Fibrin glue for the suture-less correction of penile chordee: a pilot study in a rabbit model

OBJECTIVE: To evaluate the use of fibrin glue as a scaffold for patching defects in the tunica albuginea in a rabbit model for a future application in correcting chordee. MATERIALS AND METHODS: Nine New Zealand white male rabbits were utilized. All had a 15 x 5-mm defect created in the ventral tunica albuginea. Fibrin glue (1 mL) was applied to cover the defect in tunica albuginea and the penile skin closed with a continuous 5/0 chromic catgut suture. Animals were killed in groups of three at 2, 6 and 12 weeks afterward. The evaluation included an artificial erection test with intracavernosal injection of prostaglandin E1 (5 microg), cavernosography and histopathological examination of sections of the penis stained with haematoxylin and eosin or Masson trichrome. RESULTS: None of the rabbits died during the procedure or developed bleeding or haematoma afterward. All animals had straight erections on testing with prostaglandin (5 microg). There was no evidence of corporal narrowing or venous leakage on cavernosography. Histopathological evaluation showed evidence of the fibrin sealant layer, with angiogenesis and a cell infiltrate at 2 weeks. At 6 and 12 weeks there was completely normal regeneration of the tunica albuginea. CONCLUSIONS: In this pilot study in a rabbit model the haemostatic effect of fibrin glue was confirmed on covering a defect in the tunica albuginea. Moreover, there was regeneration of normal tunica albuginea with no scarring at 6 weeks and maintained at 12 weeks. Further well-controlled studies are required before using fibrin glue for corporal body grafting to treat chordee.     

Use of oxidized cellulose for corporal body grafting and suture-less correction of severe penile chordee: an experimental study in rabbits

OBJECTIVE: To evaluate the efficacy of oxidized cellulose, Surgicel(TM) (Johnson & Johnson Medical, New Brunswick, NJ, USA) for patching defects in the tunica albuginea in a rabbit model, with a future application to correct chordee. MATERIALS AND METHODS: The study comprised nine New Zealand white male rabbits; a rectangular 15 x 5-mm defect was created in the ventral tunica albuginea that was covered by Surgicel. The skin was closed with no catheters left in situ after the procedure. The rabbits were killed in groups of three at 2, 6 and 12 weeks after surgery. The evaluation included cavernosography and histopathological examination of sections of the penis stained with haematoxylin and eosin, and Masson's trichrome. RESULTS: No deaths were caused by the procedure, and none of the rabbits developed bleeding or haematoma after surgery. Cavernosography at 2 weeks showed contrast medium leaking from the site of the Surgicel, but at 6 and 12 weeks all rabbits had a straight erection with patent corpora and no evidence of narrowing or venous leak. Histopathological evaluation revealed evidence of the remnants of Surgicel surrounded by acute inflammatory cell infiltrate with early neovascularization at 2 weeks. At 6 and 12 weeks, there was complete normal regeneration of the tunica albuginea with no foreign-body reaction. CONCLUSIONS: In this pilot study, Surgicel had a clear haemostatic effect when covering a defect in the tunica albuginea. Moreover, normal tunica albuginea regenerated by 6 weeks and was maintained at 12 weeks. These results suggest that Surgicel might be considered a safe and effective grafting material for tunica albuginea substitution, including the surgical management of penile chordee.     

Tunica albuginea acellular matrix graft for treatment of Peyronie's disease--an experimental study in dogs

OBJECTIVE: To study the value of an acellular matrix graft of the tunica albuginea for reconstruction of the penis in cases of severe Peyronie's disease. MATERIAL AND METHODS: In nine mongrel dogs, an acellular matrix graft of the tunica albuginea was used to cover a 30 x 10 mm2 tunical defect. Equal numbers of animals were sacrificed at 1, 3 and 6 months after surgery. Before death, an erection was induced by means of papaverine injection and cavernosography was performed. After death the penis was prepared for histopathological study. RESULTS: All animals survived the surgery and none developed haematoma, wound infections or dehiscence. All dogs developed a straight, rigid erection. Cavernosography showed patent corpora cavernosa in all animals. The papaverine injection and cavernosographic results did not change over time. Inspection of the graft site and measurement of its length and width showed healing with no contracture. Histologically, the regenerated matrix appeared thicker than the neighbouring tunica albuginea in the 1-month group; otherwise the appearance was normal. Gradual orientation of the fibrocytes, capillaries and collagen fibres was demonstrated at 1 month and was complete at 3 and 6 months. Comparison between an implanted tunica at 6 months and a control tunica from a normal dog showed no significant histological difference. CONCLUSION: A homologous acellular matrix graft of the tunica albuginea may be an alternative treatment for severe cases of Peyronie's disease.     

