Congenital Penile Curvature: Dermal Grafting Procedure to Prevent Penile Shortening in Adults

A scoping review on chordee correction in boys with ventral congenital penile curvature and hypospadias

Introduction

Congenital penile curvature (PC), often concomitant with hypospadias, poses challenges in urology. Surgical correction techniques, including plication and corporotomy, lack standardized guidelines. This study aims to address the paucity of high-level evidence by comprehensively reviewing the outcomes of PC correction procedures in patients with and without hypospadias. This will inform clinical decision-making and provide insights for future research and meta-analyses.

Methods

We conducted this scoping review in accordance with the JBI Manual for Evidence Synthesis and PRISMA-ScR guidelines. An extensive literature search was performed and comparative studies published in English up to June 2023 were included. The studies were divided into three categories: PC without hypospadias, PC with hypospadias, and studies comparing two or more materials for covering the ventral corporotomy. Data extraction comprised author details, patient characteristics, study design, interventions, outcomes, and complications. Methodological quality was assessed using the Newcastle-Ottawa Scale.

Results

Forty-two studies were included in the review, which collectively comprised 3180 patients. Thirteen comparative studies reported the outcomes of surgery for congenital PC without hypospadias, 22 studies compared different techniques of PC correction in patients with hypospadias and 7 studies compared the type of materials for coverage following ventral corporotomy. In cases of PC without hypospadias, the most commonly reported surgery was the Nesbit's plication. For PC with hypospadias correction, the results of ventral corporotomy were superior to that of dorsal plication in most of the studies. The two-stage repair had better results when compared to the one-stage repair for patients with perineo-scrotal hypospadias. In studies comparing materials for coverage of ventral corporotomy, the tunica vaginalis flap or graft was utilized most commonly. The majority of the studies reported a success rate ranging from 85% to 100%. The methodological quality was high in all but four studies.

Conclusion

Plication procedures are generally preferred for PC without hypospadias, but they result in penile shortening. For those with hypospadias, corporotomy is associated with superior outcomes than plication, especially for those with severe curvature and redo procedures. For ventral corporotomy coverage, the tunica vaginalis flap or graft is the most commonly reported tissue in the literature.

Shaeer's corporal rotation IV: length-preserving correction of congenital ventral penile curvature

BACKGROUND

For cases with severe penile curvature, the loss in length with shortening techniques or the loss in rigidity with incision grafting can compromise the results, hence the advent of Shaeer's corporal rotation III technique, which corrects the most severe degrees of ventral penile curvature without loss in length, though with a certain degree of narrowing.

AIM

We sought to describe Shaeer's corporal rotation IV, aiming at correction of moderate-to-severe ventral penile curvature with minimal shortening, minimal narrowing, and minimal mobilization of the neurovascular bundle, among other improvements such as using thicker suture material to decease recurrence while inverting the surgical knots.

METHODS

Forty-two patients with congenital ventral penile curvature were selected for the study with a curve ranging from 60° to 90°. Patients were randomized into 1 of the 2 groups: Shaeer's corporal rotation III (SCR-III) and SCR-IV. In SCR-IV, rotation is used to correct the main brunt of curvature, up to 70% to 80% of the curve. Plication is used to correct the residual curvature up to 100% straightness. This keeps the rotation points fewer and closer to the midline, thereby minimizing narrowing and mobilization of the neurovascular bundle.

OUTCOMES

Both groups were compared with regard to intraoperative erection angle, length, and girth, before and after rotation, as well as subjectively reported postoperative recurrence, penile sensitivity, satisfaction, and IIEF.

RESULTS

The postcorrection angle was zero for all cases in the 2 groups. Dorsal length decreased by 3% in the SCR-IV group compared with 0.5% in the SCR-III group (2.5% difference). The difference in circumference between the narrowest and widest points was 2% in the SCR-IV group vs 9.3% in the SCR-III group (7.3% difference). The average operative time was 19.2% shorter with SCR-IV. Girth asymmetry was reported in 1 (4.8%) of 21 patients in the SCR-IV group compared with 15 (71.4%) of 21 in the SCR-III group. Partial hyposensitivity of the penis was reported in 9.5% in the SCR-IV group compared with 19% in the SCR-III group.

CLINICAL IMPLICATIONS

SCR-IV is an improvement over former versions of the technique, with higher patient satisfaction.

STRENGTHS AND LIMITATIONS

A strength of the study is the long follow-up period. Limitations include being a single-center study and reliance on patient reporting to evaluate recurrence and satisfaction.

CONCLUSION

The SCR-IV technique corrects moderate and severe degrees of congenital ventral penile curvature, with little or no compromise in penile length, girth, or sensitivity.

Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review

BACKGROUND

Congenital penile curvature (CPC) is corrected surgically by various corporoplasty or tunica albuginea plication techniques, but the optimal surgical approach is not well-defined.

