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A NEW APPROACH TO THE TREATMENT OF PENILE CURVATURE
0022-5347/98/1603-1123$03.00/0
THEJOURRNAL OF UROI.OGY
Vol. 160, 1123-1127, September 1998 Printed in U.SA.
Copyright 0 1998 by AMERICAN UROLOGICAL ASSOCIATION,INC.
A NEW APPROACH TO THE TREATMENT OF PENILE CURVATURE SAVA V. PEROVIC, MIROSLAV L. J. DJORDJEVIC
AND
NENAD G. DJAKOVIC
From the Depurtment of Urology. UnIwrsity Children's Hospital, Belgrude, Yiigoslnvia
ABS'I'KACT
Purpose: Techniques for penile straightening generate t h e serious dilemma of which is most appropriate. We created and describe our penile disassembly technique to avoid penile shortening i n curvature repair. Materials and Methods: From November 1995 to March 1997 we performed our penile disassembly technique i n 87 patients 12 months to 47 years old (mean age 4.5 years). Indications for surgery were isolated penile curvature and chordee with or without hypospadias, curvature of t h e distal third of t h e corpora cavernosa and a small penis with curvature. Our method consists of separation of t h e penis into its entities, a glans cap with its neurovascular bundle dorsally, a nondivided or divided urethra, or urethral plate ventrally and corpora cavernosa that may be partially separated in t h e septa1 region. This maneuver achieves excellent correction of penile curvature. In addition, during this procedure a space is created between the glans cap and t h e tips of t h e corpora cavernosa into which various tissues may be inserted to avoid penile shortening due to corporoplasty or even to lengthen t h e penis. Results: Mean followup was 16 months (range 6 months to 2 years). There were no injuries to t h e neurovascular bundle or urethra. Complications developed only i n relation to onlay or tubularized urethroplasty i n 4 patients. Conclusions: Our penile disassembly technique seems to be the most effective procedure in select cases of severe curvature of the distal penile shaft, marked glans tilt and a small penis with curvature. In addition, the procedure provides the possibility of penile lengthening. KEYWORDS:penis, abnormalities, chordee, surgical technique Penile curvature represents a challenge t o classification technique, to avoid penile shortening in curvature repair and particularly t o correction. There are several classifica- without disturbing penile structure. tions of penile curvature, of which the most widely used is that of Devine et a1.l.' Our classification of congenital penile curvature is based on etiology and involves isolated penile curMATERIALS AND METHODS vature, and chordee with or without hypospadias. Isolated congenital penile curvature is a rare condition characterized From November 1995 to March 1997, 354 patients underby a normal penile appearance without hypospadiac features went curvature repair, including 87 who were 12 months to that may be ventral, dorsal and/or lateral (corkscrew). It is 47 years old (mean age 4.5 years) and candidates for the caused mainly by disproportional growth of the corpora cav- penile disassembly technique. In this study 62 patients were ernosa. However, in chordee with hypospadias the penis has prepubertal (age 12 months to 11years), 17 were adolescents hypospadiac features, and penile curvature is always ventral and 8 were adults. Indications for surgery were severe curand caused by several abnormalities. In chordee without vature with angulation greater than 60 degrees in 69 pahypospadias the urethral meatus is positioned normally in tients, marked glans tilt in ll and a small penis with curvathe glans and the penis is curved ventrally. Depending on the ture in 7. Preoperatively severity of curvature was evaluated specific tissue involved the condition may be cutaneous or during a pharmacological erection induced by prostaglandin fibrous chordee, a congenital short urethra and/or corporeal E l . disproportion. In chordee with hypospadias the causes are The technique, which is based on the surgical anatomy of the same but, instead of a congenital short urethra, the the penis, consists of separation of the penis into its compoproblem is a short urethral plate. Some cases in each group nent parts, including the glans cap with its neurovascular involve an association of fibrous chordee, corporal dispropor- bundle dorsally, the urethra ventrally and the corpora cavtion, congenital short urethra and short urethral plate. In se- ernosa. In chordee with or without hypospadias the short vere forms of chordee with or without hypospadias penile cur- urethra or short urethral plate is divided. Surgery is pervature is present in the majority of cases. We found penile formed during a permanent erection induced by prostaglancurvature in 20% of patients with mild forms of chordee with or din El,' enabling easier dissection of the penile entities and without hypospadias via a natural erection induced by prosta- precise correction of curvature by continuous evaluation beglandin E l . The repair of severe curvature is imperative, and fore, during and after repair. the search for new and better solutions remains ~hallenging.".