURVATURE
maximal curvature the tunica albuginea of the corpora cavernosa is incised from the 3 t o 9 o’clock positions, including incision into the septum. Care is taken to incise only the tunica and avoid the cavernous tissue. The dermal graft is trimmed t o the appropriate size and secured in place in 4 quadrants using 6-zero polyglycolic acid suture. We prefer to position the graft with the fatty side facing the corporeal tissue, although its orientation is probably insignificant. The graft is attached to the edge of the tunica albuginea using a running stitch in each of the 4 quadrants. The artificial erection is repeated and any leaks are controlled with additional interrupted 6-zero sutures. In most cases the initial graft, which is the site of maximal chordee, is placed at the mid shaft. When curvature persists, it is nearly always in the subcoronal area. If persistent curvature is minimal, we perform a dorsal Nesbit plication. If it is more significant, especially when the phallus is short, we place an additional graft in the subcoronal position in the described manner. Because the second graft is smaller, there is always sufficient dermis remaining from the initial donor site, making repeat graft harvest unnecessary. The dermal graft may bulge slightly during artificial erection but this is not significant. This bulging has not occurred when the artificial erection is repeated at second stage urethroplasty, and patients and parents have not complained beyond the immediate postoperative period. After all curvature has been corrected the penile shaft is resurfaced with skin coverage as described by Byars4 A feeding tube or Foley catheter and a bulky dressing to immobilize the penile shaft are placed and removed in 1 week. The patient receives 1 dose of perioperative antibiotics intravenously, and is then maintained on oral antibiotics until the catheter is removed. Early in the series some patients were hospitalized but nearly all recent procedures have been performed on an outpatient basis. Second stage urethroplasty repair is usually performed approximately 6 months later.
RESULTS
One graft was placed in 29 patients (57%),9 (18%)received 1 graft and underwent a Nesbit plication, (14%)received 2 grafts, 5 (10%)received 2 grafts and underwent dorsal plication, and 1 (2%) received 3 grafts. Mean graft length and width were 1.5 and 1.2 cm. (range 0.3 t o 3 and 0.2 to 31, respectively. Second stage urethral reconstruction was performed using a Thiersch-Duplay tube in 38 patients (74%). One patient underwent a Mustarde repair and in another a buccal mucosal free graft was placed. In 2 cases (4%)urethroplasty was performed at the time of dermal graft placement. Five patients (10%)await second stage repair. In 5 patients mild residual chordee noted at the time of second stage repair was corrected by simple resection in 4 and a unilateral plication stitch for lateral chordee in 1. In no case was residual chordee so severe as to preclude concomitant urethroplasty. The only other complication of dermal graft placement was an inclusion cyst in 1 patient, which resolved without surgical intervention. At 1 to 57 months of followup (mean 19) all patients have a straight phallus, as determined by repeat artificial erection at urethroplasty. In addition, a straight penis without obvious evidence of pain was reported in all patients in whom erection was observed by the parents or physician.
DISCUSSION
Incomplete correction of chordee may necessitate repeat surgery despite successful urethroplasty in patients with hypospadias or isolated chordee. Therefore, it is imperative to ensure complete penile straightening at primary repair.
