Shaeer's Corporal Rotation III: Shortening-Free Correction of Congenital Penile Curvature—The Noncorporotomy Technique

Long-term impact of commonly performed operations in pediatric urology on reproductive and sexual health

Introduction

Sexual dysfunction is highly prevalent among men of reproductive age. Clinical practice guidelines have been established to assist providers in identification and education of patients who are at increased risk for infertility and sexual dysfunction with certain congenital and acquired urogenital disorders. The authors sought to review the reproductive and sexual health implications of treating common childhood urological conditions with commonly performed surgical procedures.

Methods

To ensure the inclusion of influential and highly regarded research, we prioritized citations from the most-frequently cited articles on our respective review topics. Our inclusion criteria considered studies with substantial sample sizes and rigorously designed methodologies. Several topics were reviewed, including penile chordee, hypospadias, posterior urethral valves, varicoceles, undescended testicles, and testicular torsion.

Results

For chordee, surgical plication or corporal grafting may be employed. Erectile function remains unaltered post-surgery, while penile length may decrease after repair, which may be avoided using dermal grafts. Hypospadias repair hinges on severity and availability of the urethral plate. Those who underwent hypospadias repair report decreased penile length, but sexual satisfaction, libido, and semen quality are comparable to controls. Posterior urethral valves are usually treated with valve ablation. While valve ablation and bladder neck incision have not been found to affect ejaculatory function, high degree of concurrent renal dysfunction related to nephrogenic and bladder dysfunction may impact semen parameters and erectile function. Regarding varicocele, earlier management has been associated with better long-term fertility outcomes, and surgical intervention is advisable if there is observable testicular atrophy. Earlier repair of undescended testicle with orchiopexy has been found to improve fertility rates as well as decrease malignancy rates. Unilateral orchiectomy for testicular torsion without the ability for salvage has been shown to have decreased semen parameters but unaffected fertility rates.

Conclusion

Infertility and sexual dysfunction are multivariable entities, with etiologies both congenital and acquired. At the same time, many common pediatric urology surgeries are performed to correct anatomic pathology that may lead to reproductive dysfunction in adulthood. This review highlights the need for diagnosis and management of pediatric urologic conditions as these conditions may impact long-term sexual function post-operatively.

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.

The effectiveness of penile curvature treatment by cavernous body rotation and plication of the tunica albuginea

Background

There are several approaches to the surgical treatment of the penile curvature conditionally divided into three large groups: tunica albuginea plication (TAP), corpus cavernosum rotation (CR), and transplantation of various materials. The study aims to compare the effectiveness of TAP and CR techniques in the treatment of penile curvature. There was a prospective randomized study of the effectiveness of surgical treatment of patients with an established diagnosis of the penile curvature from 2017 to 2020 in Irkutsk, Russian Federation. The final analysis of the results included 22 cases.

Results

The analysis of the comparative intergroup effectiveness of the treatment performed based on the criteria established in the study showed good treatment results in 8 (88.8%) patients in the CR group and 9 (69.2%) patients in the TAP group (p = 0.577). The other patients obtained satisfactory results. There were no negative outcomes. Simple logistic regression analysis showed that the preoperative flexion angle > 60 degrees (OR 2.7; 95% CI 0.12; 5.28; p = 0.040) was significant in predicting the complaints of penile shortening during TAP. Both methods are safe, effective, and bring minimal risk of complications.

Conclusion

Thus, the effectiveness of both treatment methods is comparable. However, TAP surgery is not recommended for patients with an initial curvature of more than 60 degrees.

[Congenital penile curvature: Guidelines from the Andrology and Sexual Medicine Committee of the French Association of Urology (CAMS-AFU)]

INTRODUCTION

Guidelines regarding congenital penile curvature (CPC) are lacking, and this pathology has not been the subject of French recommendations to date. The Andrology and Sexual Medicine Committee (CAMS) of the French Association of Urology (AFU) propose a series of clinical practice recommendations (CPR) by answering five clinical questions concerning the diagnosis and treatment of this pathology.