AIM

To provide a comprehensive evaluation of the published literature pertaining to outcomes with penile plication and corporoplasty techniques for surgical management of CPC. To determine if plication or corporoplasty offers superior outcomes in surgical correction of CPC.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Checklist. The following databases were queried from inception to March 18, 2020 to search for studies describing surgical treatment of CPC: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus.

OUTCOMES

Objective and subjective postoperative outcomes including penile straightening, shortening, penile sensory changes, and reoperation rates for both corporoplasty and tunica albuginea plication were summarized.

RESULTS

Fifty-five articles comprising 2,956 patients with CPC who underwent a plication procedure (n = 1,375) or corporoplasty (n = 1,580) were included. The definition of "treatment success" varied widely and most often involved subjective patient reporting (22 studies; 40%) or objective assessment (15 studies; 27%). We considered curvature correction to be satisfactory if there was self-reported patient satisfaction or residual curvature after correction of <20˚. Reported rates of successful straightening ranged from 75 to 100% and 73 to 100% for plication and corporoplasty, respectively. A comprehensive and accurate assessment of surgical outcomes for CPC correction, such as satisfactory penile straightening, reoperation rates, glans sensory changes, and other complications was limited by significant inter-study heterogeneity with respect to the reporting of treatment outcomes.

CLINICAL IMPLICATIONS

While both plication and corporoplasty appear to be safe and effective options in the treatment of CPC, definitive conclusions cannot be drawn with respect to treatment superiority due to low-quality study design, methodology flaws, and significant heterogeneity in reporting.

STRENGTH & LIMITATIONS

This report represents the most comprehensive review of CPC surgical management. However, there is a significant lack of standardization in the reporting of treatment outcomes for CPC, thereby limiting the reliability of the published data summarization encompassed by our review.

CONCLUSION

Both plication and corporoplasty demonstrate high success rates and relatively low complication rates in the treatment of CPC, albeit with low-level evidence available in most research publications. Robust comparison of the surgical techniques used to correct CPC is limited by significant variation in reporting methods used in the literature. C. J. Britton, F. A. Jefferson, B. L. Findlay, et al. Surgical Correction of Adult Congenital Penile Curvature: A Systematic Review. J Sex Med 2022;19:364-376.

DORSAL Plication Technique for the Treatment of Congenital Ventral Penile Curvature: Long-Term Outcomes of 72 Cases

BACKGROUND

A total of 78 patients aged 11 to 17 years were diagnosed with congenital ventral penile curvature and underwent surgery with the dorsal plication technique between 2005 and 2014.

AIM

To investigate the long-term outcomes of 72 patients who underwent dorsal penile plication for the treatment of congenital ventral penile curvature without hypospadias.

METHODS

In all cases, the intervascular space between the deep dorsal vein and dorsal artery was dissected, and tunical plication was carried out with non-absorbable 3-0 polyamide sutures and the complication and satisfaction rates of the patients were determined in the postoperative seventh year.

OUTCOMES

At the final postoperative follow-up, the patients' satisfaction with the operation was found to be 95.8%.

RESULTS

Shortening of the penis (0.5-1 cm) in five cases, recurrence with less than a 20-degree curvature in two cases, palpable sutures in two cases was observed and no patients reported erectile dysfunction.

STRENGTHS & LIMITATIONS

The limitations of our study can be considered as the absence of pharmacological erection in the preoperative evaluation, failure to evaluate penile length at the last postoperative follow-up due to the continued development of the penis, inability to evaluate erectile function at the beginning, postoperative erectile capacity being assessed in only some of the operated cases, all operations being performed by a single surgeon in the same center, and the absence of standardized questionnaires for postoperative satisfaction or adverse events.

CONCLUSION

According to the results of this study, dorsal plication is a relatively simple method with a low risk and high success rate for the treatment of congenital ventral penile curvatures. Akdemir F, Kayıgil Ö, Okulu E. DORSAL Plication Technique for the Treatment of Congenital Ventral Penile Curvature: Long-Term Outcomes of 72 Cases. J Sex Med 2021;18:1715-1720.

Current trends in the surgical treatment of congenital penile curvature

Congenital penile curvature (CPC) is a relatively uncommon condition, characterized by congenital angulation of the erect penis. Surgical correction of CPC is the gold standard therapy with a variety of proposed surgical techniques and modifications. This review summarizes the contemporary literature on the surgical management of CPC, trying to address the current trends, as well as the advantages and disadvantages of available methods. We performed a non-systematic narrative and interpretative literature review until December 2018. We included articles with isolated CPC in human adults. We excluded original research articles regarding the surgical treatment of Peyronie's disease (PD). In total, we identified 34 studies including 2155 patients with CPC that met our inclusion criteria. Nine studies included patients with both CPC and PD, but reported sufficient data regarding the CPC cohort. Excisional corporoplasty and incisionless plication seemed to be the preferred surgical methods (10 and 12 studies, respectively), followed by incisional corporoplasty (5) and grafting (3). Four studies reported results of more than one method. Overall, patients with CPC can expect excellent outcomes with surgical repair and minimal side effects. No definite conclusions can be made regarding which technique is superior. The widely varied outcomes highlight the need for standardized outcomes measures in future research.

