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Corporal rotation for correction of isolated congenital dorsal curvature of the penis without shortening

Shaeer, Osamaa; Shaeer, Kamala; Abdulrasool, Mohamedb

doi: 10.1097/01.XHA.0000396632.75175.8e
Original articles
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Introduction Significant degrees of isolated (without epispadias) congenital dorsal curvature of the penis may interfere with sexual intercourse. Rotation of the corpora cavernosa may correct this condition with neither shortening nor erectile dysfunction.

Aim To investigate the outcome of correction of isolated congenital dorsal penile curvature by corporal rotation.

Methods The procedure was performed in eight patients with dorsal deviation of 70–90°. Through a ventral median raphe incision, the corpus spongiosum was mobilized from the corpora cavernosa by sharp dissection. Two parallel incisions were cut, one on the ventral aspect of each corpus cavernosum on each side of the midline. The incisions were approximated, achieving corporeal rotation and thereby correcting curvature.

Main outcome measures Correction of curvature, penile length, and sexual function.

Results Correction of curvature was achieved in all patients, with no shortening, asymmetry, or erectile dysfunction, with the exception of one patient who had mild residual curvature and mild girth asymmetry.

Conclusion Management of dorsal congenital penile curvature by corporal rotation offers full correction with no compromise in length or deterioration of erectile function.

aDepartments of Andrology

bUrology, Kasr El Aini Faculty of Medicine, Cairo University, Egypt

Correspondence to Osama Shaeer, 21 Gaber Ibn Hayan Street, Dokki, 12311 ARE, Cairo, Egypt Tel: + 202 33359047/33374360; fax: +202 37605181; e-mail: dr.osama@alrijal.com

Received January 5, 2011

Accepted February 3, 2011

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Introduction

Penile curvature may be of congenital or acquired origin. Congenital curvature may be associated with epispadias or isolated. The isolated form is present in 4–10% of males [1]. This may be due to tethering of the penile skin, atretic development of the corpus spongiosum, or tethering of the urethral plate onto the corpora or corporeal disproportion [2]. Acquired curvature is mostly a result of Peyronie's disease.

Congenital curvature is mostly ventral. In a series of 100 patients with congenital curvature, 95% was in the ventral direction, and only 5% was dorsal [3]. Dorsal curvature is therefore rare in the congenital domain, in contrast to cases of Peyronie's disease.

Correction of curvature is indicated according to the severity of deviation, which may interfere with and sometimes prevent sexual intercourse. There is more tolerance to the degree of deviation in cases with dorsal curvature, where a more profound degree is necessary to hinder intercourse, in contrast to ventral curvature. Nevertheless, surgery is sometimes indicated for cosmetic purposes.

Regardless of the direction of curvature, three geometrical principles exist as follows: shortening the convex aspect, widening the concave aspect, and rotation of the corpora cavernosa. The principle of shortening the convex side is achievable by the Nesbit procedure [4], modified Nesbit technique [5], and the tunica albuginea plication [6], among other techniques; all have the disadvantage of short penile length. Expanding the concave aspect is performed by interposition grafting [7]. However, erectile dysfunction is a reported complication because of venous incompetence [8]. The third principle, corporal rotation, achieves correction of curvature with neither shortening nor erectile dysfunction [9].

The former techniques have been evaluated mostly in cases of ventral curvature, because of the rarity of cases with dorsal deviation, and because of restriction of surgical intervention to the more severe cases.

This study describes the application of the principle of corporal rotation in adult male patients with considerable degrees of isolated congenital penile curvature.

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Methods

Eight patients aged 22–28 years were selected for the procedure, all with considerable curvature of 55–90° dorsally, with no concomitant epispadias or Peyronie's disease. All patients reported normal voiding and full rigidity in response to erotic stimuli. Sexual function was assessed by penile duplex and intracorporeal injection of prostaglandin E1 before surgery. This induced full rigidity for an average of 40 min and showed normal penile hemodynamics. In the erect state, curvature could neither be manually corrected nor accentuated, denoting full rigidity. International Index of Erectile Function was inapplicable to the patients because they were all single without a sex partner. All patients provided a written informed consent before surgery.