Tunica vaginalis for correcting penile chordee in a rabbit model: is there a difference in flap versus graft?

PURPOSE: We compared tunica vaginalis applied as a flap versus a graft for covering defects in the ventral tunica albuginea in a rabbit model. MATERIALS AND METHODS: We used 18 New Zealand White rabbits in the study. The urethra was mobilized off of the corpus cavernosum. A defect was created in the ventral aspect of the tunica albuginea by excising a 1 x 0.5 cm. rectangular area. The defect was covered by the testicular surface of tunica vaginalis as a vascularized flap in 9 animals and as a graft in 9. At 2, 6 and 12-week intervals 3 animals per group were sacrificed. Transverse sections of the penis at the repair site were stained with hematoxylin and eosin, and Masson's trichrome for microscopy. RESULTS: Autopsy revealed no contracture in any of the tunica vaginalis flaps. In contrast, the tunica vaginalis grafts had contracted by a mean of 22% (range 20% to 25%) at 2, 38% (range 30% to 44%) at 6 and 42% (range 38% to 48%) at 12 weeks. Microscopic examination of the tunica vaginalis flaps showed evidence of an intact blood supply and viable cremasteric muscle layer but no evidence of necrosis. Collagen remodeling and maturation was noted at 12 weeks. In tunica vaginalis grafts there was evidence of necrosis of all tunica vaginalis layers at 2 weeks with granulation tissue and active fibrosis at the periphery. At 6 and 12 weeks most necrotic tissue was replaced by fibrosis. Osseous metaplasia was identified in 1 graft at 12 weeks. CONCLUSIONS: The optimal use of tunica vaginalis for correction of chordee is as a flap rather than as a free graft. Grafts were associated with significant necrosis and contracture, of which neither was associated with flaps.     

Tunica albuginea acellular matrix graft for penile reconstruction in the rabbit: a model for treating Peyronie's disease

OBJECTIVE: To evaluate the use of an acellular matrix graft of the tunica albuginea for functional penile reconstruction in severe cases of Peyronie's disease. MATERIALS AND METHODS: In 18 rabbits, an acellular matrix graft of the tunica albuginea was used to cover a 4 x 8 mm tunical defect, and six animals each were killed 1, 3 and 6 months later; four unoperated animals served as histological controls. Before death an erection was induced by papaverine, with the quality classified on a scale of 0-5, and cavernosography performed. After death the penis was prepared for histological study, and the cell number, collagen and elastic fibre content evaluated in the regenerated matrix, and in control specimens and four unimplanted matrices. RESULTS: Of 18 experimental animals, 11 had normal erections before death, four had slight penile deviation and three developed no erection. Failure was caused by severe postoperative haematoma, resulting in scar tissue. There was no graft rejection. Histologically there was no difference between natural and regenerated tunica. The collagen content and cell number were not significantly different in regenerated and control samples. There were significantly fewer elastic fibres in the unimplanted grafts and the 1-month group, but in later samples this difference was no longer evident. CONCLUSION: The homologous acellular matrix graft of the tunica albuginea warrants further evaluation as an alternative treatment in Peyronie's disease, despite some postoperative failures. The advantage of this orthotopic biomaterial is its rapid integration, with no rejection.     

Dermal graft correction of extraordinary chordee

Severe degrees of primary chordee and persistent or recurrent chordee following previous surgical attempts at correction present a challenging problem. Inadequate resection of involved tissues, which may involve all layers of the penile investiture, or recurrent scarring of the ventral skin, Buck's fascia and tunica albuginea is usually the cause. Reoperation to achieve penile straightening often is unsuccessful unless all chordee-bearing tissue is resected extensively. Excision of large segments of tunica albuginea or wide separation of the margins creates a defect that tends to heal by dense scarring unless the defect is bridged by a graft. Various autogenous materials have been used, including blood vessel, fascia, free fat graft, dermis and tunica albuginea, as well as prosthestic materials, such as polytetrafluoroethylene, with varying results. A series of patients with extensive chordee is presented in whom tunical resection was necessary to achieve penile straightening. The results of free dermal graft replacement of the tunica are reported.     