~ Penile disassembly begins with dissection of the urethra Most existing techniques provide satisfactory curvature with its spongiosal tissue. The urethra is dissected from the correction but they mainly result in some degree of penile corporeal bodies starting laterally in the healthy area of shortening. Penile straightening by lengthening the shorter Bucks fascia1 layer. Proximally the urethra with its bulbous side and grafting with various autologous tissues avoids pe- portion is lifted with Bucks fascia. Since the distal urethra is nile ~ h o r t e n i n g . ~However, -~ these procedures disturb the wide, thin and adherent to the cavernous bodies, its dissecstructure of the corporeal bodies with subsequent conse- tion is performed laterally and as close as possible to the quences. We developed a procedure, the penile disassembly cavernous bodies. Dissection is continued close to the tunica 1123
1124
NEW APPROACH TO TREATMENT OF PENILE CURVATURE
albuginea over the tips of the corpora cavernosa toward the dorsum of the penis, beneath the neurovascular bundle and Buck's fascia. During glans dissection special attention should be directed medially from the septum of the corpora cavernosa and laterally from the neurovascular bundle. Caution should be used to avoid injury to the arteries that run lateral-ventral. For chordee with hypospadias the urethral plate is lifted with its vascularized fibrous tissue to ensure better blood supply to the plate. Further distal dissection includes preservation of the 2 vascular and fibrous pillars that are inserted into the undersurface of the glans. At the end of penile disassembly partial ventral separation of the corpora in septal area is performed. These maneuvers provide the maximal potential for correcting curvature, especially when it is in the distal third of the corpora cavernosa. Penile disassembly straightens the penis in most cases. If curvature remains, its degree of severity is significantly decreased. Curvature is then corrected by the least invasive type of corporoplasty. Using a special type of corporoplasty we neither completely incise, excise nor leave alone the tunica albuginea. The numerous net-like incisions are made without penetrating the tunica albuginea, creating a wound surface. Simple plication of the wounded
tunica albuginea follows. Incisional corporoplasty was performed (longitudinal corporotomy with a transverse closure) in some adults with a large penis (figs. 1to 4). Urethral reconstruction depends on the severity of hypospadias. If sufficient urethral length is achieved by extensive urethral mobilization, the hypospadiac meatus is brought up to the top of the glans, avoiding substitution urethroplasty (figs. 5 and 6). It is extremely important to perform this procedure while the penis is erect. The flaccid state may lead to underestimation of the necessary urethral length. In other cases extensive urethral mobilization may be done in conjunction with substitution techniques to decrease the size and extent of the additional flap. An onlay island flap procedure is performed when the lifted urethral plate is not divided. If the lifted urethral plate is short and causes the curvature, it must be divided. A tube is then created between 2 onlays or tubularized urethroplasty is done. In chordee without hypospadias and with a short urethra tubularized urethroplasty is performed to bridge the gap between the divided urethral parts. We harvest a skin flap with excessively abundant mesentery, so that the newly formed urethra is longer than the corporeal bodies. This excessive distal part of the urethra is inserted into the space between the glans cap and the tips of the corpora cavernosa. This procedure results in penile augmentation and penile lengthening, which is useful for small penises with hypospadias and chordee, or penile length loss after dorsal corporoplasty. The glans cap is fixed by a U-shaped suture to the tips of the
FIG.2. Chordee without hypospadias or congenital short urethra. a and b, aRer penile disassembl degree of angulation seventy is markedly decreased. c. additionafdorsal rornnmnlnstv hv tmnqvpr~.~ . . .r _ _ _ r _----I. -sal corp6rotomy with longitudinal closure. d, additional dorsal corporoplasty by simpleplicationof wounded tunica albuginea, consisting of numerous net- ike inclslons made without penetrating tunica albuginea. e, short urethral plate is divided and created gap is bridged by tubularized urethroplasty. ~~
FIG. 1. Simple glans tilt. a and b . penile straightening is achieved
by penile disassembly, and glans cap is fixed by U-shaped suture to tips of corpora cavernosa in normal position. c, mobilized urethra is fixed to corporeal bodies.
__I_
_ J
NEW APPROACH TO TREATMENT OF PENILE CURVATURE
FIG. 3. Chordee without hypospadias in adolescent.A, with penis erect marked SO-degree penile bending is noticeable. B , penis is disassembledand partial ventral separation of corpora in septal Brea is performed. C , after penile disassembly degree of curvature is markedly decreasedto 20 degrees.0,curvatureis corrected by minor dorsal corporoplasty and penile entities are reassembled.
