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The Fisher Technique for Correction of Penile Torsion in Children: Who Are the Candidates?
Accepted Manuscript Title: The Fisher Technique for Correction of Penile Torsion in Children: Who are the Candidates? Author: JB Marret, P Ravasse, L Raffoul, J Rod PII: DOI: Reference:
S0090-4295(17)30183-8 http://dx.doi.org/doi: 10.1016/j.urology.2017.02.038 URL 20320
To appear in:
Urology
Received date: Accepted date:
28-11-2016 24-2-2017
Please cite this article as: JB Marret, P Ravasse, L Raffoul, J Rod, The Fisher Technique for Correction of Penile Torsion in Children: Who are the Candidates?, Urology (2017), http://dx.doi.org/doi: 10.1016/j.urology.2017.02.038. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The Fisher technique for correction of penile torsion in children: who are the candidates?
MARRET JB MD (1), RAVASSE P MD, PhD (1,2), RAFFOUL L MD (3) ROD J MD, PhD (1,2) (1)
Department of Pediatric Surgery, University of Caen Hospital, France
(2)
Caen University Hospital, Avenue de la Côte de Nacre, 14000 Caen, France
(3)
Hôtel-Dieu de France Hospital, Beirut, Lebanon
Author’s Correspondence: e-mail: [email protected] Tel: +33231064483 Fax: +33231065077 Address : Caen University Hospital, Avenue de la Côte de Nacre, 14000 Caen, France
Key words: Penile Torsion, Fisher technique, Chordee, Pediatric
Acknowledgment: none Disclosure: nothing to disclose
1
Page 1 of 11
Abstract Objective: To report our experience in the treatment of penile torsion with a special reference to the Fisher technique.
Patients and methods: We reviewed thirty cases of congenital penile torsion treated from 2009 to 2015 in a single center. Sixteen patients presented a moderate rotation of 45° to 90° and 14 had a severe rotation with an angle greater than 90°. Chordee was present in 17 cases and distal glanular hypospadias in 15 cases. Median age at surgery was 10 months. In 14 cases, degloving along with skin realignment, alone, allowed correction of the torsion. In 16 cases, the Dartos flap (Fisher technique) was used.
Results: Out of the 30 patients, 29 had a good result with a complete correction of the torsion. Only one patient had a residual torsion of 30°. Complications were minor and consisted of skin excess in 11 patients; one single case needed to be reoperated for that skin complication. The need for the Dartos flap procedure was significantly correlated to the degree of torsion (p=0,001): It was used in 4 out of 16 patients (25%) with a torsion degree of less than 90, and in 12 out of 14 patients (86%) with a torsion of 90° or more.
Conclusion: Most of penile rotations of less than 90° can be corrected by skin degloving and realignment. The Fisher technique is a simple and safe procedure for correction of persistent rotation after skin degloving; such cases have usually a penile rotation greater than 90 degrees.
2
Page 2 of 11
Introduction
Congenital penile torsion is a rotation of the penis along its longitudinal axis (Figure 1). Most of the cases are, for an unknown reason, rotated in a counter clockwise direction. Penile rotation occurs as an isolated malformation. However, it can be associated with other penile anomalies such as hypospadias or ventral curvature. The true incidence of this anomaly is unknown; one recent prospective study reported a rather high incidence of 27% of neonatal penile torsion [1]. Consequences of uncorrected torsions in adulthood are not exactly known, which leads to a lack of recommendation regarding surgical treatment in infancy. Skin degloving and realignment [2] can be sufficient for correction of mild torsions of less than 60°. However, when it comes to cases of 90° or more, a complementary procedure should often be done. Prior to 2009, corporopexy [3] to the periosteum was for us the procedure of choice and we decided in 2009 to move to the fisher technique [4]. The latter procedure seemed to be easier and safer to perform for surgeons trained in surgery of hypospadias. The aim of this study is to report our global experience in the treatment of penile rotation with a special reference to the Fisher technique.
