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Parallel incisions procedure for penile curvature—Short term outcomes
British Journal of Medical and Surgical Urology (2011) 4, 64—67
ORIGINAL ARTICLE
Parallel incisions procedure for penile curvature—–Short term outcomes R.T.M. Chang, A. Sahai 1, I.K. Dickinson ∗ Department of Urology, Darent Valley Hospital, Dartford, Kent, DA2 8DA, United Kingdom Received 13 April 2010; accepted 16 May 2010
KEYWORDS Peyronie’s disease; Penile curvature; Corporotomy
Summary Objective: A modified corporotomy technique has been developed in order to overcome the problems of previous techniques such as tissue removal, urethral mobilisation, palpable knots, ‘dog ears’ and leakage on testing after repair. Our objective is to describe the technique and review the outcomes in the short term. Methods: The procedure involves two transverse parallel incisions at the bite points of Allis forceps used to correct curvature. The intervening tunica is buried, sealing the incision and preventing leakage. The incision is closed with 2-0 Polydioxanone sutures and a single 2-0 Polyglycolic to maintain knot burial. Data were collected retrospectively on all patients undergoing this technique from our department. Results: Thirty-two patients underwent daycase surgery. Mean duration of disease was 12.5 months. At three months the cosmetic result was excellent (straight) or good (<20◦ bend) in 97%. Patient satisfaction was high with 87% being happy with the outcome and 88% able to have pain free intercourse. Complications of note included glans numbness in 1 patient and chronic granuloma related to suture placement requiring excision in 1 patient. Conclusions: The modified parallel incisions procedure is easy to perform and is efficacious in the short term with good cosmetic results and high patient satisfaction. Longer term follow-up is planned in a prospective fashion. © 2010 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Penile curvature can be congenital, caused by disproportionate or asymmetrical corporal bodies of the penis, or acquired which can be traumatic ∗ 1
Corresponding author. E-mail address: [email protected] (I.K. Dickinson). Joint first author.
or more commonly related to Peyronie’s disease. Peyronie’s disease is a connective tissue disorder with associated penile curvature resulting from the development of fibrous plaques within the tunica albuginea and subtunical tissue of the corpora cavernosa. The underlying aetiology behind Peyronie’s disease however, is not fully understood. Various theories have been described including plaque formation as a result of inflammation and fibrosis
1875-9742/$ — see front matter © 2010 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2010.05.004
Parallel incisions procedure for penile curvature secondary to repeated micro-trauma, autoimmune disease, infectious and genetic causes. Independent of aetiology, significant penile curvature can cause painful erections, erectile dysfunction, difficulty with sexual intercourse and adverse psychological effect in affected individuals. Surgical treatment is usually indicated for symptomatic patients following a period of disease stabilization. The surgical techniques described in correction of penile curvature are broadly divided into those procedures to shorten the convex side of the penis via excision, plication or corporotomy; procedures to lengthen the concave side using grafting techniques and finally the use of prosthetic implants. At our institution a single surgeon with an interest in Andrology has performed a variety of procedures for the correction of penile curvature but has often found problems with plication or excision procedures such as tissue removal, urethral mobilisation, palpable knots, ‘dog ears’ and leakage on testing after repair. This prompted the use of the technique which has been described as a modified Schröder-Essed plication but essentially is a modified corporotomy and was initially described by Van der Horst et al. in 2003 [1]. The author has chosen to give the procedure its own name i.e. the parallel incisions procedure in order to avoid any confusion with any other ‘modified’ procedure.
Subjects and methods A total of 32 patients with symptomatic Peyronie’s disease underwent the modified corporotomy technique between January 2006 and March 2009. All the patients were followed up at 3 months in the outpatient clinic. Thirty-two patient case notes were analysed retrospectively looking specifically for patient demographics, aetiology of the penile curvature, duration of disease, nature of the deformity, degree of curvature, the pre- and post-operative erection quality. Patient satisfaction was noted and if the patient was dissatisfied, the reasons for dissatisfaction were noted. The duration of disease was obtained by calculating the length of time between the onset quoted in GP referral letters and the operation date or from the patient history at initial consultation. Where the onset was not noted in the GP referral letter the duration was calculated as the time between the GP referral and the operation date. The duration of disease for the patient with congenital penile curvature was not included in calculating the mean duration of disease. The degree of curvature was attained from pre-operative photographs
65 or the initial artificial erection assessment intraoperatively.