corpora cavernosa. Surgery is completed by penile shaft reconstruction done in various ways depending on the remaining available penile skin. RESULTS
Mean followup was 16 months (range 6 months to 2 years). Penile straightening was achieved in all cases without recurring curvature. Penile disassembly was sufficient to straighten the penis in 59 patients (68%),while in 28 (32%) the degree of curvature was significantly decreased. Severe 80-degree angulation was decreased to a mild 20 degrees by minor dorsal corporoplasty without shortening the penis. Penile enlargement was noticeable but the degree of augmentation in girth and length was not determined, since most patients were children, and precise measurements were not made before and after surgery. Complications developed only in relation to urethroplasty in 4 patients, including urethral stenosis in 3 and a fistula in 1.There were no injuries to the neurovascular bundle and no erectile dysfunction, as confirmed by a questionnaire, penile biothesiometry and intracavernous injection of prostaglandin E l . In young children this was confirmed by biothesiometry and parent interview. DISCUSSION
The management of penile curvature remains a challenge. Standard repairs, such as plication and grafting techniques,
1125
FIG.4. At end of surgery penis is straightened without being shortened.
are available but none provides an ideal solution. The basic approaches to tunical plication are elliptic excision and closure of the tunica albuginea, incisions and closure of the tunica albuginea, and plication by suture only. These techniques provide satisfactory repair in cases of moderate curvature. Slight shortening of the penis is a direct result of these procedures, and it is well tolerated. However, shortening may be a problem in severe curvature, particularly when the penis is small. In simple plication excessive infolding of the tunica may result in narrowing of the corporeal lumina, which may lead to decreased rigidity distally. In some cases the stitches do not hold long enough, resulting in recurrent curvature. In incisional techniques the edges of the incision heal tightly after closure and remain permanently closed. In these cases tunica tissue may also be folded inward but to a lesser degree. In severe curvature this method may result in decreased cavernous volume. In elliptic excision techniques the tunica does not infold. If excessive excision of the tunica albuginea is needed, the decrease in cavernous volume may be significant and tunical elasticity may also be decrea~ed.~ Different graft materials may be used to replace the ventral defect of the tunica albuginea, and achieve a straight penis while avoiding penile ~hortening.~~.’* lo The various tissues used include dermis, tunica vaginalis, temporalis fascia and vein. Dermal grafting has proved to be good but it is characterized by contraction. Some prefer to use vaginal tunica, especially in children, although in our experience it contracts and aneurysms may develop. Vein and fascia are promising materials but to our knowledge long-term results are not yet available. Generally these gr&s may successfully be used for replacing small ventral defects of the tunica albuginea. Otherwise extensive grafting disturbs the struc-
1126
NEW APPROACH TO TREATMENT OF PENILE CURVATURE
a
FIG. 6. Chordee with hypospadias. A, curvature is in distal third of penis. B, penile straighteningis achieved with penile disassembly,
and extensive urethral mobilization avoids substitution urethroplasty.
c
d
FIG.5. Chordee with hypospadias. a and b, penile straighteningis achieved by penile disassembly, and sufficient urethral length is obtained by extensive mobilization.Inset, bulbar urethra is dissected via same approach. c, distal portion of hypospadiac urethra and urethral plate remain attached to glans to ensure better blood suply, and urethral plate is de-epithelialized.d , hypospadiac meatus is rought up to top of glans, avoiding substitution urethroplasty, and mobilized urethra is fixed to corporeal bodies.
i
ture of the corporeal bodies with subsequent consequences. Ventral grafting may be the source of secondary penile deformities, especially during penile growth. Our aim was to develop a technique to avoid penile shortening in curvature repair without disturbing penile structure. Continued familiarity with penile disassembly technique in epispadias repair" generated the idea of using the same principle in hypospadias and curvature repair. Penile disassembly in epispadias may be easily performed, since the anomaly is characterized by partial separation of the corpora cavernosa, epispadiac urethral plate and 2 separated neurovascular bundles. In isolated curvatures and curvature with or without hypospadias the penile anatomy is the opposite, that is the penile entities are tightly joined to each other. In these cases disassembling the penis into the glans cap with its neurovascular bundle dorsally, the divided or nondivided urethra, or urethral plate ventrally and the corpora cavernosa is successful. To perform this procedure the surgeon must have excellent knowledge of penile surgical anatomy as well as experience and skill in penile reconstructive surgery. Several maneuvers are crucial for successfully disassembling the penis. Dissection begins from the ventral side of the