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Surgical technique

Artificial erection is induced by an injection of 20 mg of prostaglandin E1. The degree of deviation and the point or segment of maximum curvature are determined (Fig. 1). Length was considered as the sum of the distance from the pubis to the point of maximum curvature and the distance from this point to the tip of the penis. Symmetry of the penis was determined by comparing girth proximally and distally with the point of maximum curvature (Table 1). The urethra is catheterized. A longitudinal skin incision is cut on the ventral aspect of the penis along the median raphe, extending proximal and distal from the point of maximum curvature. Dartos fascia is cut along the same line, down to the corpus spongiosum and corpora cavernosa. The corpus spongiosum is mobilized from the corpora cavernosa by sharp dissection (Fig. 1). Spongiolysis is started proximally where the corpus spongiosum is less adhering to the cavernosum. Sharp dissection proceeds on both sides of the same point into the loose areolar tissue distinct from the spongiosal tissue and the tunica albuginea, until it gives way. Tape is looped around the spongiosum and is used to hold it from the corpora cavernosa. Sharp dissection proceeds in the same plane, cauterizing bleeding points along the way by bipolar diathermy until spongiolysis is complete, from a point proximal to the segment of maximum curvature to a point distal to it. The spongiosum is set laterally to expose the corpora cavernosa and the midline.

Table 1

Table 1

Figure 1

Figure 1

Two incisions are cut, one on the ventral aspect of each corpus cavernosum, a few millimeters from the midline. Incisions should extend both proximal and distal from the segment of maximum curvature (Fig. 2). Incisions are as deep as the outer longitudinal layer of the tunica albuginea and should not reach the cavernous tissue. This is easy in the erect state where the configuration of fibers is clear and where exceeding the required depth results in a gush of blood that warns the surgeon to proceed more superficially. The incisions converge toward their proximal and distal ends. The incisions can be cut with a blade or with unipolar diathermy, in which case the penis should be coapted to the pubic skin to dissipate current.

Figure 2

Figure 2

The two suture lines are approximated, medial edge-to-medial edge (Fig. 3) and lateral edge-to-lateral edge (Fig. 4). Approximation of these edges causes the corpora to rotate, thereby correcting curvature (Fig. 5). Approximation starts with suturing the medial edges at their proximal-most point with a continuous suture line proceeding distally, using 0/0 slowly absorbable polydioxonone sutures. The knot at the medial and distal ends should be inverted. Interrupted 0/0 vicryl sutures are used to strengthen the suture line with interrupted stitches. Once the medial edges are fully approximated and the continuous suture line reaches the distal end (Fig. 3), it is tied with an inverted knot, and the lateral edges are approximated in the same way using both continuous polydioxonone and interrupted vicryl sutures from the distal point back to the starting point, where the continuous suture line is tied with an inverted buried knot (Fig. 4). While tying the sutures, manual correction of the curvature helps approximation of the edges without excessive tension that may cause the suture to snap. Curvature is reassessed to make sure it is fully corrected. If residual curvature exists, the suture line may be extended or the plication technique may be used, where it should not cause noteworthy shortening considering that the main brunt of curvature has been corrected by rotation. The same applies to any concomitant lateral curvature.

Figure 3

Figure 3

Figure 4

Figure 4

Figure 5

Figure 5

Dartos fascia is approximated over the suture line, separating it from the corpus spongiosum, which is returned to its position in the midline and sutured with superficial absorbable sutures to the fascia. It is preferable to develop two layers from the dartos fascia, one to intervene between the corpora cavernosa and the corpus cavernosum, and another to intervene between the corpus spongiosum and the skin suture line. Artificial erection is undone and skin incision is closed.

The catheter is removed after 24–48 h. Patients are then discharged and asked to abstain from sexual activity for a minimum of 3 months to make sure that the incisions have healed firmly. Patients are counseled on the possibility of mild pain on erection that may persist for a few weeks.

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Results

Curvature was fully corrected in all patients without the need for extending the incisions or plication of the tunica albuginea. No change in length or girth was noted, whether intraoperative or postoperative, with the exception of one patient who reported residual curvature of 10° approximately, and a mild discrepancy in girth between the proximal and distal shaft (Table 1). All patients voided normally after removing the catheter. Postoperative pain upon erection was minimal.

Patients were followed for over a range of 6–18 months. They reported normal rigid erection comparable with that of preoperative rigidity, and full correction of curvature. Unfortunately, none of the patients agreed to an examination of the results with pharmacologically induced erection and documentation by photography. All patients were satisfied with the results with no reported shortening, narrowing, or asymmetry. Five patients engaged in a regular coital relationship that was reportedly successful.

Surgical correction was straightforward and operative time was an average of 90 min.

