Corporeal Plication for the Treatment of Congenital Penile Curvature

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.

Isolated ventral congenital penile curvature treated by incisionless plication of tunica albuginea in adults: A prospective case series

Background

Numerous surgical techniques are available for the correction of isolated ventral congenital penile curvature (IVCPC). This study aimed to assess the outcomes and predictors of IVCPC treatment in adults using an incisionless plication technique.

Materials and methods

This prospective case series examined patients with IVCPC who were treated in our hospital between October 2017 and February 2020 using incisionless plication of the tunica albuginea (Essed-Schroeder technique) with a covering pair of absorbable sutures. The primary outcomes were successful correction (defined as a residual curvature ≤15 degrees) and patient satisfaction. Postoperative follow-ups were performed at 3, 6, and 12 months.

Results

A total of 23 patients were treated for IVCPC with a mean (range) age of 25.3 (18-31) years. Eighteen patients (78.3%) were single with cosmetic complaints, whereas the other 5 patients (21.7%) were married and presented with a difficult vaginal intromission. The mean (range) curvature, length, and operative time were 40 (30-50) degrees, 15 (10-19) cm, and 82 (65-100) minutes, respectively. Postoperative penile pain and numbness occurred in 13 patients (56.5 %) and 7 patients (30.4%) only within the first month, respectively. Palpable suture knots were reported in 15 patients (65.5%) without being bothersome up to 12 months. The postoperative means (ranges) of penile curvature and length were significantly different from that of the preoperative values at 3 (5 [0-20] degrees and 14.5 [9-18.5] cm), 6 (5 [0-20] degrees and 14.5 [9-18.5] cm), and 12 months (5 [0-30] degrees and 14.5 [9-18.5] cm; all p < 0.001). Age, preoperative penile curvature, penile length, postoperative pain, wound infections, and knot palpation insignificantly affected curvature recurrence. Seventeen patients (73.9%) were very satisfied with their surgical outcomes.

Conclusions

Incisionless plication of the tunica albuginea is effective and safe for the correction of IVCPC in adults with high success and patient satisfaction rates.

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.

Plication for Correction of Congenital Penile Curvature: With or Without Degloving?

Introduction

Previously, incisionless plication (IP) for correction of congenital penile curvature (CPC) has been performed after penile degloving via a circumscribing incision.

Aim

To describe our experience with non-degloving incisionless penile plication (NDIP) for correction of CPC and compare these outcomes with those of men who underwent degloving incisionless penile plication (DIP).

Methods

We conducted a retrospective review of men ≤ 45 years of age who underwent incisionless penile plication for correction of CPC between 2008 and 2020 at two adult tertiary hospitals. Patients underwent either NDIP, performed through a 2-3 cm longitudinal incision along the proximal-to-mid shaft opposite the point of maximum penile curvature, or DIP via a sub-coronal circumscribing incision.

Main Outcome Measures

Surgical and patient-reported outcomes were compared between the non-degloving and degloving groups.

Results

Among the 38 men (mean age, 26 years) who met the inclusion criteria, 25 underwent NDIP, including 6 patients with biplanar curvature (2 Ventral, 4 Dorsal, 6 Lateral). Thirteen patients underwent DIP, including 1 patient with biplanar curvature (1 ventral, 1 lateral). Curvature reduction was 50 ± 23 degrees for the NDIP group and 36 ± 10 degrees for the DIP group (P = .04). Five (20%) patients in the NDIP group and nine (69%) patients in the DIP group experienced a reduction in stretched penile length following plication (SPL) (P = .01). One patient in the NDIP group underwent an additional plication for recurrent curvature.

Conclusion

Both NDIP and DIP are safe and highly efficacious techniques for the correction of CPC.

Kusin SB, Khouri RK, Dropkin BM, et al., Plication for Correction of Congenital Penile Curvature: With or Without Degloving?. Sex Med 2021;9:100462.

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.