penis over the tips of the corpora cavernosa toward the dorsal side. This step enables complete preservation of the neurovascular bundle, which cannot be achieved by starting dissection from the dorsal side of the penis. Buck's fascia is released from the underlying albuginea t o lift the urethra, urethral plate and neurovascular bundle without injury. The next crucial step is separation of the distal portion of the urethra or the urethral plate in chordee with hypospadias and glans lifting. The glans cap and the tips of the corpora cavernosa are in close contact in this region. Therefore, dissection must be meticulous and performed as close to the albuginea as possible. During this dissection the albuginea may be injured but this does not compromise the technique or its outcome. Keep in mind the course of the neurovascular bundle near the glans to avoid its injury. To prevent glans ischemia it is important to preserve both penile arteries that run lateral-ventral before entering the glans. Surgery is performed without a tourniquet, which also prevents glans ischemia. The benefits of this technique are numerous. It enables excellent repair of the most severe curvature. The technique successfully straightened the penis in 59 cases (68%)and in another 28 cases (32%),the degree of severity of penile angulation was decreased enough so that only minor corporoplasty was needed to straighten the penis completely. In these cases standard techniques would have shortened the penis and disturbed the structure of the cavernous bodies. The advantage of the penile disassembly technique is obvious. It is essential to lift the glans cap from the tips of the corpora cavernosa to repair curvature in the distal third of the corpora cavernosa. The surgical approach for correcting this curvature is only possible after the glans is completely lifted. It also enables excellent correction of glans tilt, which is not possible with other techniques. The penile disassembly technique avoids penile shortening, contrary to other existing techniques for curvature repair, which is extremely important for small penises with curvature. Penile disassembly even provides the possibility of penile enlargement. A space is created between the glans cap and the tips of the corpora cavernosa in which different tissues may be interposed. For curvature with hypospadias that tissue comprises a new urethra with abundant vascularized subcutaneous tissue. For isolated curvatures rib cartilage may be used for penile lengthening. Our experience with it has been satisfactory." The benefit to urethroplasty is obvious. When suficient urethral length is achieved by extensive urethral mobilization, the hypospadiac meatus is brought up to the top of the glans, avoiding substitution urethroplasty. In others cases exten-
NEW APPROACH TO TREATMENT OF PENILE CURVATURE
sive urethral mobilization decreases the distance between the hypospadiac meatus and top of the glans, that is the urethral defect. Our brief followup may raise some concern regarding the long-term outcome of the penile disassembly technique. However, in 24 of the 87 patients followed for more than 20 months postoperatively the results of curvature repair were good. Seven of the 87 patients are noteworthy, since they underwent surgery before and were followed during puberty, enabling documentation of genital growth. Neither recurrent curvature nor penile growth disturbance was noted during puberty, which is possible only when vascularization and integrity of all penile entities are preserved, which is an advantage of the penile disassembly technique. Therefore, we believe that in the long term there will be no recurrence of curvature and no penile deformities. In conclusion, the penile disassembly technique seems to be the most effective procedure in select cases of the most severe curvature at the distal penile shaft, marked glans tilt and a small penis with c w a ture. This technique provides the possibility of penile lengthening. REFERENCES
1. Devine, C. J. and Horton, C. E.: Chordee without hypospadias. J . Urol., 1 1 0 264, 1973. 2. Devine, C. J., Jr., Blackley, S. K., Horton, C. E. and Gilbert,
1127
D. A.: The surgical treatment of chordee without hypospadias in post adolescent man. J . Urol., 146:325, 1991. 3. Baskin, L. S.: Part I. Controversies in hypospadias surgery: penile curvature. Dial. Ped. Urol., 19 1, 1996. 4. Perovic, S.:Hypospadias sine hypospadias. World J. Urol., 1 0 85,1992. 5. 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. 6. Perlmutter, A. D., Montgomery, B. T. and Steinhardt, G. F.: Tunica vaginalis free graft for the correction of chordee. J. Urol., 134:311, 1985. 7. Brock, G., Nunes, L., von Heyden, B., Martinez-Pineiro, L., Hsu, G. L. and Lue, T. F.: Can a venous patch graft be a substitute for the tunica albuginea ofthe penis? J. Urol., 150 1306,1993. 8. Perovic. S.,Djordjevic, M. and Djakovic, N.: Natural erection induced by prostaglandin-El in the diagnosis and treatment of congenital penile anomalies. Brit. J. Urol., 79 43, 1997. 9. Baskin, L. S.,Duckett, J . W. and Lue, T. F.: Penile curvature. Urology, 48.347, 1996. 10. Rehman,J., Benet, A,, Minsky, L. S. and Melman, A.: Results of surgical treatment for abnormal penile curvature: Peyronie’s disease and congenital deviation by modified Nesbit plication (tunical shaving and plication). J . Urol., 157: 1288,1997. 11. Mitchell, M. E. and Bagli, D. J.: Complete penile disassembly for epispadias repair: Mitchell technique. J. Urol., 155:300,1996. 12. Perovic, S.,Djordjevic, M. and Djakovic, N.: Real penile enlargement. Brit. J . Urol., suppl. 2,80 308,abstract 1208,1997.