1129
Penile curvature that persists aRer resection of all abnormal fibrotic chordee tissue and urethral mobilization is usually due to a discrepancy in the length of the tunica albuginea of the corpora cavernosa. Nesbit successfully corrected this condition by placing plicating stitches on the side contralateral to the site of maximal ~ u r v a t u r e .However, ~ when penile length is already marginal, shortening may lead to suboptimal cosmesis, such as a short, squat “tuna can” penis. Thus, we and others find it preferable to lengthen the short side rather than shorten the long side.’*”* Although numerous autologous and prosthetic materials have been used to accomplish this, dermal grafts have gained the most support. The use of dermal grafts for penile reconstruction is not new. Based on experimental work in dogs Devine and Horton selected dermis as the material of choice, and in 1974 they first reported its use to correct penile curvature in patients with Peyronie’s d i ~ e a s eThey . ~ later used a dermal graft to correct secondary chordee in a patient who had undergone more than 10 operations for congenital ~ h o r d e e . ~ We previously reported our initial experience with interposition dermal grafting for severe chordee with or without hypospadias in 15 patients.’ Nine of these cases involved primary procedures, and in 6 there were extensive residual scarring and recurrent chordee after previous attempts at repair. In 14 patients complete correction of chordee was achieved with 1 graft. However, in 1 patient reoperation was required to correct residual chordee and a second dermal graft was placed intraoperatively,’ which prompted us to consider the use of multiple grafts at the initial operation. Others have reported their experience with dermal graft placement for managing severe chordee that is not corrected by conventional methods.6-8 Details of the procedure vary slightly among surgeons, although all have observed the successful correction of chordee with 1 graft. As our series illustrates, 1 dermal graft is not always sufficient to correct all curvature. This finding emphasizes the importance and usefulness of repeating artificial erection throughout the procedure, particularly after graft placement. Although to our knowledge only Hendren and Keating have previously reported a case that required more than 1 graft: our experience illustrates that only 57% of cases are corrected with 1 dermal graft. Since persistent chordee is the indication for reoperation in a number of patients referred after an initial attempt a t repair, we strongly believe that it is important that all curvature is corrected at the initial procedure. Because maximal curvature generally exists in the mid shaft region, the mid shaft is nearly always the site of the initial graft. According to our experience residual curvature is usually in the subcoronal position. The decision to perform dorsal plication versus placement of a second dermal graft is determined by residual chordee severity and phallic length. We have found that the final result is cosmetically preferable when dorsal shortening of an already short penis is avoided. Thus, we place a second dermal graft in these cases. When lateral curvature is also present, usually as a result of a discrepancy in the length of the corporeal bodies on the left versus right side, we place a unilateral plication stitch or asymmetric bilateral dorsal plication stitches to correct this curvature with or without the placement of a second graft. We and others prefer penile straightening with a free graft as a staged procedure.’.8*lo Plastic surgical principles against placing 2 free grafts in apposition guide our choice of this approach. Although Hendren and Keating: and Horton et a17 reported success with dermal graft placement and pedicle flap or free graft urethroplasty at the same sitting, we still prefer to correct this severe defect in 2 stages. While erectile dysfunction has been reported after dermal graft placement in patients with Peyronie’s disease:, erec-
’’
1130
SINGLE AND MULTIPLE DERMAL GRAFTS FOR SEVERE PENILE CURVATURE
tile dysfunction has not developed in any of our patients. Venous leakage has been described as the usual etiology of impotence aRer the surgical treatment of Peyronie’s disease,” which may sometimes necessitate the excision of large plaques. In contrast to this practice in Peyronie’s disease, we incise rather than resect the tunica albuginea, which may possibly explain the contrasting results. Our patients are also obviously much younger than those treated for Peyronie’s disease and, thus, they do not have the underlying preoperative erectile dysfunction that may be present in older patients. CONCLUSIONS
In staged repair the initial priority of stage 1is to achieve a straight phallus. Our experience is that 1 dermal graft is sufficient in 57% of cases. However, when this does not result in complete straightening, we have had success with the placement of additional graft(s) with or without dorsal plication. Whereas a Nesbit plication relies completely on shortening 1side of the discrepant corporeal bodies to accomplish straightening, placing a dermal graft provides additional length. As evidenced by the width of the grafts in our series, this difference may be up to 3 cm. after the urethral plate is transected. We believe that the additional length achieved with dermal grafting results in a dependent phallus that is cosmetically preferable to the “tuna can” type, particularly in epispadias repair.
