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The Treatment of Penile Chordee using Corporeal Rotation
0022-5347/B4/13l5-093:$02.CO TrtE JOURNAL OF' UROLOGY
Copyright© 1984 by The V{illicff.as & 'vVilkins Cc.
THE TREATMENT OF PENILE CHORDEE USING CORPOREAL ROTATION STEPHEN A KOFF
AND
MAXINE EAKINS
From the Section of Pediatric Urology, Department of Surgery, Ohio State University Medical College and Columbus Children's Hospital, Columbus, Ohio
ABSTRACT
Corporeal rotation, a simple, adjunctive, surgical technique for changing the direction of penile curvature, has been used successfully to treat chordee in patients with epispadias and hypospadias. In patients with complex penile chordee, such as those with epispadias and severe hypospadias, penile curvature may persist after all restrictive tissue is removed and conventional efforts are exhausted. Further treatment generally has consisted of excision or plication of the tunica albuginea of the corpora cavernosa, which actually shortens the phallus to some extent. We present an alternative surgical technique that uses rotation of the corpora to correct persistent penile curvature.
assumes a position unsuitable for intromission. Corporeal rotation is performed by placing a row of interrupted fine nonabsorbable sutures on the ventral surface of each corpus. When tied these sutures will bring the corpora together and cause an inward and upward mirror rotation of the erectile cylinders (fig. 2). The distal sutures should be placed close together while the proximal sutures should be placed farther apart to make the rotation symmetrical (fig. 3). Great care must be taken to avoid the superior and lateral neurovascular bundles and their branches, which are placed more laterally in cases of epispadias. The artificial erection technique is used as necessary to monitor the degree of curvature change. If more corporeal rotation is required an additional row of sutures can be placed. If overcorrection of the chordee with the development of ventral curvature occurs removal and replacement of the sutures, and partial reduction of the rotation will be corrective. If necessary, asymmetric rotation of 1 corpus to a greater degree may be used to correct an asymmetric penile curvature. Once satisfactory erectile position is achieved the epispadias correction can be completed by urethral repair and skin coverage. With modification the technique of corporeal rotation is applicable to cases of hypospadias when chordee persists after complete mobilization of the penile skin as a sleeve, mobilization of the urethra and removal of all restrictive fibrous tissue, even behind the urethra. In th.is situation corporeal. rotation may be used to counteract the ventral chordee and to produce a straight, erect phallus (fig. 2). Rotation is accomplished without separation of the corpora and placement of dorsal sutures, which risk injury to the dorsal neurovascular elements. Instead, rotation is achieved via a longitudinal incision in the ventral midhne deep to the urethra and between the corpora, and to which allows the corporeal bodies to separate rotate in the appropriate direction with erection.
MATERIALS
This technique was used in a boy with a short, angulated phallus after 3 previous operations for exstrophy and epispadias (fig. 1, A). During epispadias repair it became obvious that the corpora were disconnected and 1 had been detached previously from the glans (fig. 1, B). Interesting observations were made on the effect of corporeal rotation while determining how to connect these structures properly. No significant chordee occurred during an artificial erection when sutures were placed opposite each other in the 3 and 9 o'clock positions to approximate the corpora without rotation (fig. 2). However, dorsal chordee resulted when sutures were placed dorsally to produce inward and downward rotation with approximation of the corpora, while ventral chordee was noted when the sutures were placed on the ventral surface to approximate and rotate the corpora in an inward and upward direction. Our experience with this case suggested that the principle of mirror rotation of the corpora in a dorsal or ventral direction (depending on the desired directional correction) might be useful in the surgical management of chordee refractory to conventional treatment. The artificial erection technique can be used repeatedly to monitor the degree of change in the chordee to permit an accurate estimation and adjustment of the curvature. We have used the procedure successfully in 7 and 1 of "'"""'" """· The correction of cases of <;mJn.,ee. as during n~~,h'" 01 erection, has been satisfactory and no complications have occurred. METHOD
repair of chordee associated with epispadias the penile skin is mobilized as a sleeve and the urethral strip (or tube if closed previously) is separated from its corporeal attachments. Next, each corpus is dissected off the ischiopubic ramus according to the technique of Johnston and Kogan. 1 An artificial erection using 2 needles and simultaneous injection into each corpus cavernosum is used to assess residual penile curvature. In many instances, although the corpora have been freed sufficiently to produce a dangling, dependent phallus, the shaft parallels the anterior abdominal wall upon erection and
COMMENT
Corporeal rotation appears to be a simple, safe and effective adjunctive operative technique for inducing or changing the direction of penile curvature. Corporeal rotation works by creating a mild tethering effect on 1 side of the phallus and by transposing a portion of the erectile mass to the opposite side. The primary use for this technique is in cases of chordee associated with epispadias in which the corpora already are separated for a considerable distance and can be rotated easily. In most cases of hypospadias conventional methods for treating curvature usually are satisfactory and the indications for corporeal rotation are rare. Clinical experience with this technique has been satisfactory and has not been associated with complications to date. REFERENCE
Accepted for publication December 16, 1983. Read at annual meeting of American Urological Association Las Vegas, Nevada, April 17-21, 1983. '
1. Johnston, J. H. and Kogan, S. J.: The exstrophic anomalies and
their surgical reconstruction. Curr. Prob. Surg., p. 1, Aug. 1974. 931
Copyright© 1984 by The V{illicff.as & 'vVilkins Cc.