THEJOURRNAL OF UROI.OGY
Vol. 160, 1123-1127, September 1998 Printed in U.SA.
Copyright 0 1998 by AMERICAN UROLOGICAL ASSOCIATION,INC.
A NEW APPROACH TO THE TREATMENT OF PENILE CURVATURE SAVA V. PEROVIC, MIROSLAV L. J. DJORDJEVIC
AND
NENAD G. DJAKOVIC
From the Depurtment of Urology. UnIwrsity Children's Hospital, Belgrude, Yiigoslnvia
ABS'I'KACT
Purpose: Techniques for penile straightening generate t h e serious dilemma of which is most appropriate. We created and describe our penile disassembly technique to avoid penile shortening i n curvature repair. Materials and Methods: From November 1995 to March 1997 we performed our penile disassembly technique i n 87 patients 12 months to 47 years old (mean age 4.5 years). Indications for surgery were isolated penile curvature and chordee with or without hypospadias, curvature of t h e distal third of t h e corpora cavernosa and a small penis with curvature. Our method consists of separation of t h e penis into its entities, a glans cap with its neurovascular bundle dorsally, a nondivided or divided urethra, or urethral plate ventrally and corpora cavernosa that may be partially separated in t h e septa1 region. This maneuver achieves excellent correction of penile curvature. In addition, during this procedure a space is created between the glans cap and t h e tips of t h e corpora cavernosa into which various tissues may be inserted to avoid penile shortening due to corporoplasty or even to lengthen t h e penis. Results: Mean followup was 16 months (range 6 months to 2 years). There were no injuries to t h e neurovascular bundle or urethra. Complications developed only i n relation to onlay or tubularized urethroplasty i n 4 patients. Conclusions: Our penile disassembly technique seems to be the most effective procedure in select cases of severe curvature of the distal penile shaft, marked glans tilt and a small penis with curvature. In addition, the procedure provides the possibility of penile lengthening. KEYWORDS:penis, abnormalities, chordee, surgical technique Penile curvature represents a challenge t o classification technique, to avoid penile shortening in curvature repair and particularly t o correction. There are several classifica- without disturbing penile structure. tions of penile curvature, of which the most widely used is that of Devine et a1.l.' Our classification of congenital penile curvature is based on etiology and involves isolated penile curMATERIALS AND METHODS vature, and chordee with or without hypospadias. Isolated congenital penile curvature is a rare condition characterized From November 1995 to March 1997, 354 patients underby a normal penile appearance without hypospadiac features went curvature repair, including 87 who were 12 months to that may be ventral, dorsal and/or lateral (corkscrew). It is 47 years old (mean age 4.5 years) and candidates for the caused mainly by disproportional growth of the corpora cav- penile disassembly technique. In this study 62 patients were ernosa. However, in chordee with hypospadias the penis has prepubertal (age 12 months to 11years), 17 were adolescents hypospadiac features, and penile curvature is always ventral and 8 were adults. Indications for surgery were severe curand caused by several abnormalities. In chordee without vature with angulation greater than 60 degrees in 69 pahypospadias the urethral meatus is positioned normally in tients, marked glans tilt in ll and a small penis with curvathe glans and the penis is curved ventrally. Depending on the ture in 7. Preoperatively severity of curvature was evaluated specific tissue involved the condition may be cutaneous or during a pharmacological erection induced by prostaglandin fibrous chordee, a congenital short urethra and/or corporeal E l . disproportion. In chordee with hypospadias the causes are The technique, which is based on the surgical anatomy of the same but, instead of a congenital short urethra, the the penis, consists of separation of the penis into its compoproblem is a short urethral plate. Some cases in each group nent parts, including the glans cap with its neurovascular involve an association of fibrous chordee, corporal dispropor- bundle dorsally, the urethra ventrally and the corpora cavtion, congenital short urethra and short urethral plate. In se- ernosa. In chordee with or without hypospadias the short vere forms of chordee with or without hypospadias penile cur- urethra or short urethral plate is divided. Surgery is pervature is present in the majority of cases. We found penile formed during a permanent erection induced by prostaglancurvature in 20% of patients with mild forms of chordee with or din El,' enabling easier dissection of the penile entities and without hypospadias via a natural erection induced by prosta- precise correction of curvature by continuous evaluation beglandin E l . The repair of severe curvature is imperative, and fore, during and after repair. the search for new and better solutions remains ~hallenging.".