Patients and methods
Between January 2009 and April 2015, thirty cases of congenital penile torsion, without significant hypospadias (ie without a hypopadias needing to be corrected by urethroplasty), were repaired in a single center by two surgeons. Rotation was counter clockwise in 28 cases and clockwise in 2. The severity of rotation was
3
Page 3 of 11
considered as moderate when its degree ranged from 45 to 90 (16 cases), and as severe when degree was greater than 90 (14 cases). Preoperative degree of torsion was assessed with the penis flaccid. None of the patients had a rotation of less than 45°. None of the patients were previously circumcised. All patients had an abnormal prepuce with a ventrally opened or hooded foreskin. Chordee was present in 17 cases and glanular hypospadias in 15. Three cases had both chordee and hypospadias. The median age at surgery was 10 months (6-217). Surgical technique was performed under general anesthesia and consisted of day surgery cases. After a circumferential incision, the penile shaft skin was degloved down to the base of the penis.
In cases of curvature, whether observed
preoperatively or suspected intraoperatively, an artificial erection test was done after this first step. Residual chordee was corrected by a dorsal corpora plication, using the Nesbit procedure in 4 patients and the Baskin procedure in 3. Correction was confirmed by an artificial erection. Meatus and glanular malformations were treated by glanuloplasty (MAGPI) and Firlit preputial collar reconstruction. No urethroplasty such as the Duplay or the Snodgrass procedures was done. The correction of the torsion was evaluated at that time. In 14 cases, residual torsion was of less than 30° and the penile skin was realigned. In the remaining 16 cases, residual torsion was of more than 30° and needed the use of a dorsal Dartos flap (Table 1). The flap was dissected out of the deep layer of the dorsal mid-line foreskin, on a short distance (Figure 2.A). In cases of counter clockwise torsion, the flap was rotated around the right side of the penis, and then fixed with absorbable sutures, with some tension, at the ventral part of the left corpora beyond the corpus spongiosum (Figure 2.B). In cases of clockwise torsion, the procedure was inverted,
4
Page 4 of 11
with the flap being rotated around the left side of the penis and fixed to the ventral part of the right corpora. After suturing the Dartos flap, correction of the torsion was assessed with an artificial erection. In all cases, we tried to perform the procedure with a final aspect of a wellcircumcised penis (Figure 3). No dressing and no urinary catheter were left in place. End results were evaluated by clinical examination after at least 3 months postoperatively. Statistical analysis was done using the Fisher’s exact test.
Results
Follow-up period ranged from 10 to 72 months. All 30 patients were available for follow-up. No relevant complications occurred during the postoperative period. The 16 patients treated with the Fisher technique had a complete correction of the torsion along with a urethral meatus in a normal vertical anatomical orientation. None of the parents reported any residual torsion or chordee when phallus was erect. Residual torsion of 30° occurred in one patient initially treated by simple degloving and realignment and was not further corrected. In 12 patients (5 of which were operated with the Fisher technique), we observed a minor esthetic complication due to skin excess; one single case was re-operated in order to achieve a better cosmetic result. The need for the Dartos flap procedure was significantly (p= 0,001) correlated to the initial degree of torsion: It was used in 4 out of 16 patients (25%) with a torsion degree of less than 90, and in 12 out of 14 patients (86%) with a torsion of 90° or more.