Correction of disproportion of corpora cavernosa as cause of chordee in hypospadias

Correction of chordee is a basic step in hypospadias surgery. In some children with significant chordee, ventral deflection of the shaft will persist after all “chordee tissue” is excised from the surface of the corpora cavernosa. In the flaccid state, this persistent chordee may not be evident but is easily demonstrated with an artificial erection technique. The use of dorsal placation of the tunica albuginea to correct this deformity is emphasized.     

Chordee repair utilizing a novel technique ensuring neurovascular bundle preservation

Penile chordee, with and without hypospadias, is amenable to surgical correction. The Nesbit technique of dorsal plication of the ventral tunica albuginea is effective in correcting most cases of corporal disproportion. A hazard with this approach is the potential inclusion of the dorsal neurovascular bundle, with resultant erectile and sensory dysfunction. We developed a simple technique using the Freer elevator to isolate the neurovascular bundle prior to plication. This ensures that no injury occurs to the neurovascular bundle during plication. Since 1994, 37 boys with chordee have been repaired using this approach. Their ages at the time of operation ranged from 5 months to 28 years (mean 9 months). Following standard degloving of the penis, an incision through Buck's fascia is made lateral and parallel to the neurovascular bundle at the maximum level of the chordee. A similar incision is carried out on the contralateral side. A 4-mm-wide Freer elevator is positioned under Buck's fascia while hugging the tunica albuginea. The Freer elevator slides across the midline to the contralateral side, separating Buck's fascia and underlying layers from the tunica albuginea. Following isolation of the bundle, each corporal body is plicated by creating a longitudinal incision through the tunica albuginea, which then is closed transversely with a 5-0 polydioxanone suture. Buck's fascia subsequently is closed with an absorbable suture following confirmation of chordee correction. No complications have been encountered during a mean follow-up of 21 months (range 5-51 months). No patients have required reoperation for persistent chordee. We developed a technique that elevates the neurovascular bundle prior to plication, thereby ensuring no injury to this structure. We have successfully used this modified Nesbit technique since 1994 and have had no complications. Utilization of the Freer elevator adds an estimated 5 minutes to chordee correction compared to a standard plication lateral to the neurovascular bundles. Although long-term follow-up needs to be performed to confirm any erectile or sensory advantage, this approach should be considered whenever plication is to be performed.     

保留尿道板、带蒂鞘膜补片纠治儿童阴茎下弯

目的：探讨中重度尿道下裂合并的阴茎下弯的纠治方法。方法：回顾2008年5月-2009年11月本院对20例合伴中重度阴茎下弯的尿道下裂患儿施行了分期手术,第一期阴茎伸直术采用了保留原位尿道板、转移带蒂睾丸鞘膜补片法。结果：20例均成功实施手术,术后无皮瓣坏死、感染及渗血情况。有14例半年后施行第二期尿道成形术,术中经人工勃起试验评估阴茎弯曲纠正好。结论：保留尿道板、带蒂睾丸鞘膜补片法是一种纠治阴茎下弯的可靠方法,疗效满意。     

Tunica repair with acellular bladder matrix maintains corporal tissue function

Penile conditions, such as Peyronie's disease or tumor resection may require surgical reconstruction of the tunica albuginea. Various materials have been proposed, as a biomaterial for tunica albuginea repair, however, little functional data are available. We examined the applicability and functional outcome of a collagen-based matrix derived from the bladder (acellular bladder matrix (ABM)), as a biomaterial for tunica repair. Biocompatibility testing was performed on the matrix, which included mitochondrial metabolic activity, cell viability and apoptosis. Approximately 50% of the dorsal penile tunica albuginea was replaced with the collagen-based matrix patch after surgical removal in 24 New Zealand White rabbits. Cavernosometry and cavernosography were performed. The animals were killed 1, 2 and 3 months after surgery for analyses. The matrix showed excellent biocompatibility. All animals implanted with the matrix survived without any noticeable untoward effects. There was no evidence of inflammation or infection at the time of retrieval. Cavernosometry of the implanted animals demonstrated normal intracavernosal pressures with visual erections. Cavernosography of the repaired corpora showed a normal anatomical configuration. Biomechanical analysis of the retrieved matrices demonstrated similar tensile strengths as native tunica. Histologically, there was only a minimal inflammatory response, which gradually decreased over time. These results show that ABM is biocompatible, durable and effective when used as a tunica substitute. The matrix may be useful as an off-the-shelf biomaterial for patients requiring tunica albuginea repair.     