~ Penile disassembly begins with dissection of the urethra Most existing techniques provide satisfactory curvature with its spongiosal tissue. The urethra is dissected from the correction but they mainly result in some degree of penile corporeal bodies starting laterally in the healthy area of shortening. Penile straightening by lengthening the shorter Bucks fascia1 layer. Proximally the urethra with its bulbous side and grafting with various autologous tissues avoids pe- portion is lifted with Bucks fascia. Since the distal urethra is nile ~ h o r t e n i n g . ~However, -~ these procedures disturb the wide, thin and adherent to the cavernous bodies, its dissecstructure of the corporeal bodies with subsequent conse- tion is performed laterally and as close as possible to the quences. We developed a procedure, the penile disassembly cavernous bodies. Dissection is continued close to the tunica 1123
1124
NEW APPROACH TO TREATMENT OF PENILE CURVATURE
albuginea over the tips of the corpora cavernosa toward the dorsum of the penis, beneath the neurovascular bundle and Buck's fascia. During glans dissection special attention should be directed medially from the septum of the corpora cavernosa and laterally from the neurovascular bundle. Caution should be used to avoid injury to the arteries that run lateral-ventral. For chordee with hypospadias the urethral plate is lifted with its vascularized fibrous tissue to ensure better blood supply to the plate. Further distal dissection includes preservation of the 2 vascular and fibrous pillars that are inserted into the undersurface of the glans. At the end of penile disassembly partial ventral separation of the corpora in septal area is performed. These maneuvers provide the maximal potential for correcting curvature, especially when it is in the distal third of the corpora cavernosa. Penile disassembly straightens the penis in most cases. If curvature remains, its degree of severity is significantly decreased. Curvature is then corrected by the least invasive type of corporoplasty. Using a special type of corporoplasty we neither completely incise, excise nor leave alone the tunica albuginea. The numerous net-like incisions are made without penetrating the tunica albuginea, creating a wound surface. Simple plication of the wounded
tunica albuginea follows. Incisional corporoplasty was performed (longitudinal corporotomy with a transverse closure) in some adults with a large penis (figs. 1to 4). Urethral reconstruction depends on the severity of hypospadias. If sufficient urethral length is achieved by extensive urethral mobilization, the hypospadiac meatus is brought up to the top of the glans, avoiding substitution urethroplasty (figs. 5 and 6). It is extremely important to perform this procedure while the penis is erect. The flaccid state may lead to underestimation of the necessary urethral length. In other cases extensive urethral mobilization may be done in conjunction with substitution techniques to decrease the size and extent of the additional flap. An onlay island flap procedure is performed when the lifted urethral plate is not divided. If the lifted urethral plate is short and causes the curvature, it must be divided. A tube is then created between 2 onlays or tubularized urethroplasty is done. In chordee without hypospadias and with a short urethra tubularized urethroplasty is performed to bridge the gap between the divided urethral parts. We harvest a skin flap with excessively abundant mesentery, so that the newly formed urethra is longer than the corporeal bodies. This excessive distal part of the urethra is inserted into the space between the glans cap and the tips of the corpora cavernosa. This procedure results in penile augmentation and penile lengthening, which is useful for small penises with hypospadias and chordee, or penile length loss after dorsal corporoplasty. The glans cap is fixed by a U-shaped suture to the tips of the
FIG.2. Chordee without hypospadias or congenital short urethra. a and b, aRer penile disassembl degree of angulation seventy is markedly decreased. c. additionafdorsal rornnmnlnstv hv tmnqvpr~.~ . . .r _ _ _ r _----I. -sal corp6rotomy with longitudinal closure. d, additional dorsal corporoplasty by simpleplicationof wounded tunica albuginea, consisting of numerous net- ike inclslons made without penetrating tunica albuginea. e, short urethral plate is divided and created gap is bridged by tubularized urethroplasty. ~~
FIG. 1. Simple glans tilt. a and b . penile straightening is achieved
by penile disassembly, and glans cap is fixed by U-shaped suture to tips of corpora cavernosa in normal position. c, mobilized urethra is fixed to corporeal bodies.
__I_
_ J
NEW APPROACH TO TREATMENT OF PENILE CURVATURE
FIG. 3. Chordee without hypospadias in adolescent.A, with penis erect marked SO-degree penile bending is noticeable. B , penis is disassembledand partial ventral separation of corpora in septal Brea is performed. C , after penile disassembly degree of curvature is markedly decreasedto 20 degrees.0,curvatureis corrected by minor dorsal corporoplasty and penile entities are reassembled.
