Congenital penile curvature (chordee without hypospadias)

We treated 30 patients aged six months to nine years with congenital penile curvature from 1988 to 1993. Twenty-four patients appeared to have a primary curvature with normal corpus spongiosum. In 12 of these 24 patients dissecting skin and dartos fascia were adequate to straighten the penis. In the other 12 patients, artificial erection demonstrated a varied degree of convexity of the penis after the skin and dartos fascia release, implying a disproportion of the corpora cavernosa bodies. We corrected this deformity using dorsal tunica albuginea plications (TAP). The remaining 6 patients presented with a primary curvature and hypoplastic urethra. In 5 of these patients we divided the hypoplastic midportion of the urethra leaving the meatus naturally on the glans and replaced the midurethral segment using a tubularized island flap. Of these 5 patients 2 required TAP for penile straightening. The final patient with a hypoplastic urethra was managed by preserving the urethral plate and applying an onlay island flap urethroplasty. Complications were one fistula and two mild ventral penile curvatures, presently not severe enough for reoperation (mean follow-up 2.6 years). We present a systematic approach for the repair of congenital penile curvature using intraoperative artificial erection, TAP, and the island flap urethroplasty when needed.     

Acquired ventral penile curvature: spongiofibrosis caused by urethral manipulation

Fibrosis of the corpus spongiosum, caused by urethral manipulation, and the resulting ventral penile curvatures are known as the urethral manipulation syndrome. This acquired, largely iatrogenic deformity is noticed only be sexually active patients. Partial, gradual disappearance of glans engorgement and irregularities palpable along the penile urethra associated with ventral curvature are constant findings. The post-manipulative ventral curvature can be transient, disappearing when the inflammatory process subsides or the repeated urethral manipulation ceases. Since fibrosis of the corpus spongiosum begins with urethral inflammation, patients in whom irregularities of the penile urethra are observed during urethrography should be questioned about any erectile deformity. Surgical treatment is indicated when the deformity interferes with sexual intercourse or is accompanied by severe urethral strictures.     

Evaluation and surgical treatment of patients with penile curvature

In patients with adult penile curvatures the aim of treatment is to have a penis straight enough and firm enough to allow satisfactory sexual function. Several operative approaches have been used to correct this condition. Herein, we describe our experience with the evaluation and surgical treatment of 37 patients with penile curvature. When we have decided on surgery, we either preferred to elongate the ventral corpora cavernosa by interposition of a piece of dura mater (2 patients) or in most cases (the remaining 35 patients) only excised wedges of tunica albuginea at the arcs of the maximum curvature located with artificial erection (Nesbit's operation). In conclusion, our results showed that Nesbit's operation is a versatile procedure that proved to be useful for correction of penile curvatures in patients with Peyronie's disease. However, further studies and clinical trials are needed to determine if the dura mater is an alternative in the treatment of penile curvatures due to congenital aetiology.     

The surgical treatment of chordee without hypospadias in men.

During a 2-year period we treated 26 young men for chordee without hypospadias. Many of these patients had straight erections as children but a ventral curvature developed as they achieved puberty. We describe the anatomical findings and discuss the possible cause for the development of this anomaly. Surgical therapy begins with a circumcising incision and reflection of the skin to expose the shaft of the penis. The corpus spongiosum containing the urethra was mobilized by resecting the dysgenetic tissue in the dartos and Buck's fascia layers. In 1 patient this dissection was sufficient to straighten the penis but in the remaining 25 the penis was not straight. In those patients we mobilized the dorsal bundle of vessels and nerves, and removed 1 or several ellipses of tunica albuginea to equalize the lengths of the ventral and dorsal aspects of the corpora cavernosa. The corpus spongiosum usually is elastic and the curve almost never is caused by shortness of the urethra, which stretches to fit the straightened penis. In 24 of the 26 patients the curvature was resolved with 1 operation, while 2 needed a second procedure.     