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Discussion

Congenital curvature can be fully corrected by shortening the convex side. This has proven effective in ventral curvature [4,5] and in dorsal deviation [10]. However, this is notorious for shortening the penis altogether. In a series of eight children with isolated congenital dorsal curvature, the urethra and corpus spongiosum were mobilized away from the corpora cavernosa in the area of maximal curvature during artificial erection. The longer ventral tunica was shortened by wedge resection. In two cases, multiple smaller ellipses were excised. After resection, the corpora were reconstructed using absorbable suture. In six cases, the tunica of the corpora was imbricated ventrally using permanent suture at the area of maximal curvature, including three in which the urethra and spongiosum were not mobilized [10]. Cosmetic and functional results were fine. The investigators report that penile length was not evaluated, but considering that all patients had a penile length that was two standard deviations greater than the mean normal length for patient age, the postoperative length was acceptable. The investigators report that exaggerated penile length is a phenomenon in these patients [10]. Nevertheless, shortening may reach an unacceptable degree in extreme cases of curvature [11], especially if the penile length is within average. The alternative is grafting the concave side. Unfortunately, this is known to cause erectile dysfunction because of venous leakage [8].

Rotation of the corpora cavernosa is capable of correcting any degree of penile curvature with no impact on length or erectile function. The basic principle is shifting the concavity of both corpora cavernosa from the dorsal aspect of the penis to the lateral aspect in opposition, such that they flex against each other rather than synergistically, thereby neutralizing their curvature-inducing effect. Considering that there was no loss in length or erectile function, this technique is an alternative to be considered, especially in cases of profound curvature in a phallus of average length.

The possible drawback of disproportionate proximal and distal penile girth can be avoided by decreasing the distance between the rotating incisions and extending them along most of the length of the distal corpora cavernosa. Although it is a rare possibility and has not been overt or troublesome in the single case experiencing this mild discrepancy, the possibility should be discussed with the patient before surgery and weighed against the pros and cons of other techniques.

It is worth mentioning that the techniques relying on shortening the convex side are relatively easier to perform and may not require mobilization of the corpus spongiosum in many cases [10], thereby shortening operative time. However, corporeal rotation does not pose extreme difficulty and is still easily feasible with an average operative time of 90 min. Spongiolysis has not resulted in any complications.

In our opinion, the midline ventral incision in the median raphe is relatively concealed compared with the customary subcoronal degloving incision, and does not obligate circumcision of unwilling patients. It also spares the patient the distal edema and the possible gaping upon postoperative erections reported with the subcoronal incision [9]. However, a subcoronal degloving incision may provide better access to the dorsum of the penis to excise chordee, if any. It is our experience that chordee excision contributes very little to correction of curvature and, if performed on the dorsal aspect, may compromise the neurovascular bundle.

A shortcoming of this investigation is the low number of cases. In contrast to ventral and lateral curvatures, dorsal curvature will not impede coitus unless its degree is considerable. In our opinion, most patients with dorsal curvature are not strictly indicated for surgical repair, even for cosmetic purpose, with the exception of the less common cases of curvature of more than 70°.

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Conclusion

Management of dorsal congenital penile curvature by corporal rotation offers full correction with no compromise in length or deterioration of erectile function.

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References

1. Kramer SA, Aydin G, Kelalis PP. Chordee without hypospadias in children. J Urol. 1982;128:559–561
2. Mouriquand PD, Persad R, Sharma S. Hypospadias repair: current principles and procedures. Br J Urol. 1995;76(Suppl 3):9–22
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4. Nesbit RM. Congenital curvature of the phallus: report of three cases with description of corrective operation. J Urol. 1965;93:230–232
5. Nesbit RM. Operation for correction of distal penile ventral curvature with or without hypospadias. Trans Am Assoc Genitourin Surg. 1966;58:12–14
6. Baskin LS, Duckett JW. Dorsal tunica albuginea plication for hypospadias curvature. J Urol. 1994;151:1668–1671
7. Devine CJ Jr, Horton CE. Use of dermal graft to correct chordee. J Urol. 1975;113:56–58
8. Dalkin BL, Carter MF. Venogenic impotence following dermal graft repair for Peyronie's disease. J Urol. 1991;146:849–851
9. Shaeer O. Shaeer's corporal rotation for length-preserving correction of penile curvature: modifications and 3-year experience. J Sex Med. 2008;5:2716–2724
10. Adams MC, Chalian VS, Rink RC. Congenital dorsal penile curvature: a potential problem of the long phallus. J Urol. 1999;161:1304–1307
11. Daitch JA, Angermeier KW, Montague DK. Modified corporoplasty for penile curvature: Long-term results and patient satisfaction. J Urol. 1999;162:2006–2009
Keywords:

congenital dorsal; corporal rotation; curvature; penile

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