corpora cavernosa. Surgery is completed by penile shaft reconstruction done in various ways depending on the remaining available penile skin. RESULTS
Mean followup was 16 months (range 6 months to 2 years). Penile straightening was achieved in all cases without recurring curvature. Penile disassembly was sufficient to straighten the penis in 59 patients (68%),while in 28 (32%) the degree of curvature was significantly decreased. Severe 80-degree angulation was decreased to a mild 20 degrees by minor dorsal corporoplasty without shortening the penis. Penile enlargement was noticeable but the degree of augmentation in girth and length was not determined, since most patients were children, and precise measurements were not made before and after surgery. Complications developed only in relation to urethroplasty in 4 patients, including urethral stenosis in 3 and a fistula in 1.There were no injuries to the neurovascular bundle and no erectile dysfunction, as confirmed by a questionnaire, penile biothesiometry and intracavernous injection of prostaglandin E l . In young children this was confirmed by biothesiometry and parent interview. DISCUSSION
The management of penile curvature remains a challenge. Standard repairs, such as plication and grafting techniques,
1125
FIG.4. At end of surgery penis is straightened without being shortened.
are available but none provides an ideal solution. The basic approaches to tunical plication are elliptic excision and closure of the tunica albuginea, incisions and closure of the tunica albuginea, and plication by suture only. These techniques provide satisfactory repair in cases of moderate curvature. Slight shortening of the penis is a direct result of these procedures, and it is well tolerated. However, shortening may be a problem in severe curvature, particularly when the penis is small. In simple plication excessive infolding of the tunica may result in narrowing of the corporeal lumina, which may lead to decreased rigidity distally. In some cases the stitches do not hold long enough, resulting in recurrent curvature. In incisional techniques the edges of the incision heal tightly after closure and remain permanently closed. In these cases tunica tissue may also be folded inward but to a lesser degree. In severe curvature this method may result in decreased cavernous volume. In elliptic excision techniques the tunica does not infold. If excessive excision of the tunica albuginea is needed, the decrease in cavernous volume may be significant and tunical elasticity may also be decrea~ed.~ Different graft materials may be used to replace the ventral defect of the tunica albuginea, and achieve a straight penis while avoiding penile ~hortening.~~.’* lo The various tissues used include dermis, tunica vaginalis, temporalis fascia and vein. Dermal grafting has proved to be good but it is characterized by contraction. Some prefer to use vaginal tunica, especially in children, although in our experience it contracts and aneurysms may develop. Vein and fascia are promising materials but to our knowledge long-term results are not yet available. Generally these gr&s may successfully be used for replacing small ventral defects of the tunica albuginea. Otherwise extensive grafting disturbs the struc-
1126
NEW APPROACH TO TREATMENT OF PENILE CURVATURE
a
FIG. 6. Chordee with hypospadias. A, curvature is in distal third of penis. B, penile straighteningis achieved with penile disassembly,
and extensive urethral mobilization avoids substitution urethroplasty.
c
d
FIG.5. Chordee with hypospadias. a and b, penile straighteningis achieved by penile disassembly, and sufficient urethral length is obtained by extensive mobilization.Inset, bulbar urethra is dissected via same approach. c, distal portion of hypospadiac urethra and urethral plate remain attached to glans to ensure better blood suply, and urethral plate is de-epithelialized.d , hypospadiac meatus is rought up to top of glans, avoiding substitution urethroplasty, and mobilized urethra is fixed to corporeal bodies.
i
ture of the corporeal bodies with subsequent consequences. Ventral grafting may be the source of secondary penile deformities, especially during penile growth. Our aim was to develop a technique to avoid penile shortening in curvature repair without disturbing penile structure. Continued familiarity with penile disassembly technique in epispadias repair" generated the idea of using the same principle in hypospadias and curvature repair. Penile disassembly in epispadias may be easily performed, since the anomaly is characterized by partial separation of the corpora cavernosa, epispadiac urethral plate and 2 separated neurovascular bundles. In isolated curvatures and curvature with or without hypospadias the penile anatomy is the opposite, that is the penile entities are tightly joined to each other. In these cases disassembling the penis into the glans cap with its neurovascular bundle dorsally, the divided or nondivided urethra, or urethral plate ventrally and the corpora cavernosa is successful. To perform this procedure the surgeon must have excellent knowledge of penile surgical anatomy as well as experience and skill in penile reconstructive surgery. Several maneuvers are crucial for successfully disassembling the penis. Dissection begins from the ventral side of the