The effects of four different suture materials on penile tissue of rats

Several types of suture materials are being used for the correction of penile curvature and this study was designed to compare histopathological changes on penile tissue among different suture materials. A total of 30 male Sprague-Dawley rats were divided into five groups and right cavernosal body was sutured with 5/0 sutures (ETB: polyethylene terephthalate; PRL: polypropylene; VCR: polyglactine; and PDS: polydioxanone). An identical needle (3/8-13 mm cutting) was passed through the cavernosal bodies in the sham group (SHAM). After 3 weeks, all rats were killed and penile tissues were examined to assess the level (0-3) of inflammation, granuloma formation and fibrosis. There was a statistically significant difference among five groups regarding inflammation, granuloma formation and fibrosis levels (P<0.01 for all). The histological changes in the PRL group were not different from the SHAM group. Although the levels of granulation and fibrosis in the PDS group were also similar to the SHAM group, inflammation level was significantly higher. The inflammation, granulation and fibrosis levels were the highest in the ETB group. VCR caused similar levels of granulation and fibrosis to ETB. In conclusion, PRL suture is associated with the least histopathological change in the penile tissue. PDS can theoretically be a reasonable alternative to PRL as it causes similar levels of granulation and fibrosis.

Rotation of the corpora cavernosa for the treatment of congenital penile curvature

INTRODUCTION

Congenital penile curvature (CPC) is caused by a disorder in the embryonic development of the urethra and corpora cavernosa. The condition causes difficulty for penetration, requiring surgical correction when it prevents intercourse.

MATERIAL AND METHODS

We present the cases of 2 men in their 40s who had ventral curvature greater than 60° of 2 years of evolution, with maintained erections. The patients underwent surgery for rotation of the corpora cavernosa. After the complete denudation of the penis, athermal release of the neurovascular bundle of the penis from the ventral side to the dorsal was performed. Once the curvature was verified using artificial erection, an incision was performed in the tunica albuginea of both corpora cavernosa, continuously suturing both internal and external margins with resorbable monofilament. The rectification of the curvature was then checked, and the mucocutaneous plane was reconstructed.

RESULTS

The surgical time was 120minutes and there were no intraoperative complications. Both patients were discharged 24h after the surgery. At 1 week, the patients experienced spontaneous night-time erections and were able to maintain sexual relations 1 month after the surgery. At 6 months, the residual curvature was less than 20°, the penile shortening was less than 1 centimeter and the International Index of Erectile Function-5 was 25 for both cases.

CONCLUSIONS

Surgery for rotation of the corpora cavernosa helps correct CPC without significant penile shortening or erectile dysfunction. In our opinion, the procedure is an appropriate treatment for patients with CPC but requires studies with long-term follow-up in order to consider it the technique of choice.

Congenital penile curvature presenting as unconsummated marriage. Repair by 16-dot plication with subjectively reported patient and partner satisfaction

Objective

To evaluate self-reported patient and partner satisfaction in cases of unconsummated marriage due to congenital penile curvature that was treated by the 16-dot plication procedure.

Patients and methods

From March 2008 to March 2012, 24 couples presented to our institute with an unconsummated marriage due to congenital penile curvature. All patients were treated using the 16-dot plication operation. Patients were followed up for 3 months and were asked, with their partners, to complete a specific questionnaire to evaluate their satisfaction with the outcome of the operation.

Results

The duration of unconsummated marriage was 2–12 weeks. The mean (SD, range) angle of penile curvature was 57.4 (20.3, 30–110)°. All patients were able to consummate their marriage within a mean (SD, range) of 5.3 (1.3, 4–8) weeks after surgery. The overall satisfaction rate with the outcome of the operation among patients was nearly 100% for ‘moderately satisfied’ or greater, and among their partners was nearly 96% for ‘moderately satisfied’ or greater, at 3 months.

Conclusion

The 16-dot plication technique is an easy procedure for the emergent correction of congenital penile curvature presenting as an unconsummated marriage. Most patients and their partners were pleased with the outcome of the procedure.

Plication corporoplasty versus Nesbit operation for the correction of congenital penile curvature. A long-term follow-up

BACKGROUND AND OBJECTIVES

Aim of the study is to evaluate the long-term results of tunica albuginea plication in patients with congenital curvature of the penis and to compare them with those obtained with the Nesbit technique.