Management of urethral lesions in penile blunt trauma

BACKGROUND: Traumatic lesions to the penis may extend into the corpus spongiosum, causing laceration or complete transection of the urethra. Blunt penile trauma is usually related to sexual intercourse or manipulation. The aim of this paper was to report the authors experience with the management of urethral injuries in patients with penile blunt trauma. METHODS: The charts from 77 patients with penile blunt trauma were retrospectively reviewed, and the cases associated with urethral injuries associated were selected. Patient age ranged from 18 to 63 years (mean 33 years). RESULTS: From 77 cases assessed, 11 (14.2%) patients had urethral injury, 62 (80.5%) had injury of the corpora cavernosa and four (5.2%) had injury of the dorsal vein. The etiology of urethral injuries was sexual intercourse in 10 patients (91%) and direct trauma to the flaccid penis in one patient (9%). A partial urethral disruption was presented in eight patients (72.8%) and a total disruption in three patients (27.2%). Preoperative urethrogram was performed in seven patients with a suspicion of urethral trauma. When a partial injury was present the urethra was closed over the catheter, and in the presence of a total injury an end-to-end anastomosis was performed. CONCLUSION: The data support the reported incidence of urethral injury associated with blunt penile trauma. No clinically apparent urethral structures were appreciated with primary urethral repair after a follow up of more than 6 months.     

Maintenance of erection of penile glans, but not penile body, after transection of rat cavernous nerves

Two experiments tested the widely held assumption that the cavernous nerves (CN) are essential not only to erection of the penile body, via the corpora cavernosa, but also to erection of the glans penis, via the corpus spongiosum. In Experiment 1, the copulatory behavior and reflexive erections of male rats were studied before and after the CN were transected bilaterally (n = 8), unilaterally (n = 6), or sham-operated (n = 6). In postoperative tests, bilaterally operated males were severely impaired in their attempts to effect intromission, and they had the expected deficits in reflexive erections of the penile body, but their capacity for erection of the glans penis was only minimally impaired. Sham-operated males were unaffected by surgery, and unilaterally transected males had intermediate values. Experiment 2 tested the hypothesis that activity of the bulbospongiosus muscles was responsible for the residual erectile capacity of the glans after CN transection in Experiment 1. Males had bilateral sections of the CN (n = 9), or of the nerves innervating the bulbospongiosus muscles (n = 10), or of both of these nerves (n = 8), or sham surgery (n = 10). Relative to CN transection alone, the combined denervation further reduced glans penis erections, but did not eliminate them. These results suggest that the cavernous nerves of the rat are not the only peripheral nerves facilitating vascular engorgement of the corpus spongiosum.     

Hypospadias and associated penile anomalies: a histopathological study and a reconstruction of the pathogenesis.

Hypospadias is considered to be the result of inadequate fusion of urethral folds and, possibly, of canalization of a glandar epithelial cord during the formation of the spongy urethra. This theory had to be reconsidered because a recent study in normal human embryos has exposed such fusion and invagination as misconceptions. Autopsy specimens of five penises with hypospadias from foetuses and neonates were studied histologically. The findings complemented with data from the literature were correlated to the normal developmental process to reconstruct the pathogenesis of the disorder. Histopathological analysis revealed that the hypospadic orifice was the proximal part of a mucosal delta which revealed the structure of the roof and meatus of a flattened distal urethra. Branches of the raphe bordering the delta and terminating in prominent 'dog ears' had the characteristics of the transient urethral labia (folds). Associated curvature and torsion could be related to structural abnormalities of vascular structures, notably the distal corpus spongiosum, and fasciae predominantly proximal to the hypospadic orifice. Correlation with normal development indicated that hypospadias and associated anomalies are not caused by disturbed fusion or glandar invagination but by maldevelopment of a complex of primordial fascial and vascular tissue proximal to the urethral orifice which normally form the venter side of the penis by disproportionately strong proliferation and make the urethral orifice shift distalward. Insufficient growth may disturb that shift with the degree of deficiency determining the precise position of the urethral orifice, size of the urethral delta and defect of the prepuce. Shortage and/or poor organisation of these tissues explain curvature and, if asymmetrical, torsion, both of which can occur also with minimal urethral deformity or as congenital ventral curvature and torsion without hypospadias.     