5
Page 5 of 11
Discussion Penile glans torsion is a congenital deformity that can occur independently or in association with other malformations such as hypospadias and chordee. True incidence is difficult to evaluate. Series of surgically corrected cases are usually small. Surprisingly, in a cohort of 370 newborns [1], the incidence of glans rotation was 27% but, in fact, none of the torsions in this series exceeded 60°. Whenever surgical correction is decided, there is a consensus to start the procedure with skin degloving and realignment [2]. BarYosef et al [5] reported good results with skin realignment alone in a series of 46 children but only 3 patients had a rotation greater than 90°. In our experience, skin degloving alone was efficient in 13 out the 30 cases, 12 of them had a rotation of less than 90°. After this first step, when residual rotation exceeded 30°, an additional procedure was performed. Many techniques have been described in pertinent literature [3,4,6,7]; only two of them, the Fisher and the Zhou procedures, have been reported in different publications from those of their initial descriptions [8-10]. In our previously experience, ie prior to 2009 the additional procedure we used to perform was a corporopexy: it consisted of suturing the lateral face of the tunica albuginea of the corpora to the pubis as reported by Zhou [3]. Despite good results, we switched to the Fisher technique for several reasons 4: The exposure of the area surrounding the pubic zone for corporopexy need a rather deep and blind dissection, and there is some risk of trauma of the vasculo-nervous bundles when placing the stitches on the corpora. At the opposite, the Fischer technique refers to the principle of dissection of a dorsal flap, which is widely used and easy to perform for all surgeons involved in hypospadias surgery. There is no risk for the vasculo-nervous bundles because all the stiches are placed on the ventral part of the corpora. Adjusting the sutures in order to achieve a complete correction is easy by 6
Page 6 of 11
placing additional sutures or removing others. Our results with the Dartos flap were as good as published in rather small series of less than 10 cases [4,9,10] and in otherwise larger ones such as the series of Bauer et al. that consisted of 25 cases [8]. Aldaqadossi et al. [9], in a prospective study, compared the Dartos flap technique to the fixation to the periosteum. Results were good and similar in both techniques, although the authors concluded that the Fisher technique was easier. Elbatarny et al. [10] proposed a staged approach reserving the use of the Zhou technique to cases of incomplete correction by the Fisher technique. However, in our experience, even when rotation exceeded 90°, the Dartos flap was efficient. Concerning the final esthetic result the rate of excess skin, evaluated by the surgeon, seems quite high (40%) in our experience but only one case required revision. Skin coverage is not a simple part of the repair. In most cases after correction of the torsion the dorsal foreskin takes a lateral position, usually on the left side of the penis, with the skin defect being rather on the right side. Performing a Byars procedure in this anatomical condition is more difficult than in patients with a well oriented dorsal foreskin especially to avoid dorsolateral scars.
The limit of our study is similar to other studies and consists of a lack of longterm follow up. Puberty could worsen the situation if torsion is due to a malformation of the corpora. However, such a situation seems unlikely because correction of penile torsion is usually achieved with a procedure limited to the skin and the subcutaneous tissue, and does not include any invasive procedure on the corpora. Early surgical indications of this congenital anomaly can be discussed.
Some
families do not ask for any kind of surgery in such cases since correction is for cosmetic purposes only. The surgical correction is certain in cases of associated
7
Page 7 of 11
malformations including the ventral chordee. In our study, all operated children presented with an abnormal foreskin: skin surface was unusually opened or hooded, and parents desired both an early and esthetic correction. The incomplete aspect of the foreskin and the Fisher technique lead to a final aspect of circumcision.
Conclusion Throughout our own experience and pertinent literature we conclude that: - Most of penile rotation of less than 90° can be corrected by skin degloving and realignment - The Fisher Dartos flap is an excellent way to correct penile rotation of 90° or more in children, with very few complications. Unlike other techniques, this procedure is easy to perform for surgeons familiar with hypospadias surgery.
References
1–10
1.
Sarkis PE, Sadasivam M. Incidence and predictive factors of isolated neonatal penile glanular torsion. J Pediatr Urol. 2007;3(6):495-499. doi:10.1016/j.jpurol.2007.03.002.
2.
Azmy a, Eckstein HB. Surgical correction of torsion of the penis. Br J Urol. 1981;53(4):378-379. http://www.ncbi.nlm.nih.gov/pubmed/7260553.
3.
Zhou L, Mei H, Hwang AH, Xie HW, Hardy BE. Penile torsion repair by suturing tunica albuginea to the pubic periosteum. J Pediatr Surg. 2006;41(1):7-9.
8
Page 8 of 11
doi:10.1016/j.jpedsurg.2005.10.065. 4.
Fisher PC, Park JM. Penile Torsion Repair Using Dorsal Dartos Flap Rotation. J Urol. 2004;171(5):1903-1904. doi:10.1097/01.ju.0000120148.79867.5c.
5.
Bar-Yosef Y, Binyamini J, Matzkin H, Ben-Chaim J. Degloving and Realignment-Simple Repair of Isolated Penile Torsion. Urology. 2007;69(2):369-371. doi:10.1016/j.urology.2007.01.014.