MATERIALS AND METHODS

After a bibliographic research between 2000 and 2021, followed by a critical reading according to the CRP method. These recommendations were written to answer five questions: (1) What are the different types of CPC? (2) What are the reasons for consultation? (3) What are the assessment methods for CPCs and their consequences? (4) What are the indications for CPCs treatment? (5) What are the corrective modalities for the treatment of CPC?

RESULTS

There are two main phenotypes: CPC type 4 (the most common) and chordee without hypospadias. The diagnosis of CPC is clinical and established through enquiry and clinical examination associated with photos of the erect penis. Support can be offered if the curvature is responsible for a disability and/or sexual dissatisfaction linked to a deformation making penetration difficult and/or in the event of significant psychological impact. Only surgical treatments have demonstrated their effectiveness. For type 4 CPCs, corporoplasty (excisional, incisional, or incisionless techniques) is the gold standard.

CONCLUSION

These recommendations provide support for the management of patients consulting with CPC.

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.

ESSM Position Statement on Surgical Treatment of Peyronie's Disease

INTRODUCTION

Patients with Peyronie's disease may experience significat distress. The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity and direction of the curvature, penile length and the quality of erectile function.

AIM

To review the evidence associated with surgical treatment of Peyronie`s Disease and provide clinical recommendations on behalf of the European Society for Sexual Medicine. 131 peer-reviewed studies and systematic reviews, which were published from 2009 to 2019 in the English language, were included.

METHODS

MEDLINE, Google Scholar and EMBASE were searched for randomized clinical trials, meta-analyses, open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements on clinically relevant questions including patient involvement in the decision process, indications for surgery, choice of the approach, and the management of patient expectations. A comparison of the different grafts used in patients who have undergone plaque incision/excision and grafting in order to identify an ideal graft, has been carried out. The prevalence of postoperative complications has been summarized. Levels of evidence were provided according to the Oxford 2011 criteria and Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In order to allow shared decision making, a patient preoperative counselling regarding the pros and cons of each intervention is recommended. In particular, adverse effects of surgical treatments should be discussed to set realistic understanding and expectations of surgical outcomes and ultimately improve postoperative satisfaction rates. Surgical treatment should be only offered in the chronic phase of the condition, when the deformity and/or degree of erectile dysfunction, prevent patients from engaging in satisfying sexual interaction, or if the deformity is the cause of severe bother.

CONCLUSIONS

Current European Society for Sexual Medicine recommendations cover several aspects of Peyronie's disease treatment. These recommendations aim both to ensure patients and partners have accurate and realistic expectations of their treatment options, as well as to formulate algorithms to guide clinician management pathways. Osmonov D. et al., ESSM Position Statement on Surgical Treatment of Peyronie's Disease. Sex Med 2022;10:100459.

Vertical plication: A penile curvature correction technique that reduces the need for urethral plate transection in penoscrotal hypospadias

INTRODUCTION

Penile curvature (PC) is a frequent component associated with hypospadias. Medial corporal rotation by interrupted suturing without incising the corporal bodies is well described in patients with epispadias and we think that it is an alternative technique for the management of patients with ventral PC, with or without hypospadias.

OBJECTIVE

We describe a PC correction technique which reduces the need for urethral plate transection in penoscrotal hypospadias.

STUDY DESIGN

The main steps of "vertical plication" technique are following: The Buck's fascia at the maximum point of curvature was incised longitudinally at 12-o'clock position and then dissected from tunica albuginea from medial to lateral on each side. Minimal and precise dissection just enough to allow plication is essential to avoid injury to the neurovascular bundle. No incisions were made through the tunica albuginea. Corporal rotation was performed by approximating with polyester sutures which were placed 5 mm apart at and around the point of maximum curvature. Three to 5 sutures were enough for full straightening of PC in our cases. Follow-up range was 1.5-4.5 years (mean: 3 years).

