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Transverse corporeal plication for persistent chordee
TRANSVERSE CORPOREAL PLICATION FOR PERSISTENT CHORDEE BRENT W. SNOW, M.D. From the Division of Urology, The University of Utah School of Medicine, Salt Lake City, Utah
A B S T R A C T - - A technique is described wherein chordee which persists after resection of all evident fibrous tissue may be corrected. This technique involves a ventral midline incision and transverse dorsal plicating sutures w h i c h rotate the corporeal bodies to allow a straight erection.
Correction of ventral ehordee at the time of hypospadias repair has long been a thorn in the surgeon's side. One of the major reasons early hypospadias surgeons did two-stage hypospadias repairs was the difficulty of chordee release. Since Gittes and McLaughlin in 19741 introduced the artificial erection technique, chordee correction now can be performed with assurance. This confidence has allowed hypospadias surgery to be done in a single stage. However, in certain patients when the fibrous tissue distal to the hypospadiac meatus is excised, ventral chordee persists. Numerous solutions for this vexing problem have been suggested: excision of dorsal corporeal ellipses, 2 plicating dorsal longitudinal sutures, 3 a midline ventral incision, 4 and ventral corporeal patches. 5 Herein is described a technique that effectively corrects persistent ehordee without penile shortening.
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"
Technique The hypospadias repair is begun according to the preference of the surgeon. The penile skin is degloved and the chordee tissue distal to the hypospadiac urethra is resected. An artificial erection is then performed. 1 When persistent ventral ehordee remains in spite of adequate
360
FI(-;ui:IE1. Ventral midline incision is' made and resulting corporeal rotation due to transverse corporeal plicating sutures is illustrated.
UROLOGY
/
D E C E M B E R 1989
/
V O L U M E XXXIV, NUMBER 6
resection of the fibrous ventral tissue, a midline ventral incision is made between the corporeal cavernosus bodies. This incision is made from the coronal margin to the hypospadiae meatus. Care is taken with this incision to divide only the septum between the two corporeal cavernosus bodies. The septum is divided m i d w a y through the shaft of the penis. Then a nonabsorbable suture is passed through the tunica albuginea lateral to the dorsal neurovascular bundle and c'arried across the neurovascular bundle where it is passed through the tunica albuginea again. The suture is placed such that the knot will be buried. Three of these sutures 3-4 mm apart are usually sufficient (Fig. 1). The sutures are then tied; this rotates the corporeal eavernosus bodies from the ventral midline laterally which aeeounts for the ehordee correction. An artificial erection is repeated to verify that the ehordee has been straightened. The remainder of the hypospadias repair is completed as previously designed.
penis. Another major advantage is that by utilizing this technique there is no penile shortening as in most other techniques. The technical considerations must be emphasized. Care should be taken to avoid any sutures that would compromise the dorsal neurovascular bundle. The nonabsorbable sutu:res should be of a soft material so that they are not palpable through the skin postoperatively. Avoid entering the corporeal eavernosus bodies during the ventral midline incision. The correction of the chordee must also be verified by an artificial erection. The artificial erection will demonstrate the proximal phallus to be thicker than the distal phallus and care must be taken that this difference in girth be a gradual change rather than an abrupt change. Postoperatively this difference has not been noticeable. This represents a simple but effective technique to overcome persistent chordee during hypospadias surgery which does not shorten the penis. Salt Lake City, Utah 84132
Comment Persistent chordee after the reseetion of the fibrous ventral tissue is fortunately an uncommon problem. However, a satisfactory solution has yet to be found. The teehnique described has the advantages of not requiring any incisions into the corporeal eavernosus bodies themselves thereby avoiding the eomplieations of hemorrhage as well as abnormal scarring. Since the proeedure takes advantage of rotation of the corporeal bodies, a there is less tension on the plieating sutures than on those w h i c h are plaeed longitudinally in the dorsum of the
UROLOGY
:
DECEMBER 1989
/
tteferences 1. Gittes tlF and MeLaughlin AP III: lnjeetioe technique to induce penile erection, UroloD' 4:473 (1974). 2. Nesbit RM: Congenital curvature of the phallus: report of three eases with description of corrective operation, J Uro193:230
(1965). 3. ttodgson NB: Use of vaseularized flaps in hypospadias repair, Urol Clin North Am 8:471 (1981). 4. Devine CJ Jr: Chordee and hypospadias, in Glenn JF, and Boyee WH (Eds): Urologic Surgery, 3rd ed, Philadelphia, Lippineott Publishers, 1983, pp 775-797. 5. Das S, and Maggio AJ: Tuniea vaginalis mltografting for Pevronie's disease, an experimental study, Inw'st Urol 17:186 (1079). 6. Koff SA, and Eakins M: The treatment ot penile ehordee usin~ corporeal rotation, l Urol 131:931 (1984)
VOLUME XXXIV, NUMBEB 6
361
A B S T R A C T - - A technique is described wherein chordee which persists after resection of all evident fibrous tissue may be corrected. This technique involves a ventral midline incision and transverse dorsal plicating sutures w h i c h rotate the corporeal bodies to allow a straight erection.
