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One-stage correction of chordee and 180-degree penile torsion
ONE-STAGE 180-DEGREE
CORRECTION PENILE
JOHN F. REDMAN,
M.D.
NABIL K. BISSADA,
M.D.
OF CHORDEE
AND
TORSION
From the Department of Urology, University of Arkansas Medical Center, Little Rock, Arkansas
The surgical management of a patient with 180degree penile torsion, balanitic hypospadias, and chordee is presented. Complete resolution of the torsion was effected by completely reflecting the penile skin. Correction of the penile curvature was accomplished simultaneously by freeing the corpora spongiosa from the corpora cauernosa.
ABSTRACT -
The surgical management of congenital torsion of the penis has been described infrequently.1-4 It has been emphasized that concomitant chordee and torsion are best treated surgically as separate entities requiring two separate procedures.‘*2 A one-stage correction of torsion of the penis and coexistent chordee has been previously described.4 Reports of its use are few. We herein report a one-stage correction of chordee and a 180-degree penile torsion.
Case Report A three-year-old black male was seen at Arkansas Children’s Hospital in February, 1975, for evaluation of congential penile torsion. His physical examination was normal with the exception of a 180-degree penile torsion to the left and balanitic hypospadias (Fig. 1A). On erection the patient was noted to have significant penile curvature dorsally. He voided with a large, forceful stream. An excretory urogram showed no abnormalities.
FIGURE 1. (A) Preoperative appearance of penis showing 180-degree torsion. Arrow indicates meatus. (B) Photograph showing mobilization of urethra to effect penile straightening. (C)Postoperative appearance of penis. Some redundancy of prepuce remains ventrally.
632
UROLOGY
/ JUNE 1976 / VOLUME
VII, NUMBER 6
Surgical correction was initiated by making a circumferential incision at the level of the corona, proximal to the urethral meatus. The penile skin was freed and retracted in sleeve fashion to the base of the penis. As the dissection proceeded the torsion diminished and was essentially corrected with freeing of the skin alone. Because of the previously noted penile curvature, it was elected to assure penile straightening by freeing the corpora spongiosa from its bed5,6 (Fig. 1B). Closure was effected after the excision of redundant prepuce which remained in a ventral position. Postoperatively, the penis is straight and without torsion (Fig. 1C). Comment A 180-degree congenital torsion of the penis is unusual. In a series of 400 cases of hypospadias Culp2 found only 17 cases with coexistent penile rotation. None had more than 90 degrees of torsion. Culp found that even with the removal of all chordee, penile torsion was unchanged. His technique of correction of the torsion was carried out after at least six months had elapsed following penile straightening. The procedure consisted of a circumferential incision at the level of the penoscrotal juncture with deep freeing of tissue followed by counterrotation and reapproximation of skin. All of his patients were corrected by this method.2 Mobley’ reported the surgical correction of a patient with coronal hypospadias, chordee, and a 180-degree torsion. After removal of the chordee the torsion was corrected to 120 degrees. Six months later, after the manner of Culp,
UROLOGY
I
JUNE 1976 / VOLUME
VII, NUMBER 6
a circumferential incision was made at the base of the penis, and with counterrotation the torsion was completely corrected. In our patient, resolution of the torsion progressed as the skin was reflected but was completed only after the penis was completely denuded. On the basis of our case we would question, as did Allen and Spence,3 the necessity for separate procedures for the correction of torsion and chordee. After the correction of severe torsion, the resultant persistence of the preputial hood in a ventral position would provide ample opportunity for the application of a Hodgson4*’ urethroplasty. 4301 West Markham Street Little Rock, Arkansas 72201 (DR. REDMAN) References 1. MOBLEY, J. E.: Congenital torsion of the penis, J. Urol. 109: 517 (1973). 2. CULP, 0. S.: Struggles and triumphs with hypospadias and associated anomalies: review of 406 cases, ibid. 96: 339 (1966). 3. ALLEN, T. D., and SPENCE, H. M.: The surgical treatment of coronal hypospadias and related problems, ibid. 199: 504 (1968). 4. HODGSON, N. B.: Hypospadias, in Glenn, J. F., Ed.: Urologic Surgery, New York, Harper and Row, 1975, p. 656. 5. PERSKY, L., HOFFMAN, A., and DES PREZ, J.: The repair of chordee without hypospadias and coronal hypospadias, J. Urol. 98: 216 (1969). 6. GROSS, M., FEIN, R., and WATERHOUSE, K.: Single stage correction of chordee without hypospadias and coronal hypospadias, ibid. 102: 70 (1969). 7. HODGSON, N. B.: A one-stage hypospadias repair, ibid. 194: 281 (1970).