Operative technique A stay suture is placed into the glans penis and a 19 G butterfly needle is then introduced into one of the corpora via the glans and secured with the stay suture. An artificial erection is achieved with the use of normal saline infused with a pressure bag in order to assess the deformity. A circumferential incision is made approximately 1 cm from the coronal sulcus and the penis is degloved. Following a further artificial erection, correction of the penile curvature is simulated by placing Allis forceps on the contralateral side of the maximal point of curvature. The penis is marked just above and below the Allis forceps, the forceps are removed and two parallel horizontal transverse incisions into the tunica albuginea are made approximately at the marking sites. Any overlying fascia is then removed and the markings are approximated with a Polydiaxone 2-0 suture placed in the corner of the parallel incisions on the same side. This is repeated on the other side of the parallel incision, invaginating the tunica and maintaining the straightened position with good strength. A 2-0 polyglactin suture is then used to bury the knot (see Fig. 1). A final artificial erection test is used to confirm that the cosmetic effect is satisfactory. Finally, skin on the penis is repositioned, a circumcision performed if required and then resutured utilising 4-0 polyglactin sutures (Vicryl Rapide® ).
Results Two patients had traumatic, one congenital and the rest had idiopathic Peyronie’s disease. One patient had had a previous correction of penile curvature. The mean duration of disease was 12.5 months. Six patients had purely ventral deviations, and the rest of the cohort had a mixture of pure lateral, pure dorsal or a combination of the two. No patients had waist deformities, ‘S’ deformities or rotational deformities. The mean deviation angle was 43◦ . Seven patients complained of poor quality erections pre-operatively and/or were on oral medications for erectile dysfunction. This remained unchanged post-operatively. At the 3 month post-operative follow-up interval 97% (n = 31) of the patients had a straight penis or had penile curvatures less than 20◦ . One patient had a 25◦ deformity. The overall satisfaction rate at 3 months was 72% with the main reasons for dissat-
66
R.T.M. Chang et al.
Figure 1 Parallel incisions technique. (A) Artificial erection with dorsal curvature. Stay suture and butterfly needle secured to glans penis within the corpora; (B) deformity corrected with Allis forceps; (C) forceps marked at site of bites and incised transverse; (D) overlying fascia removed; (E and F) Polydiaxone sutures placed at the corners of the incisions and tied in and in to out and out to in fashion to correct the deformity securely; (G) inverted Polydiaxone suture buried with polyglactin suture; and (H) corrected deformity following corporotomy. Adapted from [1].
Parallel incisions procedure for penile curvature isfaction being penile length shortening, persistent erectile dysfunction and not perfectly straight penis. If those with pre-existing erectile dysfunction are removed the overall satisfaction rate increases to 84%. Pain free intercourse was achievable in 88% (n = 28) of the patients at 3 months. Complications of note included glans numbness in one patient, chronic penile pain in one patient and a chronic granuloma in the penile shaft. In the case of the latter the patient was explored under anaesthesia and was found to have a track from the skin to the corpora. This was most likely to be at the site of the suture placement and the track was excised.