Correction of chordee. The Nesbit procedure

In select patients the Nesbit operation is a useful procedure for the correction of congenital or acquired chordee. This operation results in a deliberate shortening of the convex surface of the corpora cavernosa to counterbalance congenital or acquired shortening on the opposite side. Precise placement of the corrective tuck allows complete correction of the chordee with minimal disturbance of normal tissue. An artificial erection should be created to permit precise identification of the point of maximal curvature on the longer (convex) side of the penis. The transverse elliptical segment to be removed should be placed precisely at this point and should be of sufficient width to result in complete correction of the chordee. Care should be taken to remove only a segment of the tunica albuginea without damaging the underlying erectile tissue. In cases of ventral chordee, the corrective procedure will require elevation of the neurovascular bundle. In cases of dorsal chordee, the procedure will require elevation of the urethra and corpus spongiosum. A repeat artificial erection insures that an adequate correction has been obtained.     

The dorsal lamina of the rectus sheath: a suitable grafting material for the penile tunica albuginea in Peyronie's disease?

OBJECTIVE: To estimate the morphological suitability of human connective tissue structures from different regions as graft material in Peyronie's disease, and to present preliminary results from 12 patients with grafting of corporal bodies using autologous rectus sheath. PATIENTS AND METHODS: In five male cadavers the penile tunica albuginea was compared with the dorsal lamina of the rectus sheath, the palmar aponeurosis, the iliotibial tract and the Achilles tendon by using histological sections stained with haematoxylin and eosin, Crossmon's trichrome stain and resorcin-fuchsin. Surgical results and complication rates were investigated in 12 patients with Peyronie's disease after grafting the corporal bodies with autologous rectus sheath to correct their penile curvature. RESULTS: On histology, the penile tunica albuginea showed a three-dimensional meshwork of collagenous and elastic fibres. The dorsal lamina of the rectus sheath had a remarkably similar fibre structure. The other tissues had a different histology, with long collagenous fibres in parallel orientation and elastic fibres restricted to the loose connective tissue around blood vessels and nerves. Clinically, the penile deviation was successfully corrected in 10 patients; there were two residual deviations (15 degrees and 35 degrees ). There were minor complications after surgery in six patients, not requiring surgery. CONCLUSIONS: The dorsal lamina of the rectus sheath has similar morphological characteristics to the tunica albuginea, and therefore represents an ideal autologous graft; the first clinical results are promising.     

Hydrodissection technique to preserve the thin distal urethra when correcting chordee without hypospadias

PURPOSE: We introduce a hydrodissection technique to preserve the thin distal urethra when treating chordee without hypospadias. MATERIALS AND METHODS: A total of 18 patients with chordee but without hypospadias were surgically treated in 3 years, including 7 (38.9%) with a segment of thin distal urethra. A hydrodissection technique was used to preserve the thin distal urethra in 6 patients with a mean age plus or minus SD of 9.0 +/- 3.6 years. Artificial erection was induced after circumcision and penile skin degloving. Tunica albuginea plication to correct residual chordee was needed in only 1 patient. The thin distal urethra was covered by preputial subcutaneous tissue in 3 cases and by Y to I spongioplasty in 3. RESULTS: All 6 thin distal urethras were preserved. The thin distal urethra was a mean of 23.3 +/- 3.9 mm. long and mean followup was 17.8 months. Postoperatively penile cosmesis was excellent in all patients and urinary flow was normal. CONCLUSIONS: Using the hydrodissection technique to preserve the thin distal urethra simplifies the operation of correcting chordee without hypospadias by avoiding additional urethroplasty and tunica albuginea plication for residual chordee.     

