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From the Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China.
| Correspondence to: Dr Yun-Man Tang, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China (e-mail: tangyunman{at}126.com). |
| Received for publication December 25, 2006; accepted for publication March 22, 2007. |
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Abstract |
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Key words: Surgery, penis, orthoplasty
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Materials and Methods |
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Surgical Technique
A circumcision was made, and the skin was degloved down to the base of the
penis. Then an artificial erection was induced with injection of normal saline
into the corpora cavernosa to identify the presence of residual curvature.
Patients whose penis straightened after degloving were considered to have
group I chordee (skin tethering). When chordee persisted, any abnormal dense
fibrous tissue was excised over the urethra. If release of fibrous tissue
resulted in satisfactory orthoplasty, group II chordee (fascial chordee) was
designated. For patients of groups I and II, penoplasty was performed after
orthoplasty. For patients in whom the 2 steps failed and the curvature was not
thoroughly resolved, the urethra and corpora cavernosa were checked for the
cause of curvature. If the penis was still ventrally curved under artificial
erection, although no significant urethral tethering was shown, the cause was
ascribed to a disproportion of dorsal and ventral aspects of the corpora
cavernosa (group III chordee, corporal disproportion), and the patients were
treated with dorsal midline plication (DMP). On the contrary, when the urethra
was found tethering the corpora cavernosa under artificial erection and
forming a bow to string configuration, group IV chordee (urethral tethering)
was considered and urethral replacement warranted. For group I, II, and III
patients, if the distal urethra was dysgenic and showed a lack of corpus
spongiosum, a tubularized incised plate (TIP) urethroplasty was done. For
group III patients, when dorsal tunica albuginea plication was not enough to
straighten the penis and/or DMP alone for curvature correction might lead to
significant penile shortening, additional urethroplasty was done. Similarly,
for group IV patients with severe curvature that was not likely to be
corrected through a single urethroplasty, a DMP procedure was completed in
addition. At the end of surgery, an artificial erection was done to confirm
penile straightening.
Postoperative dressing and stenting varied according to surgical procedure. For patients who did not undergo urethroplasty, the urethral stent was removed 3 days after surgery and the dressing was changed and finally removed at 7 days. For those who did undergo urethroplasty, the urethral stent was reserved for 9 days. The dressing was changed at 3 days and removed at 9 days.
On follow-up, the correction of penile curvature was evaluated by physical examination and patient and/or parental observation of erection.
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Results |
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Follow-up was 2 to 63 months (mean, 14.8 months). Of the 79 cases, 75 (94.9%) were cured after 1 operation. All group I patients were successfully treated with 1 operation. In 1 case of group II patients who underwent a TIP urethroplasty, glans dehiscence developed 10 days after the operation and a repeat TIP urethroplasty 8 months later was successful. Chordee recurrence was found in 1 group III patient who had a 90-degree curvature and underwent DMP plus longitudinal island flap (LIF) urethroplasty; this patient was managed with another DMP operation 1 year later. Complications occurred in 2 group IV patients, including urethrocutaneous fistula in 1 patient who underwent LIF urethroplasty and urethral stricture in 1 who underwent LIF plus Duplay procedure. The 2 patients were treated successfully with a second repair. No significant penile shortening was reported.
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Discussion |
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The categorization system recommended by Donnahoo et al (1998) was adopted in our institution with some modifications. When the urethra was abnormal, they believed that 2 entities should be treated—either a congenital short urethra with dense fibrous tissue beneath or a hypoplastic distal urethra lacking the corpus spongiosum. The former was included as group IV isolated chordee and was treated with division of the urethra and creation of an interposition graft. The latter was excluded because such patients were thought to have poor-quality distal urethras, which required excision of the abnormal urethral segment and subsequent reconstruction. According to the categorization described by Kramer et al (1982) and formerly Devine et al (1973), the latter condition was ascribed to urethral dysgenic tethering and the treatments of choice included division of the urethra with urethral reconstruction or mobilization of the anterior urethra with excision of the underlying fibrous tissue (Kramer et al, 1982) or alternatively preservation of all the layers around the local dysgenic distal urethra (Hernandez et al, 2001). All congenital chordee patients, including those with chordee with orthotopic meatus, should be included in the classifications (ie, a single criterion for classification should be insisted upon), and chordee and urethral abnnormality should be corrected as 2 relatively isolated problems, similar to hypospadias correction (Baskin and Ebbers, 2006). When the distal urethra is dysgenic and contributes little to penile curvature, a urethra-preserving urethroplasty is a rational choice; when an abnormal urethra tethers the corpora cavernosa, urethral replacement is warranted. In our series, a hypoplastic distal urethra segment was noted in 1 group I patient, 3 group II patients, and 1 group III patient. However, the hypoplastic segment was not considered responsible for the chordee; thus, the dorsal healthy urethra was preserved and a TIP procedure performed. Urethral replacement is necessary for group IV patients. Various options are available, and the technique selection is influenced by several factors and dependent on the surgeon's experience and preference (Cook et al, 2005). In our clinical practice, the principal technique for urethral replacement is based on the LIF procedure (Chen et al, 1993; Duckett, 1998). The success rate for 1 operation being sufficient to fix the chordee was 89.5% in this series, which is comparable to that reported by other authors (Scuderi et al, 2006; Duckett, 2002).
Great variety exists as to the dorsal correction of chordee or the treatment for corporal disproportion (Bologna et al, 1999). The Nesbit (1965) technique was formerly a popular method for the correction of penile curvature. Based on their own anatomic and embryologic investigations, Baskin et al (2000) developed a DMP technique. According to their findings, the dorsal midline area is nearly nerve free and the tunica albuginea is thick. The DMP procedure is theoretically and practically acceptable and has been widely applied (Bar Yosef et al, 2004; Soygur et al, 2004; Yucel et al, 2006). In the current series, all of the patients (n = 12) who underwent a DMP had a good outcome except 1 group III patient with recurring curvature that was managed with another DMP. In our experience of correction of chordee with and without hypospadias, multiple plication might be effective for postpubertal patients; however, for prepubertal patients with undeveloped penises, DMP remains the mainstay of dorsal correction. This series represents no experience at this institution with more complicated procedures, such as corporal rotation and penile disassembly (Decter, 1999; Dessanti et al, 2002; Perovic et al, 1998).
To date, none of our patients were followed up to the postpubertal stage; therefore, data on erectile function and related symptoms were limited. Long-term follow-up is still needed for outcome evaluation.
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References |
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