633
CORRECTION PENILE
JOHN F. REDMAN,
M.D.
NABIL K. BISSADA,
M.D.
OF CHORDEE
AND
TORSION
From the Department of Urology, University of Arkansas Medical Center, Little Rock, Arkansas
The surgical management of a patient with 180degree penile torsion, balanitic hypospadias, and chordee is presented. Complete resolution of the torsion was effected by completely reflecting the penile skin. Correction of the penile curvature was accomplished simultaneously by freeing the corpora spongiosa from the corpora cauernosa.
ABSTRACT -
The surgical management of congenital torsion of the penis has been described infrequently.1-4 It has been emphasized that concomitant chordee and torsion are best treated surgically as separate entities requiring two separate procedures.‘*2 A one-stage correction of torsion of the penis and coexistent chordee has been previously described.4 Reports of its use are few. We herein report a one-stage correction of chordee and a 180-degree penile torsion.
Case Report A three-year-old black male was seen at Arkansas Children’s Hospital in February, 1975, for evaluation of congential penile torsion. His physical examination was normal with the exception of a 180-degree penile torsion to the left and balanitic hypospadias (Fig. 1A). On erection the patient was noted to have significant penile curvature dorsally. He voided with a large, forceful stream. An excretory urogram showed no abnormalities.
FIGURE 1. (A) Preoperative appearance of penis showing 180-degree torsion. Arrow indicates meatus. (B) Photograph showing mobilization of urethra to effect penile straightening. (C)Postoperative appearance of penis. Some redundancy of prepuce remains ventrally.
632
UROLOGY
/ JUNE 1976 / VOLUME
VII, NUMBER 6
Surgical correction was initiated by making a circumferential incision at the level of the corona, proximal to the urethral meatus. The penile skin was freed and retracted in sleeve fashion to the base of the penis. As the dissection proceeded the torsion diminished and was essentially corrected with freeing of the skin alone. Because of the previously noted penile curvature, it was elected to assure penile straightening by freeing the corpora spongiosa from its bed5,6 (Fig. 1B). Closure was effected after the excision of redundant prepuce which remained in a ventral position. Postoperatively, the penis is straight and without torsion (Fig. 1C). Comment A 180-degree congenital torsion of the penis is unusual. In a series of 400 cases of hypospadias Culp2 found only 17 cases with coexistent penile rotation. None had more than 90 degrees of torsion. Culp found that even with the removal of all chordee, penile torsion was unchanged. His technique of correction of the torsion was carried out after at least six months had elapsed following penile straightening. The procedure consisted of a circumferential incision at the level of the penoscrotal juncture with deep freeing of tissue followed by counterrotation and reapproximation of skin. All of his patients were corrected by this method.2 Mobley’ reported the surgical correction of a patient with coronal hypospadias, chordee, and a 180-degree torsion. After removal of the chordee the torsion was corrected to 120 degrees. Six months later, after the manner of Culp,
UROLOGY
I
JUNE 1976 / VOLUME
VII, NUMBER 6
a circumferential incision was made at the base of the penis, and with counterrotation the torsion was completely corrected. In our patient, resolution of the torsion progressed as the skin was reflected but was completed only after the penis was completely denuded. On the basis of our case we would question, as did Allen and Spence,3 the necessity for separate procedures for the correction of torsion and chordee. After the correction of severe torsion, the resultant persistence of the preputial hood in a ventral position would provide ample opportunity for the application of a Hodgson4*’ urethroplasty. 4301 West Markham Street Little Rock, Arkansas 72201 (DR. REDMAN) References 1. MOBLEY, J. E.: Congenital torsion of the penis, J. Urol. 109: 517 (1973). 2. CULP, 0. S.: Struggles and triumphs with hypospadias and associated anomalies: review of 406 cases, ibid. 96: 339 (1966). 3. ALLEN, T. D., and SPENCE, H. M.: The surgical treatment of coronal hypospadias and related problems, ibid. 199: 504 (1968). 4. HODGSON, N. B.: Hypospadias, in Glenn, J. F., Ed.: Urologic Surgery, New York, Harper and Row, 1975, p. 656. 5. PERSKY, L., HOFFMAN, A., and DES PREZ, J.: The repair of chordee without hypospadias and coronal hypospadias, J. Urol. 98: 216 (1969). 6. GROSS, M., FEIN, R., and WATERHOUSE, K.: Single stage correction of chordee without hypospadias and coronal hypospadias, ibid. 102: 70 (1969). 7. HODGSON, N. B.: A one-stage hypospadias repair, ibid. 194: 281 (1970).
633