Evaluation of corporal fibrosis in cadaveric pericardium and vein grafts for tunica albuginea substitution in rats

Abstract Aim: To evaluate the degree of corporal fibrosis in rats with cadaveric pericardium or vein as grafting materials for tunica albuginea substitution. Materials and methods: Thirty male Sprague-Dawley rats (300 g-325 g) were divided at random into 3 groups of 10 animals each: group 1 was the sham-operated controls and groups 2 and 3 underwent wedge excision of tunica albuginea and replacement with cadaveric pericardium and vein grafts, respectively. Four months later, rats were sacrificed and the penis removed to assess the degree of fibrosis using RT PCR technique for TGP-β1 mRNA expression. The tissues were fixed in 10 % formalin, paraffin-embedded and stained with Masson's trichrome and Verhoff's van Giesen for collagen and elastic fibers. Results: Four months after grafting, there was minimal fibrosis surrounding the patch in the vein graft rats and moderate fibrosis in the pericardial graft rats. The degree of penile fibrosis in the pericardial graft rats was significantly higher than that i     

Dorsal tunica albuginea plication to correct congenital and acquired penile curvature: a long-term follow-up

OBJECTIVE: To evaluate the long-term efficacy of a tunica albuginea dorsal plication technique for treating congenital and acquired penile curvature. PATIENTS AND METHODS: We retrospectively evaluated 83 patients (median age 1.8 years) who had their penile curvature corrected surgically using dorsal tunica albuginea plication between 1992 and 2002. The results were evaluated objectively using a pharmacological erection test or subsequently based either on the parents' reports or patients' self-assessment. The median (range) follow-up was 6 (0.7-10) years. RESULTS: Seventy (84%) patients had penile plication as an integral part of hypospadias repair, while the remaining 13 (16%) with a normal urethra had dorsal plication only. Twenty-eight (34%) of the 83 patients had an erection test during a repeat hypospadias repair or closure of a urethrocutaneous fistula; 22 of these had a straight penis, while the remaining six required additional plication for a satisfactory cosmetic outcome. Parents of 45 (54%) children reported that their child had a normal erection with no chordee during the follow-up. Ten (12%) adult patients reported straight erections enabling satisfactory penetration and sensation during sexual intercourse. None of the patients reported penile shortening or erectile dysfunction after surgery, and none had recurrent curvature during the follow-up. There was no difference in the results between patients with congenital or acquired penile curvature. CONCLUSIONS: Dorsal plication of the tunica albuginea is a simple and effective method in the long term for correcting congenital and acquired penile curvature.     

尿道口蒂皮瓣与口腔黏膜联合一期修复尿道下裂

目的探讨尿道口蒂皮瓣与口腔黏膜对合重建尿道的方法.方法 2002年3月～2004年5月,采用尿道口蒂皮瓣与口腔黏膜联合重建尿道21例,年龄14个月～8岁.切断挛缩尿道板,彻底矫直阴茎后,将口腔黏膜移植于阴茎腹侧白膜,尿道口蒂皮瓣翻转后与口腔黏膜对合,形成管状尿道.结果术后所有患儿均获3～18个月随访,平均7个月.阴茎弯曲完全矫正,尿道外口位于阴茎头前端,阴茎外形良好,排尿通畅.2例发生尿瘘,其中1例自愈,1例术后6个月再修补成功.结论尿道口蒂皮瓣与口腔黏膜联合重建尿道能彻底矫正阴茎弯曲,提高手术成功率和改善术后阴茎外形.     

Dynamic cavernosography: venous outflow studies of cavernous bodies

Based on dynamic cavernosography studies in 15 patients, including 8 with simultaneous passive erection, we present more precise details of the venous drainage of the penis. The venous drainage is comprised of 3 different systems. The superficial dorsal vein drains mainly the penile skin and prepuce, and empties via the external pudendal veins into the femoral vein. The deep dorsal vein, located between the tunica albuginea and Buck's fascia, drains the glans and all 3 corpora. The venae profundae penis emerge from each crus of the corpora cavernosa and drain only the corpora themselves. Considerable individual differences were found regarding further drainage via the pelvic venous system, including the prostatovesical plexus and internal pudendal veins. Passive erection was tried in 11 patients and was successful immediately after cavernosography in 8. The flow rates to induce an erection averaged 111 ml. per minute (range 55 to 160 ml. per minute), while the rate to maintain the erection was 48 ml. per minute (range 12 to 90 ml. per minute).     