Postoperative pulmonary edema secondary to rapid fluid injection into the corporal bodies during surgical correction of penile curvature: a rare consequence of artificial erection

Some experts contend that occlusion of the proximal corpora cavernosal bodies of the penis with a tourniquet or manual compression during induction of an artificial erection distorts the penile anatomy and potentially masks proximal curvatures. The current report highlights a rare, but potentially morbid, case of postoperative pulmonary edema as a consequence of rapid fluid injection into the corporal bodies during surgical correction of penile curvature, in a 48-year-old male with a high-risk cardiac history.     

Personal treatment of congenital penile curvature

Severe type I congenital curvature of the penis is characterised by an almost transparent hypoplasia uretra. Treatment consists of resecetion of the dysplasic urethra and its replacement by tubular grafts of preputial or extragenital skin or of the vesical or buccal mucous membrane. We present our experience of four patient with type I congenital curvature of the penis which we treated with a simple surgical technique consisting of leaving the over-lying skin attached to the hypoplasia urethra and resecting the remaining fibrotic tissue which is connected to and retracts the skin and the cavernous bodies. We performed plastic surgery of the dorsal surface of the tunica albuginea to achieve correct penis hardening and finalized the surgery with reconstruction of the ventral surface of the penis by spreading out the dorsal prepuce or by using a pediculated graft of surplus preputial skin.     

Paediatric penile trauma

OBJECTIVE: To report our experience with paediatric penile trauma in a retrospectively evaluated series. PATIENTS AND METHODS: The records of 64 boys (mean age 7 years, sd 4) who were hospitalized over the last 20 years because of penile trauma were reviewed. The cause of trauma was circumcision in 43 (67%), a human hair-tie strangulation injury in 10 (16%), an animal attack in four (6%), a bicycle accident in four (6%), a zipper injury in two (3%) and electrical injury in one (2%). Patients were managed according to the severity of the injury. Eight (12%) with minimal skin loss or meatal injury underwent primary skin closure or meatoplasty; 40 (62%) with urethrocutaneous fistulae underwent repair and five (8%) with a glans hanging on a thin pedicle had the glans and the urethra reconstructed. Patients with partial or complete amputation of the glans (10) underwent primary haemostasis and meatoplasty; the penis was lengthened in one. One child with complete avulsion of the penis underwent perineal urethrostomy. RESULTS: Fifty-four patients (84%) were followed for a mean (sd) of 5.7 (4) years; there were good cosmetic and functional results in 45 (83%). Fifteen patients are now adults; 13 (86%) reported normal sexual function. Of the 40 patients assessed with circumcision-related injuries, six (15%) had functional disability (short penis in one and fistulae in five). Of the 10 patients with a hair-tie injury, none lost their glans. Of the four injuries caused by animal attacks, three had poor results (emasculation in one, short penis in one and severe curvature in the remaining patient). There was no functional disability in the remaining forms of trauma. CONCLUSIONS: In our region, ritual circumcision and hair-tie strangulation injuries are the most common causes of penile trauma in children. Good functional and cosmetic results are possible in most cases. However, animal attacks are associated with the highest rate of long-term functional and cosmetic disability.     

Management of Peyronie's disease with penile prostheses

Peyronie's disease is a common malady affecting men mostly between the ages of 40 and 60. When penile curvature and erectile softening are present and the erectile dysfunction does not respond to Viagra a penile implant will strengthen and usually straighten the penis. If curvature persists after implant placement 'modeling' the erect penis will successfully achieve straightening in most patients. Plaque incision and grafting or a Nesbit procedure are rarely necessary to straighten the penis but will afford excellent results when employed. A thorough explanation of the pathogenesis of Peyronie's disease and effects of the disease and treatment on penile size will help avoid some of the disappointment seen when a shorter erection occurs.     