6.
Snow BW. Penile torsion correction by diagonal corporal plication sutures. Int Braz J Urol. 2009;35(1):56-57. doi:10.1590/S1677-55382009000100009.
7.
Bhat A, Bhat MP, Saxena G. Correction of penile torsion by mobilization of urethral plate and urethra. J Pediatr Urol. 2009;5(6):451-457. doi:10.1016/j.jpurol.2009.05.013.
8.
Bauer R, Kogan BA. Modern Technique for Penile Torsion Repair. J Urol. 2009;182(1):286-291. doi:10.1016/j.juro.2009.02.133.
9.
Aldaqadossi HA, Elgamal SA, Seif Elnasr MK. Dorsal dartos flap rotation versus suturing tunica albuginea to the pubic periosteum for correction of penile torsion: A prospective randomized study. J Pediatr Urol. 2013;9(5):643647. doi:10.1016/j.jpurol.2012.07.014.
10.
Elbatarny AM, Ismail KA. Penile torsion repair in children following a ladder step: Simpler steps are usually sufficient. J Pediatr Urol. 2014;10(6):1187-1192. doi:10.1016/j.jpurol.2014.05.009.
9
Page 9 of 11
Figure 1: Severe penile torsion Figure 2: Dissection of the flap as in Fisher's technique A. Dissection of the flap from the deep face of the foreskin B. Fixation at the ventral part of the left corpora Figure 3: Penis after correction by Fisher's technique
10
Page 10 of 11
Table1. Population's characteristics Penile torsion n (%) Patients characteristics
Moderate
Severe
(n= total)
16 (53)
14 (47)
- Age (months)
19,9
24,6
- Chordee (17)
8 (50)
9 (64)
- Glanular hypospadias (15)
8 (50)
7 (50)
12 (75)
2 (14)
4 (25)
12 (86)
- Complete correction (29)
15 (94)
14 (100)
- Minor esthetic complication (11)
6 (37)
5 (36)
Preoperative
Peroperative - Only degloving and realignment (14) - Dorsal dartos flap rotation (16) Postoperative
11
Page 11 of 11
S0090-4295(17)30183-8 http://dx.doi.org/doi: 10.1016/j.urology.2017.02.038 URL 20320
To appear in:
Urology
Received date: Accepted date:
28-11-2016 24-2-2017
Please cite this article as: JB Marret, P Ravasse, L Raffoul, J Rod, The Fisher Technique for Correction of Penile Torsion in Children: Who are the Candidates?, Urology (2017), http://dx.doi.org/doi: 10.1016/j.urology.2017.02.038. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The Fisher technique for correction of penile torsion in children: who are the candidates?
MARRET JB MD (1), RAVASSE P MD, PhD (1,2), RAFFOUL L MD (3) ROD J MD, PhD (1,2) (1)
Department of Pediatric Surgery, University of Caen Hospital, France
(2)
Caen University Hospital, Avenue de la Côte de Nacre, 14000 Caen, France
(3)
Hôtel-Dieu de France Hospital, Beirut, Lebanon
Author’s Correspondence: e-mail: [email protected] Tel: +33231064483 Fax: +33231065077 Address : Caen University Hospital, Avenue de la Côte de Nacre, 14000 Caen, France
Key words: Penile Torsion, Fisher technique, Chordee, Pediatric
Acknowledgment: none Disclosure: nothing to disclose
1
Page 1 of 11
Abstract Objective: To report our experience in the treatment of penile torsion with a special reference to the Fisher technique.
Patients and methods: We reviewed thirty cases of congenital penile torsion treated from 2009 to 2015 in a single center. Sixteen patients presented a moderate rotation of 45° to 90° and 14 had a severe rotation with an angle greater than 90°. Chordee was present in 17 cases and distal glanular hypospadias in 15 cases. Median age at surgery was 10 months. In 14 cases, degloving along with skin realignment, alone, allowed correction of the torsion. In 16 cases, the Dartos flap (Fisher technique) was used.