Discussion Plication techniques such as the original SchröderEssed technique [2] have an advantage over excision techniques like Nesbit’s [3] and Yachia’s [4] in that they are minimally invasive, avoiding mobilization of the dorsal neurovascular bundle or ventral corpus spongiosum. A consequential advantage is that extensive surgical experience is not required to perform the plication technique. In the original Schroeder-Essed plication non-absorbable sutures are used to shorten the convex sided of the penis when they are tied. However, the problem with this technique is that there is no permanent remodeling of the underlying tunica albuginea and hence failure of the sutures would result in recurrence of the penile curvature. Also the use of non-absorbable sutures can result in palpable knots post-operatively. The procedure described in this study using two parallel incisions in the tunica albuginea adds strength to the correction not possible with simple plication. The incisions also allow better invagination of tissue and burying of the suture knot that results in a better cosmetic effect without ‘dog ears’ or long lasting palpable defects. Using this ‘modified corporoplasty’ technique, Van der Horst et al., reported on a sexual intercourse success rate of 90% compared with 61% pre-operatively [1,5]. The overall satisfaction rate (moderate to very satisfied) was 78% with the majority indicating that they would choose the surgery again. Twelve percent required some form
67 of revision surgery either for recurrent deviation or granuloma formation. Our results are comparable. The study suggests that it is suitable to perform this technique in moderate penile curvatures in symptomatic Peyronie’s disease in the absence of complicated deformities or curvature >60◦ . Although patients are fully counselled about the procedure and expected complications such as penile length shortening discussed, this was still a significant cause of patient dissatisfaction post procedure. We would recommend that patients are counselled appropriately prior to surgery with particular emphasis on penile shortening and to document carefully pre-operative erectile function status. Further data collection is planned in a prospective fashion with longer term telephone questionnaire follow-up and assessment of erectile function pre- and post-operatively using validated questionnaires. Data will also be sent to the BAUS section of Andrology audit database.
Conclusions The parallel incisions procedure is easy to perform and is efficacious in the short term with good cosmetic results and high patient satisfaction. Longer term follow-up is planned in a prospective fashion.
References [1] van der Horst C, Martinez Portillo FJ, Melchior D, Bross S, Alken P, Juenemann KP. Polytetrafluoroethylene versus polypropylene sutures for Essed-Schroeder tunical plication. J Urol 2003;170(2 Pt 1):472—5. [2] Essed E, Schroeder FH. New surgical treatment for Peyronie disease. Urology 1985;25(6):582—7. [3] Nesbit RM. Congenital curvature of the phallus: report of three cases with description of corrective operation. J Urol 1965;93:230—2. [4] Yachia D. Modified corporoplasty for the treatment of penile curvature. J Urol 1990;143(1):80—2. [5] van der Horst C, Martinez Portillo FJ, Seif C, Alken P, Juenemann KP. Treatment of penile curvature with Essed-Schroder tunical plication: aspects of quality of life from the patients’ perspective. BJU Int 2004;93(1):105—8.
Available online at www.sciencedirect.com
ORIGINAL ARTICLE
Parallel incisions procedure for penile curvature—–Short term outcomes R.T.M. Chang, A. Sahai 1, I.K. Dickinson ∗ Department of Urology, Darent Valley Hospital, Dartford, Kent, DA2 8DA, United Kingdom Received 13 April 2010; accepted 16 May 2010
KEYWORDS Peyronie’s disease; Penile curvature; Corporotomy
Summary Objective: A modified corporotomy technique has been developed in order to overcome the problems of previous techniques such as tissue removal, urethral mobilisation, palpable knots, ‘dog ears’ and leakage on testing after repair. Our objective is to describe the technique and review the outcomes in the short term. Methods: The procedure involves two transverse parallel incisions at the bite points of Allis forceps used to correct curvature. The intervening tunica is buried, sealing the incision and preventing leakage. The incision is closed with 2-0 Polydioxanone sutures and a single 2-0 Polyglycolic to maintain knot burial. Data were collected retrospectively on all patients undergoing this technique from our department. Results: Thirty-two patients underwent daycase surgery. Mean duration of disease was 12.5 months. At three months the cosmetic result was excellent (straight) or good (<20◦ bend) in 97%. Patient satisfaction was high with 87% being happy with the outcome and 88% able to have pain free intercourse. Complications of note included glans numbness in 1 patient and chronic granuloma related to suture placement requiring excision in 1 patient. Conclusions: The modified parallel incisions procedure is easy to perform and is efficacious in the short term with good cosmetic results and high patient satisfaction. Longer term follow-up is planned in a prospective fashion. © 2010 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Penile curvature can be congenital, caused by disproportionate or asymmetrical corporal bodies of the penis, or acquired which can be traumatic ∗ 1
Corresponding author. E-mail address: [email protected] (I.K. Dickinson). Joint first author.