THE TREATMENT OF PENILE CHORDEE USING CORPOREAL ROTATION STEPHEN A KOFF
AND
MAXINE EAKINS
From the Section of Pediatric Urology, Department of Surgery, Ohio State University Medical College and Columbus Children's Hospital, Columbus, Ohio
ABSTRACT
Corporeal rotation, a simple, adjunctive, surgical technique for changing the direction of penile curvature, has been used successfully to treat chordee in patients with epispadias and hypospadias. In patients with complex penile chordee, such as those with epispadias and severe hypospadias, penile curvature may persist after all restrictive tissue is removed and conventional efforts are exhausted. Further treatment generally has consisted of excision or plication of the tunica albuginea of the corpora cavernosa, which actually shortens the phallus to some extent. We present an alternative surgical technique that uses rotation of the corpora to correct persistent penile curvature.
assumes a position unsuitable for intromission. Corporeal rotation is performed by placing a row of interrupted fine nonabsorbable sutures on the ventral surface of each corpus. When tied these sutures will bring the corpora together and cause an inward and upward mirror rotation of the erectile cylinders (fig. 2). The distal sutures should be placed close together while the proximal sutures should be placed farther apart to make the rotation symmetrical (fig. 3). Great care must be taken to avoid the superior and lateral neurovascular bundles and their branches, which are placed more laterally in cases of epispadias. The artificial erection technique is used as necessary to monitor the degree of curvature change. If more corporeal rotation is required an additional row of sutures can be placed. If overcorrection of the chordee with the development of ventral curvature occurs removal and replacement of the sutures, and partial reduction of the rotation will be corrective. If necessary, asymmetric rotation of 1 corpus to a greater degree may be used to correct an asymmetric penile curvature. Once satisfactory erectile position is achieved the epispadias correction can be completed by urethral repair and skin coverage. With modification the technique of corporeal rotation is applicable to cases of hypospadias when chordee persists after complete mobilization of the penile skin as a sleeve, mobilization of the urethra and removal of all restrictive fibrous tissue, even behind the urethra. In th.is situation corporeal. rotation may be used to counteract the ventral chordee and to produce a straight, erect phallus (fig. 2). Rotation is accomplished without separation of the corpora and placement of dorsal sutures, which risk injury to the dorsal neurovascular elements. Instead, rotation is achieved via a longitudinal incision in the ventral midhne deep to the urethra and between the corpora, and to which allows the corporeal bodies to separate rotate in the appropriate direction with erection.
MATERIALS
This technique was used in a boy with a short, angulated phallus after 3 previous operations for exstrophy and epispadias (fig. 1, A). During epispadias repair it became obvious that the corpora were disconnected and 1 had been detached previously from the glans (fig. 1, B). Interesting observations were made on the effect of corporeal rotation while determining how to connect these structures properly. No significant chordee occurred during an artificial erection when sutures were placed opposite each other in the 3 and 9 o'clock positions to approximate the corpora without rotation (fig. 2). However, dorsal chordee resulted when sutures were placed dorsally to produce inward and downward rotation with approximation of the corpora, while ventral chordee was noted when the sutures were placed on the ventral surface to approximate and rotate the corpora in an inward and upward direction. Our experience with this case suggested that the principle of mirror rotation of the corpora in a dorsal or ventral direction (depending on the desired directional correction) might be useful in the surgical management of chordee refractory to conventional treatment. The artificial erection technique can be used repeatedly to monitor the degree of change in the chordee to permit an accurate estimation and adjustment of the curvature. We have used the procedure successfully in 7 and 1 of "'"""'" """· The correction of cases of <;mJn.,ee. as during n~~,h'" 01 erection, has been satisfactory and no complications have occurred. METHOD
repair of chordee associated with epispadias the penile skin is mobilized as a sleeve and the urethral strip (or tube if closed previously) is separated from its corporeal attachments. Next, each corpus is dissected off the ischiopubic ramus according to the technique of Johnston and Kogan. 1 An artificial erection using 2 needles and simultaneous injection into each corpus cavernosum is used to assess residual penile curvature. In many instances, although the corpora have been freed sufficiently to produce a dangling, dependent phallus, the shaft parallels the anterior abdominal wall upon erection and
COMMENT
Corporeal rotation appears to be a simple, safe and effective adjunctive operative technique for inducing or changing the direction of penile curvature. Corporeal rotation works by creating a mild tethering effect on 1 side of the phallus and by transposing a portion of the erectile mass to the opposite side. The primary use for this technique is in cases of chordee associated with epispadias in which the corpora already are separated for a considerable distance and can be rotated easily. In most cases of hypospadias conventional methods for treating curvature usually are satisfactory and the indications for corporeal rotation are rare. Clinical experience with this technique has been satisfactory and has not been associated with complications to date. REFERENCE
Accepted for publication December 16, 1983. Read at annual meeting of American Urological Association Las Vegas, Nevada, April 17-21, 1983. '
1. Johnston, J. H. and Kogan, S. J.: The exstrophic anomalies and
their surgical reconstruction. Curr. Prob. Surg., p. 1, Aug. 1974. 931