METHODS

Overall, 62 patients underwent surgical correction of congenital curvature of the penis from 2003 to 2008 at our institution. Of these, only 31 consented to be reevaluated. Nineteen patients had plication corporoplasty by means of one or more double crossed introflecting stitches (group A) while 12 patients had a traditional Nesbit technique with excision of small parts of tunica albuginea (group B). All patients were reevaluated with physical examination, a specific questionnaire and self-photography on erection, after a mean follow-up of 38 months in group A and 40 months in group B. Student's t test was employed for statistical analyses.

RESULTS

A total of 3 recurrences of curvature were observed in group A, 1-3 months after surgery, which required surgical correction. In all three patients, reabsorbable sutures had been employed for albuginea plication. No recurrences were observed in group B (P = 0.15). A minimal persistent deviation was present in 6 patients in group A (31%) and in 6 patients in group B (50%) (P = 0.29). A minimal hyposensitivity of glans and prepuce was reported in 7 patients in group A (38%) and in 9 patients in group B (75%) (P = 0.03).

CONCLUSIONS

Plication corporoplasty yields good and stable results when compared to the Nesbit technique provided that unabsorbable sutures are used and superficial scalpel incision of the albuginea is performed.

Circumcision is not mandatory in penile surgery

OBJECTIVE

To assess the outcome of not circumcising patients having surgery to correct a congenital or acquired curvature, through a subcoronal approach.

PATIENTS AND METHODS

In a series of 251 consecutive patients (mean age 46 years, range 17-74) that had their penis straightened by either a Lue (86), or a Nesbit procedure (162) or a combination of both (three) between 2000 and 2008, a subcoronal circumferential incision was used for the degloving in 241. Among the 183 patients who had not been previously circumcised, 22 presented with a tight foreskin and were offered a circumcision; six of them refused to be circumcised. Of the remaining 161 patients, 115, including two who had previous penile surgery, opted not to be circumcised.

RESULTS

After a median (range) follow-up of 5.5 (1-50) months, secondary circumcision was performed in three of the six patients with a tight foreskin, in one of the 113 (0.8%) with a normal retractable foreskin and in one of the two who had had previous penile surgery and had a normal foreskin.

CONCLUSIONS

Circumcision should not be considered as a routine part of penile surgery unless a significant phimosis is present or revisional surgery is contemplated.

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.

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

OBJECTIVES

We report the results of a derma graft corporoplasty in a selected group of patients with congenital penile curvature (CPC) who refused a simple plication technique for the risk of penile shortening, even if minimal.

METHODS

Between January 1995 and January 2004, 15 potent patients with CPC underwent corporoplasty with inguinal derma graft, with or without tunica albuginea plication. Mean age was 26.6 years (range 19-36). Six patients had a simple lateral left curvature, three had a simple lateral right curvature, four had a ventro-lateral left curvature, one patient had a ventro-lateral right curvature, and one patient had ventral curvature. In nine patients the preoperative mean IIEF-5 score was 22.55 (range 21-24). All the patients were evaluated after three, six and 12 months.

RESULTS

One graft was placed in one patient (6.6%), seven (46.6%) received one graft and underwent a tunica albuginea plication, four (26.6%) received two grafts, three (20%) received two grafts and underwent tunica albuginea plication. A residual curvature after three, six and 12 months was present respectively in all (100%), seven (46.6%) and one (6.6%) patients. No patients had a decrease of penile length. The mean difference in the IIEF-5 score before and after the surgical procedure was not statistically significant.

CONCLUSIONS

Surgical correction of CPC with derma grafts in potent patients restores penile straightening with no postoperative shortening and preserves normal erectile capacity. Patient satisfaction indicates that the proposed technique may be used in selected cases.

Correction of congenital penile curvature using modified tunical plication with absorbable sutures: the long-term outcome and patient satisfaction

OBJECTIVES

Although plication of the tunica albuginea with nonabsorbable sutures is an effective method in correcting congenital penile curvature (CPC), suture-related complications may happen. We investigated the long-term outcome and patient satisfaction of a modified tunical plication technique using absorbable sutures.

MATERIALS AND METHODS

From January 1999 to July 2005, 114 consecutive patients with CPC treated with a modified tunical plication technique by a single surgeon were retrospectively reviewed. With the modified corporeal plication technique, two, interrupted, U-shaped sutures with 2-zero polyglactin were applied to create bumps on the tunica albuginea. The long-term outcome and patient satisfaction were assessed by a post hoc questionnaire interview.