REFERENCES
1. Kogan, S.J., Reda, E. F., Smey, P. L. and Levitt, S. B.: Dermal graft correction of extraordinq chordee. J . Urol., 130:952,1983. 2. Gittes, R. F. and McLaughlin, A. P., 111.: Injection technique to induce penile erection. Urology, 4 473, 1974. 3. Nesbit, R. M.: Congenital curvature of the phallus: report of three cases with description of corrective operation. J. Urol., 93 230, 1965. 4. Byars, L. T.: Technique for consistently satisfactory repair of hypospadias. Surg., Gynec. & Obst., 100:184,1955. 5. Devine, C. J., Jr. and Horton, C. E.: Use of dermal graft to correct chordee. J. Urol., 113 56, 1975. 6. Hendren, W.H. and Keating, M. A.: Use of dermal graft and free urethral graft in penile reconstruction. J. Urol., part 2, 140 1265,1988. 7. Horton, C. E., Jr., Gearhart, J . P. and Jeffs, R. D.: Dermal grafts for correction of severe chordee associated with hypospadias. J. Urol., 150 452,1993. 8. Pope, J . C., IV,Kropp, B. P., McLaughlin, K. P., Adams, M. C., Rink, R. C., Keating, M. A. and Brock, J . W., 111.: Penile orthoplasty using dermal graRs in the outpatient setting. Urology, 48: 124,1996. 9. Devine, C. J., Jr. and Horton, C. E.: Surgical treatment of Peyronie’s disease with a dermal graft. J . Urol., 111: 44,1974. 10. Ehrlich, R. M., Reda, E. F., Koyle, M. A., Kogan, S. J . and Levitt, S. B.: Complications of bladder mucosa graft. J . Urol., 142: 626,1989. 11. Dalkin, B. L. and Carter, M. F.: Venogenic impotence following dermal graft repair for Peyronie’s disease. J. Urol., 146 849, 1991.
Vol. 160,1128-1130, September 1998 Printed in U.S.A.
Copyright 8 1998 by AMERICAN UROLOGICAL AMTION, INC
SINGLE AND MULTIPLE DERMAL GRAFTS FOR THE MANAGEMENT OF SEVERE PENILE CURVATURE BRUCE W. LINDGREN, EDWARD F. REDA, SELWYN B. LEVITT, WILLIAM A. BROCK AND ISRAEL FRANC0 From the Long Island Jewish Medical Center, Schneider Children's Hospital, New Hyde Park and Westchester County Medical Center, Valhalla, New York
ABSTRACT
Purpose: Conventional techniques result in chordee correction in the majority of patients. However, some with extensive chordee require further treatment to correct persistent extraordinary penile curvature. Our practice has been to treat this condition with interpositional dermal grafting. We review our experience with this procedure. Materials and Methods: During a 5-year period dermal grafts harvested from the nonhairbearing inguinal skin fold were placed in 51 patients with a mean age of 29 months. The primary diagnosis was penoscrotal or perineal hypospadias in 36 patients (hypospadias cripple in 41, the exstrophy-epispadias complex in 3, mid shaft or distal hypospadias with severe chordee in 10 and chordee without hypospadias in 2. A total of 49 patients (96%) underwent staged urethroplasty. Results: One graft was placed in 29 patients (57%),9 (18%)received 1 graft and underwent a Nesbit plication, (14%) received 2 grafts, 5 (10%) received 2 grafts and underwent dorsal plication, and 1 (2%) received 3 grafts. Second stage urethral reconstruction was done using a Thiersch-Duplay tube in the majority of cases. In 5 patients mild residual chordee was easily corrected a t the time of second stage repair. Conclusions: In a staged repair the first priority of the initial stage is to achieve a straight phallus. While our experience indicates that a single dermal graft is sufficient in approximately 57% of cases, when it does not result in complete straightening, we have had success with placing additional graft(s) and/or performing dorsal plication. We believe that the additional penile length achieved with dermal grafting results in a dependent phallus and cosmesis preferable to that of plication only. KEYWORDS:penis, hypospadias, abnormalities Penile curvature may develop as an isolated malformation, or in association with hypospadias or epispadias. Conventional techniques for correcting penile curvature involve the release of all tethering skin attachments followed by sharp resection of the fibrous chordee tissue. When residual curvature exists, the urethral plate is divided, the urethra is mobilized and any remaining fibrous tissue is excised sharply, resulting in the correction of penile curvature in the majority of patients. When curvature persists despite these conventional techniques, the cause most often appears to be a discrepancy in corporeal body dorsal-to-ventral length. The procedure that we use to correct this condition is determined by the remaining degree of curvature. In mild cases dorsal plication is performed with excellent success. However, when severe chordee of approximately 30 degrees or more persists, especially when the penis is short, we prefer to interpose a dermal graft, as previously reported.' We present our recent experience with this procedure. METHODS