Results: Out of the 30 patients, 29 had a good result with a complete correction of the torsion. Only one patient had a residual torsion of 30°. Complications were minor and consisted of skin excess in 11 patients; one single case needed to be reoperated for that skin complication. The need for the Dartos flap procedure was significantly correlated to the degree of torsion (p=0,001): It was used in 4 out of 16 patients (25%) with a torsion degree of less than 90, and in 12 out of 14 patients (86%) with a torsion of 90° or more.
Conclusion: Most of penile rotations of less than 90° can be corrected by skin degloving and realignment. The Fisher technique is a simple and safe procedure for correction of persistent rotation after skin degloving; such cases have usually a penile rotation greater than 90 degrees.
2
Page 2 of 11
Introduction
Congenital penile torsion is a rotation of the penis along its longitudinal axis (Figure 1). Most of the cases are, for an unknown reason, rotated in a counter clockwise direction. Penile rotation occurs as an isolated malformation. However, it can be associated with other penile anomalies such as hypospadias or ventral curvature. The true incidence of this anomaly is unknown; one recent prospective study reported a rather high incidence of 27% of neonatal penile torsion [1]. Consequences of uncorrected torsions in adulthood are not exactly known, which leads to a lack of recommendation regarding surgical treatment in infancy. Skin degloving and realignment [2] can be sufficient for correction of mild torsions of less than 60°. However, when it comes to cases of 90° or more, a complementary procedure should often be done. Prior to 2009, corporopexy [3] to the periosteum was for us the procedure of choice and we decided in 2009 to move to the fisher technique [4]. The latter procedure seemed to be easier and safer to perform for surgeons trained in surgery of hypospadias. The aim of this study is to report our global experience in the treatment of penile rotation with a special reference to the Fisher technique.
Patients and methods
Between January 2009 and April 2015, thirty cases of congenital penile torsion, without significant hypospadias (ie without a hypopadias needing to be corrected by urethroplasty), were repaired in a single center by two surgeons. Rotation was counter clockwise in 28 cases and clockwise in 2. The severity of rotation was
3
Page 3 of 11
considered as moderate when its degree ranged from 45 to 90 (16 cases), and as severe when degree was greater than 90 (14 cases). Preoperative degree of torsion was assessed with the penis flaccid. None of the patients had a rotation of less than 45°. None of the patients were previously circumcised. All patients had an abnormal prepuce with a ventrally opened or hooded foreskin. Chordee was present in 17 cases and glanular hypospadias in 15. Three cases had both chordee and hypospadias. The median age at surgery was 10 months (6-217). Surgical technique was performed under general anesthesia and consisted of day surgery cases. After a circumferential incision, the penile shaft skin was degloved down to the base of the penis.
In cases of curvature, whether observed
preoperatively or suspected intraoperatively, an artificial erection test was done after this first step. Residual chordee was corrected by a dorsal corpora plication, using the Nesbit procedure in 4 patients and the Baskin procedure in 3. Correction was confirmed by an artificial erection. Meatus and glanular malformations were treated by glanuloplasty (MAGPI) and Firlit preputial collar reconstruction. No urethroplasty such as the Duplay or the Snodgrass procedures was done. The correction of the torsion was evaluated at that time. In 14 cases, residual torsion was of less than 30° and the penile skin was realigned. In the remaining 16 cases, residual torsion was of more than 30° and needed the use of a dorsal Dartos flap (Table 1). The flap was dissected out of the deep layer of the dorsal mid-line foreskin, on a short distance (Figure 2.A). In cases of counter clockwise torsion, the flap was rotated around the right side of the penis, and then fixed with absorbable sutures, with some tension, at the ventral part of the left corpora beyond the corpus spongiosum (Figure 2.B). In cases of clockwise torsion, the procedure was inverted,
4
Page 4 of 11
with the flap being rotated around the left side of the penis and fixed to the ventral part of the right corpora. After suturing the Dartos flap, correction of the torsion was assessed with an artificial erection. In all cases, we tried to perform the procedure with a final aspect of a wellcircumcised penis (Figure 3). No dressing and no urinary catheter were left in place. End results were evaluated by clinical examination after at least 3 months postoperatively. Statistical analysis was done using the Fisher’s exact test.