penis over the tips of the corpora cavernosa toward the dorsal side. This step enables complete preservation of the neurovascular bundle, which cannot be achieved by starting dissection from the dorsal side of the penis. Buck's fascia is released from the underlying albuginea t o lift the urethra, urethral plate and neurovascular bundle without injury. The next crucial step is separation of the distal portion of the urethra or the urethral plate in chordee with hypospadias and glans lifting. The glans cap and the tips of the corpora cavernosa are in close contact in this region. Therefore, dissection must be meticulous and performed as close to the albuginea as possible. During this dissection the albuginea may be injured but this does not compromise the technique or its outcome. Keep in mind the course of the neurovascular bundle near the glans to avoid its injury. To prevent glans ischemia it is important to preserve both penile arteries that run lateral-ventral before entering the glans. Surgery is performed without a tourniquet, which also prevents glans ischemia. The benefits of this technique are numerous. It enables excellent repair of the most severe curvature. The technique successfully straightened the penis in 59 cases (68%)and in another 28 cases (32%),the degree of severity of penile angulation was decreased enough so that only minor corporoplasty was needed to straighten the penis completely. In these cases standard techniques would have shortened the penis and disturbed the structure of the cavernous bodies. The advantage of the penile disassembly technique is obvious. It is essential to lift the glans cap from the tips of the corpora cavernosa to repair curvature in the distal third of the corpora cavernosa. The surgical approach for correcting this curvature is only possible after the glans is completely lifted. It also enables excellent correction of glans tilt, which is not possible with other techniques. The penile disassembly technique avoids penile shortening, contrary to other existing techniques for curvature repair, which is extremely important for small penises with curvature. Penile disassembly even provides the possibility of penile enlargement. A space is created between the glans cap and the tips of the corpora cavernosa in which different tissues may be interposed. For curvature with hypospadias that tissue comprises a new urethra with abundant vascularized subcutaneous tissue. For isolated curvatures rib cartilage may be used for penile lengthening. Our experience with it has been satisfactory." The benefit to urethroplasty is obvious. When suficient urethral length is achieved by extensive urethral mobilization, the hypospadiac meatus is brought up to the top of the glans, avoiding substitution urethroplasty. In others cases exten-
NEW APPROACH TO TREATMENT OF PENILE CURVATURE
sive urethral mobilization decreases the distance between the hypospadiac meatus and top of the glans, that is the urethral defect. Our brief followup may raise some concern regarding the long-term outcome of the penile disassembly technique. However, in 24 of the 87 patients followed for more than 20 months postoperatively the results of curvature repair were good. Seven of the 87 patients are noteworthy, since they underwent surgery before and were followed during puberty, enabling documentation of genital growth. Neither recurrent curvature nor penile growth disturbance was noted during puberty, which is possible only when vascularization and integrity of all penile entities are preserved, which is an advantage of the penile disassembly technique. Therefore, we believe that in the long term there will be no recurrence of curvature and no penile deformities. In conclusion, the penile disassembly technique seems to be the most effective procedure in select cases of the most severe curvature at the distal penile shaft, marked glans tilt and a small penis with c w a ture. This technique provides the possibility of penile lengthening. REFERENCES
1. Devine, C. J. and Horton, C. E.: Chordee without hypospadias. J . Urol., 1 1 0 264, 1973. 2. Devine, C. J., Jr., Blackley, S. K., Horton, C. E. and Gilbert,
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D. A.: The surgical treatment of chordee without hypospadias in post adolescent man. J . Urol., 146:325, 1991. 3. Baskin, L. S.: Part I. Controversies in hypospadias surgery: penile curvature. Dial. Ped. Urol., 19 1, 1996. 4. Perovic, S.:Hypospadias sine hypospadias. World J. Urol., 1 0 85,1992. 5. 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. 6. Perlmutter, A. D., Montgomery, B. T. and Steinhardt, G. F.: Tunica vaginalis free graft for the correction of chordee. J. Urol., 134:311, 1985. 7. Brock, G., Nunes, L., von Heyden, B., Martinez-Pineiro, L., Hsu, G. L. and Lue, T. F.: Can a venous patch graft be a substitute for the tunica albuginea ofthe penis? J. Urol., 150 1306,1993. 8. Perovic. S.,Djordjevic, M. and Djakovic, N.: Natural erection induced by prostaglandin-El in the diagnosis and treatment of congenital penile anomalies. Brit. J. Urol., 79 43, 1997. 9. Baskin, L. S.,Duckett, J . W. and Lue, T. F.: Penile curvature. Urology, 48.347, 1996. 10. Rehman,J., Benet, A,, Minsky, L. S. and Melman, A.: Results of surgical treatment for abnormal penile curvature: Peyronie’s disease and congenital deviation by modified Nesbit plication (tunical shaving and plication). J . Urol., 157: 1288,1997. 11. Mitchell, M. E. and Bagli, D. J.: Complete penile disassembly for epispadias repair: Mitchell technique. J. Urol., 155:300,1996. 12. Perovic, S.,Djordjevic, M. and Djakovic, N.: Real penile enlargement. Brit. J . Urol., suppl. 2,80 308,abstract 1208,1997.