Using computerized office records we identified all patients in whom dermal graft placement was performed in a 5-year period. We retrospectively reviewed their office charts and hospital records, including preoperative and postoperative visits, and operative reports. Included in this study were 51 patients 6 months to 14 years old (mean age 29 months) at graft placement on whom sufficient information was available. The primary diagnosis was penoscrotal or perineal hypospadias in 36 patients (hypospadias cripple in 4), the
exstrophy-epispadias complex in 3, mid shaft or distal hypospadias with severe chordee in 10 and chordee without hypospadias in 2. The penile shaft skin is first mobilized and all residual chordee tissue is sharply excised. The urethral plate is divided and the urethra is mobilized. As described by Gittes and McLaughlin,' an artificial erection is then initiated. If the remaining curvature is less than approximately 30 degrees, dorsal plication is performed, similar to that described by N e ~ b i t When .~ more severe chordee persists, the tourniquet is released and the penis is wrapped in a moist antibiotic soaked gauze pad while the dermal graft is harvested. The nonhair bearing inguinal skin fold is the site of graft harvest. The graft placement site is measured with calipers. The elliptical graft outlined with the skin marking pen is larger in anticipation of the possibility that a second graft may be needed. The whole epithelial surface of the graft site is then colored with ink. The skin is pulled taut and the epithelium is incised along the previous outline using a number 15 scalpel blade. The epithelium is elevated from the dermis via sharp dissection using several new scalpel blades as needed. The epithelial ink marking aids in identifying the proper depth of resection, so that all epithelium is removed. The dermis is incised along the periphery and removed from the underlying fat with dissecting scissors. The dermal graft is defatted and placed in Ringer's lactate solution until needed. The donor site is inspected for hemostasis, packed with a moist gauze pad and closed in 2 layers after penile reconstruction is completed. The artificial erection test is repeated, and a t the point of
1128
SINGLE AND MULTIPLE DERMAL GRAFTS FOR SEVERE PENILE CURVATURE
maximal curvature the tunica albuginea of the corpora cavernosa is incised from the 3 t o 9 o’clock positions, including incision into the septum. Care is taken to incise only the tunica and avoid the cavernous tissue. The dermal graft is trimmed t o the appropriate size and secured in place in 4 quadrants using 6-zero polyglycolic acid suture. We prefer to position the graft with the fatty side facing the corporeal tissue, although its orientation is probably insignificant. The graft is attached to the edge of the tunica albuginea using a running stitch in each of the 4 quadrants. The artificial erection is repeated and any leaks are controlled with additional interrupted 6-zero sutures. In most cases the initial graft, which is the site of maximal chordee, is placed at the mid shaft. When curvature persists, it is nearly always in the subcoronal area. If persistent curvature is minimal, we perform a dorsal Nesbit plication. If it is more significant, especially when the phallus is short, we place an additional graft in the subcoronal position in the described manner. Because the second graft is smaller, there is always sufficient dermis remaining from the initial donor site, making repeat graft harvest unnecessary. The dermal graft may bulge slightly during artificial erection but this is not significant. This bulging has not occurred when the artificial erection is repeated at second stage urethroplasty, and patients and parents have not complained beyond the immediate postoperative period. After all curvature has been corrected the penile shaft is resurfaced with skin coverage as described by Byars4 A feeding tube or Foley catheter and a bulky dressing to immobilize the penile shaft are placed and removed in 1 week. The patient receives 1 dose of perioperative antibiotics intravenously, and is then maintained on oral antibiotics until the catheter is removed. Early in the series some patients were hospitalized but nearly all recent procedures have been performed on an outpatient basis. Second stage urethroplasty repair is usually performed approximately 6 months later.