Cavernosography following clinical failure of penile vein ligation for erectile dysfunction

In an attempt to determine what occurs to the venous circulation of the penis after ligation of the deep dorsal vein, 9 men with veno-occlusive dysfunction who underwent deep dorsal penile vein ligation and failed to achieve normal erectile function postoperatively consented to a postoperative cavernosogram. Preoperatively, the deep dorsal vein was visualized in all 9 patients, the cavernous vein in 2 and the corpus spongiosum in 1. Postoperatively, the deep dorsal vein was visualized in 1 patient, the cavernous vein in 1 and the corpus spongiosum in 8. These observations suggest that either the inability to identify a cavernous-spongiosal communication preoperatively or the induction of such a communication postoperatively may lead to a clinical failure in patients who undergo deep dorsal penile vein ligation.     

Incomplete epispadiac urethral duplication with dorsal penile curvature

Incomplete urethral duplication, although not uncommon, usually is associated with insignificant chordee of the penis and it is clinically asymptomatic. We report a case of incomplete urethral duplication with marked dorsal curvature of the penis and other congenital anomalies. Excision of wedge-shaped ellipses of the tunica albuginea from the ventral aspect of the corpus provided an excellent result.     

Use of transurethral alprostadil (MUSE) (prostaglandin E1) for glans tumescence in a patient with penile prosthesis

The presence of communication between the emissary veins from the corpora cavernosa and the circumflex veins draining the corpus spongiosum makes it possible for the transfer of alprostadil (prostaglandin E1) in MUSE from the spongiosal compartment to the cavernosal compartment of the penis after its absorption through the urethral mucosa. This leads to engorgement and tumescence of the corpus spongiosum as well as the corpora cavernosa. Lack of tumescence of the glans penis and poor penile girth can be a cause for disappointment and frustration in patients following penile prosthetic surgery. MUSE was used successfully in a patient with a Dynaflex penile prosthesis to enhance the tumescence of the glans penis. It will be a useful adjunct for patients in similar circumstances.     

Tunica albuginea plication for the correction of penile curvature

OBJECTIVE: To evaluate the efficacy of tunica albuginea plication (TAP) in the correction of congenital and acquired penile curvatures and determine key points for a successful outcome of this procedure. MATERIALS AND METHODS: From December 1995 to January 2001, 40 patients with penile curvature (10 congenital and 30 secondary to Peyronie's disease) underwent surgical correction by TAP. Indications were difficult or impossible penetration, normal erectile function, stable disease. For TAP we used non-absorbable inverted stitches tied with the assistant pushing down the tunica albuginea with a mosquito clamp to create an adequate groove for the knot. The results were evaluated subjectively and objectively. RESULTS: At mean follow-up of 30 months, full subjective and objective success (straight penis, mild shortening, normal erection, penetration and sensation) was achieved in 37 (92.5%) patients. Objective but not subjective success was achieved in 2 patients (5%), 1 complaining of psychogenic erectile dysfunction and the other of excessive penile shortening. There was only one failure, namely persistent glans numbness due to damage of the non-mobilized neurovascular bundle. CONCLUSIONS: TAP is a simple and effective method for the correction of congenital and acquired penile curvatures. Key points for successful outcome are adequate preoperative evaluation and counselling, careful preparation of tunica albuginea, mobilization of urethra or neurovascular bundle when needed, use of inverted stitches carefully buried, objective postoperative evaluation with a pharmacological erection test.     

Correction of severe penile curves with tunica albuginea autografts

Nesbit's technique of excising ellipses of the tunica albuginea has been effective in correcting penile curvatures. When this procedure is used for severe angulations, penile shortening can be significant. We report the use of Nesbit ellipses autografted to the contralateral corpus for correction of severe penile curvatures in 3 men. This method resulted in a straight penis with minimal shortening.     