Tunica vaginalis testis autografting for Peyronie's disease: report of two cases

Two patients with refractory Peyronie's disease were treated by tunica vaginalis testis autografting following surgical excision of indurated tunica albuginea of the corpora cavernosa. One patient could achieve relief of pain and a straight erection of the penis 3 months after surgery. Another patient could not obtain a satisfactory erection during the follow-up of 6 months, but could have sexual intercourse after 7 months. A tunica vaginalis testis autograft might be an ideal substitute for tunica albuginea because it has several advantages: it causes no rejection at the recipient site; it is flexible enough to accommodate to expansion; there is no development of sebaceous glands and hair follicles that may occur in the use of a dermal graft; and it is easy to obtain.     

Penile enhancement using a porcine small intestinal submucosa graft in a rat model

Several biodegradable materials have been experimented for penile enhancement, but none show the potential for clinical use. This study was designed to use porcine small intestinal submucosa (SIS) augmenting the normal tunica albuginea to increase the functional girth of the rat penis. In all, 20 adult male Sprague-Dawley rats constituted the study population. The animals were divided into two groups: group 1 consisted of the control (n=10) and group 2 (n=10) consisted of rats that underwent penile enhancement by a longitudinal I-shaped incision of the tunica albuginea on both sides, and the dissection of the plane between tunica albuginea and cavernosal tissue was carried out (n=10). The incision was then patched with a 3 x 10 mm2 piece of SIS, using a 6/0 nylon suture material. The penile length and mid-circumference were then measured using a Vernier Caliper before and 2 months after surgery. All rat penises underwent histological examination using Masson's trichome and Verhoff's van Giesen's stain for collagen and elastic fibers. The penile length, mid-circumference and degree of fibrosis score were expressed as mean+/-s.e. (standard error) and analyzed using a Wilcoxon rank-sum test. A statistical significance was accepted at P-value < or =0.05. Our results showed similar preoperative penile length and circumference in both groups. However, 2 months after the surgery, the mean penile circumference of the SIS group has grown significantly larger than the control group, while the mean penile length remained unchanged. The histological study of the rat penises revealed minimal amounts of fibrosis under the graft, and the elastic fibers of the graft showed orientation in a circular manner. In conclusion, SIS appears promising for material use in a penile enhancement.     

Urethral replacement: a comparison between small intestinal submucosa grafts and spontaneous regeneration

OBJECTIVE: To evaluate the use of commercially available single-layer small intestinal submucosa (SIS) for urethral replacement, both as an onlay and as a tube, in a rabbit model. MATERIALS AND METHODS: Thirty-six male rabbits were assigned to four experimental groups. Group 1 had the ventral wall of the penile urethra excised for 15 mm; in group 2 this created defect was patched with a SIS onlay graft; group 3 had complete excision of a 15 mm segment of the penile urethra; and in group 4, this created defect was replaced with a SIS tube graft. In all rabbits the urethra was stented for 2 weeks. A retrograde urethrogram was taken in all rabbits before death at 3, 6 and 12 weeks after surgery. The urethra was then exposed, examined carefully and excised for histopathological examination. RESULTS: In groups 1 and 2 the retrograde urethrograms were normal in 13 rabbits and there was relative narrowing in two rabbits in group 1 and three in group 2. In groups 3 and 4 all rabbits developed urethral fistulae or strictures. Histological examination of the urethra showed epithelial regeneration supported by smooth muscle backing in all rabbits in group 1, while rabbits in group 2 showed no regeneration of smooth muscle. By contrast, rabbits in groups 3 and 4 showed incomplete regeneration and progressive fibrosis. CONCLUSIONS: Single-layer SIS is not a suitable urethral substitute in this animal model. When used as an onlay, healing is inferior to spontaneous urethral regeneration, as SIS impedes smooth muscle cell regeneration. When used as a tube, there is complete scarring and urethral luminal occlusion.