RESULTS

Among the 114 patients, complete straightness of the penis was achieved in 65 (57%) patients, and 33 (29%) patients reported a 15-degree or less residual or recurrent curvature at 6 mo postoperatively. Although 32 (28%) patients experienced suture failure (median time: 38.5 d), only half of them had a residual or recurrent curvature greater than 15 degrees. Younger patients (<24 yr) had a higher chance of suture failure than elder patients (p=0.03). Among the 103 patients completing the questionnaire, no palpable suture knots, suture granuloma, erectile discomfort, or erectile dysfunction was reported (median follow-up time: 41.5 mo). Eighty-three (81.5%) patients were either very or moderately satisfied with the surgical outcome.

CONCLUSIONS

The modified technique using double, interrupted, U-shaped sutures and absorbable suture material is a simple and effective method for treating CPC. Suture-related complications rarely happen. The long-term outcome is satisfactory, and most patients are pleased with the procedure.

Color Doppler US of the Postoperative Penis: Anatomy and Surgical Complications

A number of surgical procedures that significantly change the penile anatomy and vasculature can be used to manage pathologic conditions of the penis (eg, congenital and acquired deformities, erectile dysfunction, priapism). Phallic reconstruction surgery can be used for sex reassignment and after penile amputation or for correction of congenital malformations. Color Doppler ultrasonography (US) clearly depicts the normal penile anatomy and postoperative changes (eg, changes of the tunica albuginea, extraalbugineal pathologic fluid collections, cavernosal tissue changes produced by scars and fibrosis). It is also effective in evaluating surgery-related complications and determining the causes of erectile dysfunction and other unsatisfactory long-term results. Moreover, color Doppler US of the penile vessels and vascular anastomoses following revascularization allows direct evaluation of flow characteristics, shunt patency, and venous engorgement. Color Doppler US is the imaging modality of choice in evaluating patients who have undergone penile surgery.

Treatment of penile curvature with Essed-Schroder tunical plication: aspects of quality of life from the patients' perspective

OBJECTIVES

To investigate retrospectively the long-term functional results and quality of life of patients undergoing the Essed-Schröder procedure (a simple plication of the tunica albuginea) to correct penile deviation, using a standardized questionnaire.

PATIENTS AND METHODS

Between 1998 and 2001, 59 patients had surgery in our hospital to correct penile deviation (mean age 40 years at the time of surgery; mean follow-up 30 months for this study). All 59 patients received a standardized questionnaire via mail, of which 50 could be assessed as valid.

RESULTS

Of the 50 patients, 22 had a congenital penile deviation and 28 Peyronie's disease. In all patients the penis was completely straightened. The proportion of patients capable of sexual intercourse was significantly higher after surgery (90%) than before (62%). The frequency of pain during intercourse was halved. Of the 50 patients, 60% would have the same operation again, 32% were undecided and 8% would not; 22% were dissatisfied with the results. None of the patients had complete erectile dysfunction after surgery; 74% reported a decrease in penile length and 78% of the patients' partners were satisfied with the outcome.

CONCLUSIONS

The tunical plication procedure is simple and minimally invasive for correcting penile deviation. In the opinion of most patients the Essed-Schröder method provides a significant improvement in sexual function and quality of life with maximum protection of erectile function.

Vaginal and penile reconstruction

PURPOSE OF REVIEW

Reconstructive surgery for patients with genital abnormalities or for patients who require reconstructive efforts is challenging. This review highlights those articles, which are outstanding among all those important papers, which have been published during the last year (2002-2003).

RECENT FINDINGS

A greater understanding of embryonal development improves the success of reconstructive surgery. Other factors, such as the patient's sex, influence the surgical technique used and the degree of invasiveness or complexity. In the adult the pressure to shorten hospital stays has played a big part in the continual modification and enhancement of surgical techniques. In addition to modified techniques, new off-the-shelf materials are introduced to the clinic, which seem to have the potential to improve the surgical outcome and shorten hospital stays.

SUMMARY

With the continued successful basic anatomy and basic research, reconstructive surgery brings higher success rates. Long-term results are still required to validate the reliability of these new surgical techniques and materials.