Arterialization of deep dorsal vein of penis for penile ischemia

Penile ischemia, a rare complication of diabetic end-stage renal disease, is usually treated by penectomy once conservative measures fail. We present a patient with diabetes mellitus and end-stage renal disease with penile ischemia that was successfully treated with an arteriovenous interposition bypass graft between the common femoral artery and the deep dorsal vein of the penis. Retrograde flow into the corpus spongiosum resulted in immediate pain relief and healing of the ischemic lesions.     

Neurovascular bundle dissection for Nesbit procedure in congenital penile curvature patients： medial or lateral？

The objective of this study was to compare the outcomes of the modified Nesbit procedure using different techniques for dissecting the neurovascular bundle （NVB） to correct ventral congenital penile curvatures （CPCs）. The bundle was mobilized using the medial and lateral dissection technique in 21 （Group 1） and 13 （Group 2） patients, respectively. In the medial technique, Buck＇s fascia is opened at the dorsal side of the penis, the deep dorsal vein is removed at the most prominent site of the curvature and a diamond-shaped tunica albuginea （TA） is excised from the midline of the penis. In the lateral technique, the bundle is mobilized using a longitudinal lateral incision of the Buck＇s fascia above the urethra at the 5 and 7 o＇clock positions via a bilateral approach. The localization and degree of curvature was evaluated using the combined intracavernous injection stimulation test or from the patients＇ photographs. The mean patient age and degree of curvature were similar between groups. The mean operation time was longer for Group 2 （P= 0.01）. In Group 1, nine patients （42.8%） required one diamond excision, 10 （47.6%） required two diamond excisions and two （9.5%） required more than two excisions; in Group 2, six patients （46.2%） required two diamond excisions and seven patients （53.8%） required more than two diamond excisions （P = 0.019）. The differences in penile shortening, penile straightening and numbness of the glans penis were not statistically significant. Medial dissection of the bundle for the modified Nesbit procedure reduces the number of diamond-shaped removals of TA and thus shortens operation time in comparison with its lateral counterpart.     

Congenital dorsal penile curvature: a potential problem of the long phallus

PURPOSE: We report the results of surgical correction of severe congenital dorsal penile curvature associated with a long slender phallus. MATERIALS AND METHODS: In the last 7 years we treated 16 boys with a mean age of 2 years 10 months who had severe dorsal penile curvature. The series included 5 patients with megameatus variant hypospadias and a full foreskin, 3 who presented with hypospadias and 8 who were referred when dorsal penile curvature was noticed by the family or primary physician. Mean penile length was 6.5 cm. without stretching. In each case length was greater than 2 standard deviations above the mean for patient age. Penile circumference decreased from a mean of 4.2 cm. at the base of the shaft to 4.1 cm. at the mid shaft and 3.7 cm. at the corona. Penile circumference was generally normal for patient age until corrected for length, when it was revealed to be small. Surgical correction of severe curvature was performed in 14 patients, while 2 who presented as newborns had remarkable spontaneous improvement in the first year of life. In each case curvature was due to corporeal disproportion. RESULTS: All patients have erections postoperatively. There has been no residual or recurrent curvature and cosmetic results are good. CONCLUSIONS: Congenital dorsal penile curvature is a potential problem of the long phallus. In severe cases surgical repair improves the appearance of the penis but it must also address the problem of corporeal disproportion.     

Corporeal penile plication for correction of erectile penile deformity.

Penile curvature causing functional impairment of sexual intercourse is uncommon but a number of patients are significantly inconvenienced by this condition. Seven patients who had marked erectile deviation were treated with surgical plication for their penile deformity. Mean follow-up was 16 months (range 3-48 months) and no postoperative complications were encountered. In six cases the penis has remained straight. In one patient recurrence of deformity occurred 12 months after corporeal plication. The simplicity of the corporeal plication technique with the low incidence of associated complications makes it an attractive surgical alternative for the treatment of penile erectile deformity.