Urethral Duplication With Dorsal Chordee: A Case Report and Literature Review

Urethral duplication is a diverse spectrum of disease having multiple anatomic variants. The clinical presentation varies from being asymptomatic to recurrent urinary tract infections. A high level of clinical suspicion and awareness among primary caregivers is needed to make a proper diagnosis. All patients presenting with any sort of penile deformity or abnormality of the urinary stream should be evaluated to rule out this condition. In this case report the patient had presented with the urinary stream being directed towards his abdomen due to abnormal dorsal curvature of the penis which was due to tethering of the accessory urethra.

Efficacy of collagenase Clostridium histolyticum in men with congenital penile curvature

BACKGROUND

Collagenase Clostridium histolyticum (CCH) has been proven effective in multiple subpopulations of PD men; however, no studies have evaluated its role with congenital penile curvature (CPC).

AIM

To evaluate the safety and efficacy of CCH in men with CPC.

METHODS

A prospective registry was queried of men undergoing CCH injections at our institution. Beginning in 2016, CCH was administered to CPC men using a similar protocol to PD. A comparative analysis was performed between cohorts to evaluate the safety and efficacy of therapy.

OUTCOMES

Objective measures included penile length and curvature, while subjective outcomes included standardized (International Index of Erectile Function and Peyronie's Disease Questionnaire) and non-standardized assessments. Curvature outcomes were categorized as follows: 1 - included all men, with the most recent assessment considered final, and 2 - only men who had completed eight CCH injections or stopped early due to satisfaction.

RESULTS

From 2014 to Oct 2021, a total of 453 men (408 PD, 45 CPC) underwent one or more CCH injections. In comparing cohorts, CPC men were younger (33 vs 58 years, p<0.0001), had lesser baseline curvatures (52.5 vs 65°, p<0.01), more ventral curves (25.7 vs 9.2%, p<0.01), and longer penile lengths (12.5 vs 12.0 cm, p=0.04). Following treatment, both cohorts experienced similar curvature improvements. Specifically, PD men experienced 20-25° or 33-35% improvements depending on definition compared to 25-30° or 40-50% in CPC men (all p-values >0.05). CPC and PD men also demonstrated similar changes on standardized questionnaires, with the exception of the Psychological and Physical subdomain, which was more improved in CPC men (-11 vs -4, p<0.01). Baseline curvature was positively correlated with greater absolute (degree) and relative (percent) improvements. Adverse events were similar between groups after controlling for confounders.

CLINICAL IMPLICATIONS

CCH may be safely and effectively administered in men with CPC. These data provide the first evidence for the efficacy of a non-surgical therapeutic option in this cohort.

STRENGTHS AND LIMITATIONS

Strengths - large, prospective series with standardized assessments; Limitations - non-randomized study, short-term follow-up, and lack of standardized method to differentiate CPC from PD.

CONCLUSIONS

CCH may be safely and effectively administered to men with CPC, with similar success rates compared to PD. Increasing curvature was associated with greater absolute (degree) and relative (percent) improvements, supporting the role for CCH in men with mild, moderate, or severe curvatures. External validation is warranted prior to routine implementation.

The extra-tunical grafting procedure for Peyronie's disease hourglass and indent deformities

Background

To describe a novel, tunica-sparing surgical technique—extra-tunical grafting (ETG)—for the treatment of penile indent and hourglass (HG) deformities and to describe patient-reported outcomes after the ETG procedure.

Methods

An IRB-approved, retrospective chart review of ETG patients was performed to collect data including pre-operative deformity, operation performed, and post-operative patient-reported perception of deformity, erectile function, penile sensation, and overall satisfaction with the ETG operation. The indications for surgery were difficulty with sexual intercourse due to deformity and/or poor cosmesis of the penis. Pre-operatively all patients had erections adequate for intercourse with or without medications. The ETG procedure is performed through a ventral longitudinal penile skin incision. The dissection is continued to the level between Dartos and Bucks fascia, circumferentially for HG deformity and focally for indent deformity. The neurovascular bundle (NVB) is left undisturbed. A cadaveric fascia graft is applied, singly or in multiple layers, to fill the exposed tunical depressions. Our preferred graft material is Tutoplast Suspend^® (Coloplast, Minneapolis, MN, USA). The graft is sutured into position with multiple interrupted, long-lasting absorbable sutures to achieve the desired penile shaft contour. The urethra is excluded from the graft.

Results

From October 2013 to June 2017, 36 patients had the ETG procedure for HG and/or indent with or without penile curvature. Results with a minimum of 6 months of follow-up could be extracted for 18 of the patients. One was excluded as he required concurrent excision of a large calcified tunical plaque, which necessitated incision into the tunica albuginea (TA). Follow-up was between 6 and 44 months (average 21 months). All patients reported satisfactory resolution of the HG or indent. No patient reported worsened erectile function. Two patients (11.8%) reported slight penile hypoesthesia, with one of these having had multiple previous penile degloving surgeries for trauma. Ten of the patients reported being “very satisfied” and six reported being “satisfied” with the procedure. One was neutral. All reported that they would recommend the ETG procedure to a friend, and all would repeat the same surgery again.

Conclusions

The ETG procedure is a straightforward approach to HG and indent deformities to correct the penile deformity and to provide structural support to prevent penile buckling during intercourse. The procedure does not violate the TA and does not require dissection of the NVB. Thus, ETG carries a very low risk of de novo impotence or hypoesthesia as highlighted by this patient series. With such low risk and high patient-reported satisfaction rates, the ETG procedure is a valuable surgical technique for the treatment of complex penile deformities.