RESULTS
One graft was placed in 29 patients (57%),9 (18%)received 1 graft and underwent a Nesbit plication, (14%)received 2 grafts, 5 (10%)received 2 grafts and underwent dorsal plication, and 1 (2%) received 3 grafts. Mean graft length and width were 1.5 and 1.2 cm. (range 0.3 t o 3 and 0.2 to 31, respectively. Second stage urethral reconstruction was performed using a Thiersch-Duplay tube in 38 patients (74%). One patient underwent a Mustarde repair and in another a buccal mucosal free graft was placed. In 2 cases (4%)urethroplasty was performed at the time of dermal graft placement. Five patients (10%)await second stage repair. In 5 patients mild residual chordee noted at the time of second stage repair was corrected by simple resection in 4 and a unilateral plication stitch for lateral chordee in 1. In no case was residual chordee so severe as to preclude concomitant urethroplasty. The only other complication of dermal graft placement was an inclusion cyst in 1 patient, which resolved without surgical intervention. At 1 to 57 months of followup (mean 19) all patients have a straight phallus, as determined by repeat artificial erection at urethroplasty. In addition, a straight penis without obvious evidence of pain was reported in all patients in whom erection was observed by the parents or physician.
DISCUSSION
Incomplete correction of chordee may necessitate repeat surgery despite successful urethroplasty in patients with hypospadias or isolated chordee. Therefore, it is imperative to ensure complete penile straightening at primary repair.
1129
Penile curvature that persists aRer resection of all abnormal fibrotic chordee tissue and urethral mobilization is usually due to a discrepancy in the length of the tunica albuginea of the corpora cavernosa. Nesbit successfully corrected this condition by placing plicating stitches on the side contralateral to the site of maximal ~ u r v a t u r e .However, ~ when penile length is already marginal, shortening may lead to suboptimal cosmesis, such as a short, squat “tuna can” penis. Thus, we and others find it preferable to lengthen the short side rather than shorten the long side.’*”* Although numerous autologous and prosthetic materials have been used to accomplish this, dermal grafts have gained the most support. The use of dermal grafts for penile reconstruction is not new. Based on experimental work in dogs Devine and Horton selected dermis as the material of choice, and in 1974 they first reported its use to correct penile curvature in patients with Peyronie’s d i ~ e a s eThey . ~ later used a dermal graft to correct secondary chordee in a patient who had undergone more than 10 operations for congenital ~ h o r d e e . ~ We previously reported our initial experience with interposition dermal grafting for severe chordee with or without hypospadias in 15 patients.’ Nine of these cases involved primary procedures, and in 6 there were extensive residual scarring and recurrent chordee after previous attempts at repair. In 14 patients complete correction of chordee was achieved with 1 graft. However, in 1 patient reoperation was required to correct residual chordee and a second dermal graft was placed intraoperatively,’ which prompted us to consider the use of multiple grafts at the initial operation. Others have reported their experience with dermal graft placement for managing severe chordee that is not corrected by conventional methods.6-8 Details of the procedure vary slightly among surgeons, although all have observed the successful correction of chordee with 1 graft. As our series illustrates, 1 dermal graft is not always sufficient to correct all curvature. This finding emphasizes the importance and usefulness of repeating artificial erection throughout the procedure, particularly after graft placement. Although to our knowledge only Hendren and Keating have previously reported a case that required more than 1 graft: our experience illustrates that only 57% of cases are corrected with 1 dermal graft. Since persistent chordee is the indication for reoperation in a number of patients referred after an initial attempt a t repair, we strongly believe that it is important that all curvature is corrected at the initial procedure. Because maximal curvature generally exists in the mid shaft region, the mid