or more commonly related to Peyronie’s disease. Peyronie’s disease is a connective tissue disorder with associated penile curvature resulting from the development of fibrous plaques within the tunica albuginea and subtunical tissue of the corpora cavernosa. The underlying aetiology behind Peyronie’s disease however, is not fully understood. Various theories have been described including plaque formation as a result of inflammation and fibrosis
1875-9742/$ — see front matter © 2010 British Association of Urological Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjmsu.2010.05.004
Parallel incisions procedure for penile curvature secondary to repeated micro-trauma, autoimmune disease, infectious and genetic causes. Independent of aetiology, significant penile curvature can cause painful erections, erectile dysfunction, difficulty with sexual intercourse and adverse psychological effect in affected individuals. Surgical treatment is usually indicated for symptomatic patients following a period of disease stabilization. The surgical techniques described in correction of penile curvature are broadly divided into those procedures to shorten the convex side of the penis via excision, plication or corporotomy; procedures to lengthen the concave side using grafting techniques and finally the use of prosthetic implants. At our institution a single surgeon with an interest in Andrology has performed a variety of procedures for the correction of penile curvature but has often found problems with plication or excision procedures such as tissue removal, urethral mobilisation, palpable knots, ‘dog ears’ and leakage on testing after repair. This prompted the use of the technique which has been described as a modified Schröder-Essed plication but essentially is a modified corporotomy and was initially described by Van der Horst et al. in 2003 [1]. The author has chosen to give the procedure its own name i.e. the parallel incisions procedure in order to avoid any confusion with any other ‘modified’ procedure.
Subjects and methods A total of 32 patients with symptomatic Peyronie’s disease underwent the modified corporotomy technique between January 2006 and March 2009. All the patients were followed up at 3 months in the outpatient clinic. Thirty-two patient case notes were analysed retrospectively looking specifically for patient demographics, aetiology of the penile curvature, duration of disease, nature of the deformity, degree of curvature, the pre- and post-operative erection quality. Patient satisfaction was noted and if the patient was dissatisfied, the reasons for dissatisfaction were noted. The duration of disease was obtained by calculating the length of time between the onset quoted in GP referral letters and the operation date or from the patient history at initial consultation. Where the onset was not noted in the GP referral letter the duration was calculated as the time between the GP referral and the operation date. The duration of disease for the patient with congenital penile curvature was not included in calculating the mean duration of disease. The degree of curvature was attained from pre-operative photographs
65 or the initial artificial erection assessment intraoperatively.
Operative technique A stay suture is placed into the glans penis and a 19 G butterfly needle is then introduced into one of the corpora via the glans and secured with the stay suture. An artificial erection is achieved with the use of normal saline infused with a pressure bag in order to assess the deformity. A circumferential incision is made approximately 1 cm from the coronal sulcus and the penis is degloved. Following a further artificial erection, correction of the penile curvature is simulated by placing Allis forceps on the contralateral side of the maximal point of curvature. The penis is marked just above and below the Allis forceps, the forceps are removed and two parallel horizontal transverse incisions into the tunica albuginea are made approximately at the marking sites. Any overlying fascia is then removed and the markings are approximated with a Polydiaxone 2-0 suture placed in the corner of the parallel incisions on the same side. This is repeated on the other side of the parallel incision, invaginating the tunica and maintaining the straightened position with good strength. A 2-0 polyglactin suture is then used to bury the knot (see Fig. 1). A final artificial erection test is used to confirm that the cosmetic effect is satisfactory. Finally, skin on the penis is repositioned, a circumcision performed if required and then resutured utilising 4-0 polyglactin sutures (Vicryl Rapide® ).
Results Two patients had traumatic, one congenital and the rest had idiopathic Peyronie’s disease. One patient had had a previous correction of penile curvature. The mean duration of disease was 12.5 months. Six patients had purely ventral deviations, and the rest of the cohort had a mixture of pure lateral, pure dorsal or a combination of the two. No patients had waist deformities, ‘S’ deformities or rotational deformities. The mean deviation angle was 43◦ . Seven patients complained of poor quality erections pre-operatively and/or were on oral medications for erectile dysfunction. This remained unchanged post-operatively. At the 3 month post-operative follow-up interval 97% (n = 31) of the patients had a straight penis or had penile curvatures less than 20◦ . One patient had a 25◦ deformity. The overall satisfaction rate at 3 months was 72% with the main reasons for dissat-
66
R.T.M. Chang et al.
