Procedures used for correction of isolated penile torsion: are they competitive or complementary?

OBJECTIVES

To report our experience in starting the correction of penile torsion, whatever its degree (moderate or severe) with one or more simple procedures either separately or complementary in the same session.

PATIENTS AND METHODS

Between 2013 and 2018, 62 patients who have significant isolated penile torsion (> 45°) were involved in this study. Those patients were subjected to either simple degloving with skin reposition, degloving with skin overcorrection and/or dartos flap procedures. Those procedures were performed either separately or complementarily. All patients were examined postoperatively after 7 days and followed up at 3, 6, and 9 months postoperatively.

RESULTS

37 out of 62 patients had a moderate degree (45-90) of penile torsion; 21 of them were corrected using skin degloving-reattachment technique, 11 patients were corrected by degloving with skin overcorrection, and in the remaining 4 patients dartos flap technique was used for correction. In 25/62 patients who had severe degree (> 90°) of torsion; 9 patients were managed by degloving with skin overcorrection, while in 13 patients the procedure was shifted to dartos flap technique, and the remaining 3 patients, 2 of whom had 180° torsion, were managed by dartos flap with added skin overcorrection.

CONCLUSION

Performing degloving and skin reattachment with or without skin overcorrection procedure and dartos flap procedure either separately or complementarily in the same patient whatever the degree of torsion (moderate or severe) is associated with good results and can protect some patients from exposure to more difficult and extensive procedures as corporopexy and corporeal plication.

Spiral nesbit plication: A simple method for simultaneous correction of penile torsion and chordee ("spiral chordee")

Penile torsion and chordee may be corrected by a variety of techniques; however, when corporal body disproportion is involved plication may be necessary. Herein we describe a technique of placing oblique plication sutures to simultaneously correct both conditions, which we term "spiral chordee". The spiral Nesbit plication (SNP) has been performed on 21 boys at our institution. Median preoperative penile torsion and chordee were 49° (range 30-90°) and 35° (range 15-60°) respectively. Surgical success was 84.6% with two patients exhibiting mild residual chordee (15°) requiring no further treatment. This technique provides a simple and effective surgical option for correction of spiral chordee.

Penile torsion repair in children following a ladder step: simpler steps are usually sufficient

OBJECTIVE

To evaluate the correction of different degrees of penile torsion following a ladder step so that simpler steps are used whenever possible. This can avoid the morbidity and complications of complex procedures.

PATIENTS AND METHODS

Cases of congenital and acquired penile torsion were repaired on a ladder step basis irrespective of the degree of torsion, starting with degloving and skin realignment, then a dorsal dartos flap and finally corporopexy. The torsion is checked with artificial erection after each step, and if corrected completely then the next step(s) is omitted.

RESULTS

Twenty-five cases of penile torsion (30-180°) were repaired over a 4-year period. Three cases were corrected by degloving only, 12 by degloving and skin realignment, five by a dartos flap and four required a corporopexy. Postoperative complications included five cases of penile edema, one case of hematoma and one case of dorsal skin gangrene. Residual torsion of <15° occurred in three cases. No cases required redo surgery.

CONCLUSION

A ladder step approach is a good option for penile torsion repair, starting with simpler techniques until complete correction is achieved. There is no need to plan a complex procedure in advance.

Correction of penile torsion and chordee by mobilization of urethra with spongiosum in chordee without hypospadias

OBJECTIVE

To investigate the feasibility of correcting coexistent penile torsion and chordee without hypospadias by mobilization of the urethra and spongiosum.

MATERIALS AND METHODS

A retrospective study of nine patients with simultaneous penile torsion and chordee without hypospadias was undertaken between January 2006 and December 2012. During this period, a total of 364 cases of hypospadias and 38 of chordee without hypospadias were operated on, making a total of 402 patients with hypospadias-related complexes. The same steps were used for correction of both torque and chordee. After a circumcoronal incision, the penis was fully degloved and the spongiosum with urethra was lifted up off the cavernosa. Next, mobilization of the hypoplastic urethra with spongiosum was extended into the glans. If chordee or torque persisted, urethral mobilization was performed proximally up to the bulbar urethra, as required. Spongioplasty and glansplasty were done and a per-urethral stent was kept in for three to five days.

RESULTS

The age of the patients ranged from 5 to 16 years (median 6 years). Penile torsion ranged from 30° to 120°, with a median of 75°. Ventral chordee ranged from 45° to 100°, with a median of 50°. A ratio of 1:9.6 was found for chordee without hypospadias compared to the total hypospadias cases, with an incidence of 9.5%. The ratio of chordee without hypospadias with torsion compared to the total hypospadias cases was 1:29. There was an incidence of chordee without hypospadias with penile torsion of 3.5% in all patients with hypospadias. The ratio of chordee without hypospadias with torsion to only chordee without hypospadias was 1:1.71, with an incidence of 37.0%. Every step contributed to the correction of curvature and torsion. Chordee was corrected in two patients by penile degloving and lifting of the spongiosa off the urethral plate; three patients required additional mobilization of the urethra into the glans. Another two patients needed proximal urethral mobilization and one required a dorsal plication. In five patients, torque was corrected by penile degloving, lifting of the spongiosa and mobilization of the urethra into the glans; four patients required further proximal urethral mobilization. All patients had excellent functional and cosmetic results. No residual chordee or torque was observed in any patient on follow-up at 12-24 months.

CONCLUSION

The technique of distally mobilizing a hypoplastic urethra with spongiosum from the corpora into the glans, and proximally up to the bulbar region corrects moderate to severe chordee and torsion with excellent cosmetic results. The incidence of torsion with chordee without hypospadias was 3.5% of all cases of hypospadias.

The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion

Objectives

To evaluate the effectiveness of urethral mobilisation for correcting moderate and severe penile torsion associated with distal hypospadias.

Patients and methods

Nineteen patients with distal hypospadias and congenital moderate and severe penile torsion were treated surgically. The hypospadias was at the distal shaft, coronal and glanular in seven, eight and four patients, respectively, and six had mild chordee. The mean (SD, range) angle of torsion was 94.7 (19.9, 75–160)°. The urethra was mobilised down to the perineum. If the urethral mobilisation was insufficient the right border of the tunica albuginea was anchored to the pubic periosteum. The hypospadias was repaired using the urethral mobilisation and advancement technique, with a triangular plate flap for meatoplasty. The patients were followed up for 12–18 months.

Results

All patients had a successful functional and cosmetic outcome, with no residual torsion. Two patients had a small subcutaneous haematoma that resolved after conservative treatment. Massive oedema occurred in three patients and was treated conservatively. Urethral mobilisation did not correct the penile torsion completely. Although the mean (SD, range) angle of torsion was reduced to 86.1 (14.3, 65–130)°, statistically significantly different (P = 0.001), it was not clinically important. The presence of chordee had no significant correlation with the reduction of penile torsion.

Conclusion

Urethral mobilisation cannot completely correct moderate and severe penile torsion but it might only partly decrease the angle of torsion. Periosteal anchoring of the tunica albuginea might be the most reliable manoeuvre for the complete correction of penile torsion.