shaft is nearly always the site of the initial graft. According to our experience residual curvature is usually in the subcoronal position. The decision to perform dorsal plication versus placement of a second dermal graft is determined by residual chordee severity and phallic length. We have found that the final result is cosmetically preferable when dorsal shortening of an already short penis is avoided. Thus, we place a second dermal graft in these cases. When lateral curvature is also present, usually as a result of a discrepancy in the length of the corporeal bodies on the left versus right side, we place a unilateral plication stitch or asymmetric bilateral dorsal plication stitches to correct this curvature with or without the placement of a second graft. We and others prefer penile straightening with a free graft as a staged procedure.’.8*lo Plastic surgical principles against placing 2 free grafts in apposition guide our choice of this approach. Although Hendren and Keating: and Horton et a17 reported success with dermal graft placement and pedicle flap or free graft urethroplasty at the same sitting, we still prefer to correct this severe defect in 2 stages. While erectile dysfunction has been reported after dermal graft placement in patients with Peyronie’s disease:, erec-
’’
1130
SINGLE AND MULTIPLE DERMAL GRAFTS FOR SEVERE PENILE CURVATURE
tile dysfunction has not developed in any of our patients. Venous leakage has been described as the usual etiology of impotence aRer the surgical treatment of Peyronie’s disease,” which may sometimes necessitate the excision of large plaques. In contrast to this practice in Peyronie’s disease, we incise rather than resect the tunica albuginea, which may possibly explain the contrasting results. Our patients are also obviously much younger than those treated for Peyronie’s disease and, thus, they do not have the underlying preoperative erectile dysfunction that may be present in older patients. CONCLUSIONS
In staged repair the initial priority of stage 1is to achieve a straight phallus. Our experience is that 1 dermal graft is sufficient in 57% of cases. However, when this does not result in complete straightening, we have had success with the placement of additional graft(s) with or without dorsal plication. Whereas a Nesbit plication relies completely on shortening 1side of the discrepant corporeal bodies to accomplish straightening, placing a dermal graft provides additional length. As evidenced by the width of the grafts in our series, this difference may be up to 3 cm. after the urethral plate is transected. We believe that the additional length achieved with dermal grafting results in a dependent phallus that is cosmetically preferable to the “tuna can” type, particularly in epispadias repair.
REFERENCES
1. Kogan, S.J., Reda, E. F., Smey, P. L. and Levitt, S. B.: Dermal graft correction of extraordinq chordee. J . Urol., 130:952,1983. 2. Gittes, R. F. and McLaughlin, A. P., 111.: Injection technique to induce penile erection. Urology, 4 473, 1974. 3. Nesbit, R. M.: Congenital curvature of the phallus: report of three cases with description of corrective operation. J. Urol., 93 230, 1965. 4. Byars, L. T.: Technique for consistently satisfactory repair of hypospadias. Surg., Gynec. & Obst., 100:184,1955. 5. Devine, C. J., Jr. and Horton, C. E.: Use of dermal graft to correct chordee. J. Urol., 113 56, 1975. 6. Hendren, W.H. and Keating, M. A.: Use of dermal graft and free urethral graft in penile reconstruction. J. Urol., part 2, 140 1265,1988. 7. Horton, C. E., Jr., Gearhart, J . P. and Jeffs, R. D.: Dermal grafts for correction of severe chordee associated with hypospadias. J. Urol., 150 452,1993. 8. Pope, J . C., IV,Kropp, B. P., McLaughlin, K. P., Adams, M. C., Rink, R. C., Keating, M. A. and Brock, J . W., 111.: Penile orthoplasty using dermal graRs in the outpatient setting. Urology, 48: 124,1996. 9. Devine, C. J., Jr. and Horton, C. E.: Surgical treatment of Peyronie’s disease with a dermal graft. J . Urol., 111: 44,1974. 10. Ehrlich, R. M., Reda, E. F., Koyle, M. A., Kogan, S. J . and Levitt, S. B.: Complications of bladder mucosa graft. J . Urol., 142: 626,1989. 11. Dalkin, B. L. and Carter, M. F.: Venogenic impotence following dermal graft repair for Peyronie’s disease. J. Urol., 146 849, 1991.