Figure 1 Parallel incisions technique. (A) Artificial erection with dorsal curvature. Stay suture and butterfly needle secured to glans penis within the corpora; (B) deformity corrected with Allis forceps; (C) forceps marked at site of bites and incised transverse; (D) overlying fascia removed; (E and F) Polydiaxone sutures placed at the corners of the incisions and tied in and in to out and out to in fashion to correct the deformity securely; (G) inverted Polydiaxone suture buried with polyglactin suture; and (H) corrected deformity following corporotomy. Adapted from [1].
Parallel incisions procedure for penile curvature isfaction being penile length shortening, persistent erectile dysfunction and not perfectly straight penis. If those with pre-existing erectile dysfunction are removed the overall satisfaction rate increases to 84%. Pain free intercourse was achievable in 88% (n = 28) of the patients at 3 months. Complications of note included glans numbness in one patient, chronic penile pain in one patient and a chronic granuloma in the penile shaft. In the case of the latter the patient was explored under anaesthesia and was found to have a track from the skin to the corpora. This was most likely to be at the site of the suture placement and the track was excised.
Discussion Plication techniques such as the original SchröderEssed technique [2] have an advantage over excision techniques like Nesbit’s [3] and Yachia’s [4] in that they are minimally invasive, avoiding mobilization of the dorsal neurovascular bundle or ventral corpus spongiosum. A consequential advantage is that extensive surgical experience is not required to perform the plication technique. In the original Schroeder-Essed plication non-absorbable sutures are used to shorten the convex sided of the penis when they are tied. However, the problem with this technique is that there is no permanent remodeling of the underlying tunica albuginea and hence failure of the sutures would result in recurrence of the penile curvature. Also the use of non-absorbable sutures can result in palpable knots post-operatively. The procedure described in this study using two parallel incisions in the tunica albuginea adds strength to the correction not possible with simple plication. The incisions also allow better invagination of tissue and burying of the suture knot that results in a better cosmetic effect without ‘dog ears’ or long lasting palpable defects. Using this ‘modified corporoplasty’ technique, Van der Horst et al., reported on a sexual intercourse success rate of 90% compared with 61% pre-operatively [1,5]. The overall satisfaction rate (moderate to very satisfied) was 78% with the majority indicating that they would choose the surgery again. Twelve percent required some form
67 of revision surgery either for recurrent deviation or granuloma formation. Our results are comparable. The study suggests that it is suitable to perform this technique in moderate penile curvatures in symptomatic Peyronie’s disease in the absence of complicated deformities or curvature >60◦ . Although patients are fully counselled about the procedure and expected complications such as penile length shortening discussed, this was still a significant cause of patient dissatisfaction post procedure. We would recommend that patients are counselled appropriately prior to surgery with particular emphasis on penile shortening and to document carefully pre-operative erectile function status. Further data collection is planned in a prospective fashion with longer term telephone questionnaire follow-up and assessment of erectile function pre- and post-operatively using validated questionnaires. Data will also be sent to the BAUS section of Andrology audit database.
Conclusions The parallel incisions procedure is easy to perform and is efficacious in the short term with good cosmetic results and high patient satisfaction. Longer term follow-up is planned in a prospective fashion.
References [1] van der Horst C, Martinez Portillo FJ, Melchior D, Bross S, Alken P, Juenemann KP. Polytetrafluoroethylene versus polypropylene sutures for Essed-Schroeder tunical plication. J Urol 2003;170(2 Pt 1):472—5. [2] Essed E, Schroeder FH. New surgical treatment for Peyronie disease. Urology 1985;25(6):582—7. [3] Nesbit RM. Congenital curvature of the phallus: report of three cases with description of corrective operation. J Urol 1965;93:230—2. [4] Yachia D. Modified corporoplasty for the treatment of penile curvature. J Urol 1990;143(1):80—2. [5] van der Horst C, Martinez Portillo FJ, Seif C, Alken P, Juenemann KP. Treatment of penile curvature with Essed-Schroder tunical plication: aspects of quality of life from the patients’ perspective. BJU Int 2004;93(1):105—8.
Available online at www.sciencedirect.com