Correction of ventral ehordee at the time of hypospadias repair has long been a thorn in the surgeon's side. One of the major reasons early hypospadias surgeons did two-stage hypospadias repairs was the difficulty of chordee release. Since Gittes and McLaughlin in 19741 introduced the artificial erection technique, chordee correction now can be performed with assurance. This confidence has allowed hypospadias surgery to be done in a single stage. However, in certain patients when the fibrous tissue distal to the hypospadiac meatus is excised, ventral chordee persists. Numerous solutions for this vexing problem have been suggested: excision of dorsal corporeal ellipses, 2 plicating dorsal longitudinal sutures, 3 a midline ventral incision, 4 and ventral corporeal patches. 5 Herein is described a technique that effectively corrects persistent ehordee without penile shortening.
..~-.~i<~
"
Technique The hypospadias repair is begun according to the preference of the surgeon. The penile skin is degloved and the chordee tissue distal to the hypospadiac urethra is resected. An artificial erection is then performed. 1 When persistent ventral ehordee remains in spite of adequate
360
FI(-;ui:IE1. Ventral midline incision is' made and resulting corporeal rotation due to transverse corporeal plicating sutures is illustrated.
UROLOGY
/
D E C E M B E R 1989
/
V O L U M E XXXIV, NUMBER 6
resection of the fibrous ventral tissue, a midline ventral incision is made between the corporeal cavernosus bodies. This incision is made from the coronal margin to the hypospadiae meatus. Care is taken with this incision to divide only the septum between the two corporeal cavernosus bodies. The septum is divided m i d w a y through the shaft of the penis. Then a nonabsorbable suture is passed through the tunica albuginea lateral to the dorsal neurovascular bundle and c'arried across the neurovascular bundle where it is passed through the tunica albuginea again. The suture is placed such that the knot will be buried. Three of these sutures 3-4 mm apart are usually sufficient (Fig. 1). The sutures are then tied; this rotates the corporeal eavernosus bodies from the ventral midline laterally which aeeounts for the ehordee correction. An artificial erection is repeated to verify that the ehordee has been straightened. The remainder of the hypospadias repair is completed as previously designed.
penis. Another major advantage is that by utilizing this technique there is no penile shortening as in most other techniques. The technical considerations must be emphasized. Care should be taken to avoid any sutures that would compromise the dorsal neurovascular bundle. The nonabsorbable sutu:res should be of a soft material so that they are not palpable through the skin postoperatively. Avoid entering the corporeal eavernosus bodies during the ventral midline incision. The correction of the chordee must also be verified by an artificial erection. The artificial erection will demonstrate the proximal phallus to be thicker than the distal phallus and care must be taken that this difference in girth be a gradual change rather than an abrupt change. Postoperatively this difference has not been noticeable. This represents a simple but effective technique to overcome persistent chordee during hypospadias surgery which does not shorten the penis. Salt Lake City, Utah 84132
Comment Persistent chordee after the reseetion of the fibrous ventral tissue is fortunately an uncommon problem. However, a satisfactory solution has yet to be found. The teehnique described has the advantages of not requiring any incisions into the corporeal eavernosus bodies themselves thereby avoiding the eomplieations of hemorrhage as well as abnormal scarring. Since the proeedure takes advantage of rotation of the corporeal bodies, a there is less tension on the plieating sutures than on those w h i c h are plaeed longitudinally in the dorsum of the
UROLOGY
:
DECEMBER 1989
/
tteferences 1. Gittes tlF and MeLaughlin AP III: lnjeetioe technique to induce penile erection, UroloD' 4:473 (1974). 2. Nesbit RM: Congenital curvature of the phallus: report of three eases with description of corrective operation, J Uro193:230
(1965). 3. ttodgson NB: Use of vaseularized flaps in hypospadias repair, Urol Clin North Am 8:471 (1981). 4. Devine CJ Jr: Chordee and hypospadias, in Glenn JF, and Boyee WH (Eds): Urologic Surgery, 3rd ed, Philadelphia, Lippineott Publishers, 1983, pp 775-797. 5. Das S, and Maggio AJ: Tuniea vaginalis mltografting for Pevronie's disease, an experimental study, Inw'st Urol 17:186 (1079). 6. Koff SA, and Eakins M: The treatment ot penile ehordee usin~ corporeal rotation, l Urol 131:931 (1984)
VOLUME XXXIV, NUMBEB 6
361