Results
Follow-up period ranged from 10 to 72 months. All 30 patients were available for follow-up. No relevant complications occurred during the postoperative period. The 16 patients treated with the Fisher technique had a complete correction of the torsion along with a urethral meatus in a normal vertical anatomical orientation. None of the parents reported any residual torsion or chordee when phallus was erect. Residual torsion of 30° occurred in one patient initially treated by simple degloving and realignment and was not further corrected. In 12 patients (5 of which were operated with the Fisher technique), we observed a minor esthetic complication due to skin excess; one single case was re-operated in order to achieve a better cosmetic result. The need for the Dartos flap procedure was significantly (p= 0,001) correlated to the initial degree of torsion: It was used in 4 out of 16 patients (25%) with a torsion degree of less than 90, and in 12 out of 14 patients (86%) with a torsion of 90° or more.
5
Page 5 of 11
Discussion Penile glans torsion is a congenital deformity that can occur independently or in association with other malformations such as hypospadias and chordee. True incidence is difficult to evaluate. Series of surgically corrected cases are usually small. Surprisingly, in a cohort of 370 newborns [1], the incidence of glans rotation was 27% but, in fact, none of the torsions in this series exceeded 60°. Whenever surgical correction is decided, there is a consensus to start the procedure with skin degloving and realignment [2]. BarYosef et al [5] reported good results with skin realignment alone in a series of 46 children but only 3 patients had a rotation greater than 90°. In our experience, skin degloving alone was efficient in 13 out the 30 cases, 12 of them had a rotation of less than 90°. After this first step, when residual rotation exceeded 30°, an additional procedure was performed. Many techniques have been described in pertinent literature [3,4,6,7]; only two of them, the Fisher and the Zhou procedures, have been reported in different publications from those of their initial descriptions [8-10]. In our previously experience, ie prior to 2009 the additional procedure we used to perform was a corporopexy: it consisted of suturing the lateral face of the tunica albuginea of the corpora to the pubis as reported by Zhou [3]. Despite good results, we switched to the Fisher technique for several reasons 4: The exposure of the area surrounding the pubic zone for corporopexy need a rather deep and blind dissection, and there is some risk of trauma of the vasculo-nervous bundles when placing the stitches on the corpora. At the opposite, the Fischer technique refers to the principle of dissection of a dorsal flap, which is widely used and easy to perform for all surgeons involved in hypospadias surgery. There is no risk for the vasculo-nervous bundles because all the stiches are placed on the ventral part of the corpora. Adjusting the sutures in order to achieve a complete correction is easy by 6
Page 6 of 11
placing additional sutures or removing others. Our results with the Dartos flap were as good as published in rather small series of less than 10 cases [4,9,10] and in otherwise larger ones such as the series of Bauer et al. that consisted of 25 cases [8]. Aldaqadossi et al. [9], in a prospective study, compared the Dartos flap technique to the fixation to the periosteum. Results were good and similar in both techniques, although the authors concluded that the Fisher technique was easier. Elbatarny et al. [10] proposed a staged approach reserving the use of the Zhou technique to cases of incomplete correction by the Fisher technique. However, in our experience, even when rotation exceeded 90°, the Dartos flap was efficient. Concerning the final esthetic result the rate of excess skin, evaluated by the surgeon, seems quite high (40%) in our experience but only one case required revision. Skin coverage is not a simple part of the repair. In most cases after correction of the torsion the dorsal foreskin takes a lateral position, usually on the left side of the penis, with the skin defect being rather on the right side. Performing a Byars procedure in this anatomical condition is more difficult than in patients with a well oriented dorsal foreskin especially to avoid dorsolateral scars.
The limit of our study is similar to other studies and consists of a lack of longterm follow up. Puberty could worsen the situation if torsion is due to a malformation of the corpora. However, such a situation seems unlikely because correction of penile torsion is usually achieved with a procedure limited to the skin and the subcutaneous tissue, and does not include any invasive procedure on the corpora. Early surgical indications of this congenital anomaly can be discussed.