RESULTS

17 patients underwent this technique. 16 of them had a penoscrotal hypospadias and one patient had congenital PC without hypospadias. Full PC correction was achieved in 15 patients and residual curvature below 10° was seen in two patients. We were able to perform single-stage repair in 13 (81,25%) of our penoscrotal hypospadias cases without transection of urethral plate.

DISCUSSION

High recurrence rates were reported in dorsal plication technique when compared to ventral corporal lengthening in patients with PC > 30°. In the presence of high grade PC, a penile elongation technique is the preferred option for many authors. However, it requires incision of tunica albuginea. Although the variations of medial corporal rotation to correct ventral PC has been described in the past, they did not gain popularity.

CONCLUSION

This technique allows the surgeon to proceed with single stage repair in patients with proximal hypospadias associated with high grade PC. Narrowing is the only disadvantages of our technique, which can easily be resolved by de-epithelialized flap coverage harvested from foreskin. No parents subjectively reported nor we detected narrowing, recurrence or shortening during follow-up.

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.

Clinical characteristics and surgical outcomes in men undergoing tunica albuginea plication for congenital penile curvature who present with worsening penile deformity

PURPOSE

Men with congenital penile curvature (CPC) can develop new onset worsening of their lifelong curvature. We sought to evaluate clinical characteristics and postoperative outcomes after tunica albuginea plication (TAP) in patients presenting with CPC who reported new onset worsened curvature (CPC-WC), and compare these with patients reporting stable lifelong curve ("CPC-only").

METHODS

A retrospective review of demographics, history/exam findings, and postoperative outcomes for patients with CPC who underwent TAP from 2012 to 2018 was performed. Patients were differentiated based on whether or not they reported new onset worsening of their penile curvature preoperatively (CPC-WC versus CPC only). Statistical analysis was performed to identify differences in clinical characteristics and postoperative outcomes after TAP.

RESULTS

60 patients were included [CPC only (n = 39) and CPC-WC (n = 21)]. Mean curvature was 62° (SD 23). CPC-WC patients were older [median 34 years (IQR 27:52) versus 24 years (IQR 20:34); p = 0.004], and more likely to report penile shortening and psychological bother (p < 0.05). On physical examination, CPC-WCs were more likely to have a discrete palpable tunical scar and diminished penile elasticity (p ≤ 0.0002). With median follow up of 12 months, satisfactory straightening with TAP was reported in 56/60 patients (93%) including 35/39 (90%) CPC only and 21/21 (100%) CPC-WC.

CONCLUSIONS

In men undergoing TAP for CPC, we found that 35% reported new onset worsening of their original curvature preoperatively. These patients were older and more likely to report penile shortening or exhibit palpable tunical scarring with decreased elasticity on examination compared to those with lifelong stable curvature. Regardless, TAP resulted in satisfactory penile straightening in the majority of patients.

Penile curvature: an update for management from 20 years experience in a high volume centre

Our aim was to review the literature and discuss about penile curvature in order to have an update for management after 20 years experience in the field.Penile curvature may be congenital or acquired. Congenital penile curvature is a relatively uncommon condition that may present in late adolescent or early adult life. The incidence is estimated to be 0.6 %. On the other side, acquired penile curvature has an overall prevalence of 0.5-13%. Three main factors seem to increase the risk of developing an acquired penile curvature, often related to Peyronie's disease: penile traumatism, genetic and familiar conditions and a history of diseases of the genital tract. In treating Peyronie's disease, no medical therapy is fully effective, and surgery remains the gold standard in cases of severe deformity and/or erectile disfunction. Peyronie's disease is associated with significant psychological stress for patients and their partners. Appropriate treatment should be individualized and tailored to the patient's goals and expectations. There is not the 'best' surgical technique and outcomes are satisfactory when proper treatment decisions are made.