Factors affecting post-pubertal penile size in patients with hypospadias

Objectives

To evaluate actual post-pubertal penile size and factors affecting it in hypospadias patients, we retrospectively reviewed medical charts.

Patients and methods

Hypospadias patients whose external genitalia were categorized into Tanner stage 5, and whose stretched penile length was evaluated at 15 years old or older from April 2008 to April 2015, were enrolled in the present study. Stretched penile length was measured by a single examiner. Actual post-pubertal stretched penile length and factors affecting the post-pubertal stretched penile length were estimated. Statistical analysis was performed using Mann–Whitney U test and univariate and multivariate linear regression models for the determination of independent factors.

Results

Thirty patients met the inclusion criteria. Median age at evaluation was 17.2 years. Thirteen and 17 had mild and severe hypospadias, respectively. Endocrinological abnormality was identified in 5. Multivariate analysis showed that the severity of hypospadias and endocrinological abnormality were significant factors affecting stretched penile length. Stretched penile length in 25 patients without endocrinological abnormality was significantly longer than that in those with endocrinological abnormality (p = 0.036). Among patients without endocrinological abnormality, stretched penile length in 13 with severe hypospadias was significantly shorter than that in 12 with mild hypospadias (p = 0.004).

Conclusions

While the severity of hypospadias and endocrinological abnormality at post-pubertal evaluation were factors affecting post-pubertal penile size, stretched penile length in patients with severe hypospadias was shorter even in cases without endocrinological abnormality. These results suggest that severe hypospadias is not only a disorder of urethral development, but also a disorder of penile development.

Penile septoplasty for congenital ventral penile curvature: results in 51 patients

PURPOSE

The technique most widely used to correct congenital ventral penile curvature is still corporoplasty as originally described by Nesbit. We present results in patients treated with a variation of Nesbit corporoplasty used specifically for congenital ventral penile curvature.

MATERIALS AND METHODS

From June 2000 to June 2007 we treated 51 patients with congenital ventral penile curvature using modified corporoplasty (septoplasty), consisting of accessing the bed of the penile dorsal vein and excising 1 or more diamonds of tunica albuginea from it, extending in wedge-like formation 4 to 5 mm deep into the septum, until the penis is completely straightened. Patient history, clinical findings, self-photography results and the International Index of Erectile Function score were assessed. Curvature grade is expressed using the equation, 180 degrees - X, where X represents the deviation in degrees from the penis axis. Mean preoperative ventral curvature was 131.4 degrees (median 135, range 145 to 110). Of the patients 13 also had erectile dysfunction.

RESULTS

At followup postoperative mean ventral curvature was 178.3 degrees (median 179.1, range 180 to 175). A total of 49 stated that they were completely satisfied. Penile shortening was 5 to 15 mm. Compared to preoperative values there were marked improvements in the International Index of Erectile Function score in the various groups. No major postoperative complications developed. In 4 patients wound healing occurred by secondary intent.

CONCLUSIONS

This technique provides excellent straightening of the curved penis. By avoiding isolation of the whole dorsal neurovascular bundle there is no risk of neurovascular lesions. Suture perception is minimized.

Management of congenital penile curvature

PURPOSE

The long-term results of the management in adulthood of congenital curvature of the penis (ventral, lateral and dorsal) without hypospadias using 3 different techniques are carefully evaluated based on our experience.

MATERIALS AND METHODS

A total of 116 patients were operated on for congenital curvature of the penis without hypospadias in adulthood between January 1985 and December 2004 of whom 87 (75%) (mean age 24 years) were available for evaluation by a telephone survey. A total of 54 ventral, 28 lateral and 5 dorsal penile curvatures were operated on with a mean followup of 89 months. Bend was managed with Nesbit's procedure in 18, plication in 7 and the Heineke-Mikulitz technique in 62 men.

RESULTS

There were no significant intraoperative or postoperative complications. Overall 81 of the 87 patients (93.1%) were successfully treated with 1 operation. Curvature recurrence was less common in patients treated with the Heineke-Mikulitz technique. There were no complaints of de novo erectile dysfunction, but 15 men complained of shortening of the penis and 4 experienced decreased sensation of the glans.

CONCLUSIONS

Although feasible in cases of different types of congenital curvature, in our 20-year experience chordectomy always reduced the bend but patients could never completely straighten the penis by themselves. Surgical correction was reported by patients to be highly successful using the Heineke-Mikulitz technique, and statistical analysis revealed it to be significantly better than plication or the Nesbit procedure in terms of palpable nodules, recurrence and overall satisfaction.