Some
families do not ask for any kind of surgery in such cases since correction is for cosmetic purposes only. The surgical correction is certain in cases of associated
7
Page 7 of 11
malformations including the ventral chordee. In our study, all operated children presented with an abnormal foreskin: skin surface was unusually opened or hooded, and parents desired both an early and esthetic correction. The incomplete aspect of the foreskin and the Fisher technique lead to a final aspect of circumcision.
Conclusion Throughout our own experience and pertinent literature we conclude that: - Most of penile rotation of less than 90° can be corrected by skin degloving and realignment - The Fisher Dartos flap is an excellent way to correct penile rotation of 90° or more in children, with very few complications. Unlike other techniques, this procedure is easy to perform for surgeons familiar with hypospadias surgery.
References
1–10
1.
Sarkis PE, Sadasivam M. Incidence and predictive factors of isolated neonatal penile glanular torsion. J Pediatr Urol. 2007;3(6):495-499. doi:10.1016/j.jpurol.2007.03.002.
2.
Azmy a, Eckstein HB. Surgical correction of torsion of the penis. Br J Urol. 1981;53(4):378-379. http://www.ncbi.nlm.nih.gov/pubmed/7260553.
3.
Zhou L, Mei H, Hwang AH, Xie HW, Hardy BE. Penile torsion repair by suturing tunica albuginea to the pubic periosteum. J Pediatr Surg. 2006;41(1):7-9.
8
Page 8 of 11
doi:10.1016/j.jpedsurg.2005.10.065. 4.
Fisher PC, Park JM. Penile Torsion Repair Using Dorsal Dartos Flap Rotation. J Urol. 2004;171(5):1903-1904. doi:10.1097/01.ju.0000120148.79867.5c.
5.
Bar-Yosef Y, Binyamini J, Matzkin H, Ben-Chaim J. Degloving and Realignment-Simple Repair of Isolated Penile Torsion. Urology. 2007;69(2):369-371. doi:10.1016/j.urology.2007.01.014.
6.
Snow BW. Penile torsion correction by diagonal corporal plication sutures. Int Braz J Urol. 2009;35(1):56-57. doi:10.1590/S1677-55382009000100009.
7.
Bhat A, Bhat MP, Saxena G. Correction of penile torsion by mobilization of urethral plate and urethra. J Pediatr Urol. 2009;5(6):451-457. doi:10.1016/j.jpurol.2009.05.013.
8.
Bauer R, Kogan BA. Modern Technique for Penile Torsion Repair. J Urol. 2009;182(1):286-291. doi:10.1016/j.juro.2009.02.133.
9.
Aldaqadossi HA, Elgamal SA, Seif Elnasr MK. Dorsal dartos flap rotation versus suturing tunica albuginea to the pubic periosteum for correction of penile torsion: A prospective randomized study. J Pediatr Urol. 2013;9(5):643647. doi:10.1016/j.jpurol.2012.07.014.
10.
Elbatarny AM, Ismail KA. Penile torsion repair in children following a ladder step: Simpler steps are usually sufficient. J Pediatr Urol. 2014;10(6):1187-1192. doi:10.1016/j.jpurol.2014.05.009.
9
Page 9 of 11
Figure 1: Severe penile torsion Figure 2: Dissection of the flap as in Fisher's technique A. Dissection of the flap from the deep face of the foreskin B. Fixation at the ventral part of the left corpora Figure 3: Penis after correction by Fisher's technique
10
Page 10 of 11
Table1. Population's characteristics Penile torsion n (%) Patients characteristics
Moderate
Severe
(n= total)
16 (53)
14 (47)
- Age (months)
19,9
24,6
- Chordee (17)
8 (50)
9 (64)
- Glanular hypospadias (15)
8 (50)
7 (50)
12 (75)
2 (14)
4 (25)
12 (86)
- Complete correction (29)
15 (94)
14 (100)
- Minor esthetic complication (11)
6 (37)
5 (36)
Preoperative
Peroperative - Only degloving and realignment (14) - Dorsal dartos flap rotation (16) Postoperative
11
Page 11 of 11