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Keywords:

  • Congenital penile curvature;
  • Nesbit procedure;
  • corporoplasty;
  • outcome

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

Objective

To reduce the incidence of postoperative palpable induration after treating congenital penile curvature, using a modified corporoplasty technique.

Patients and methods

In a retrospective unrandomized clinical trial, 105 patients with a congenital penile angulation of >30° and for whom coitus was therefore difficult or impossible, underwent surgical correction. Of the 105 patients, 55 underwent the Nesbit–Kelâmi technique, whereby a diamond-shaped section of the tunica albuginea is excised and the defect closed with an interrupted suture. The remaining 50 patients underwent the modified corporoplasty, the edges of the tunica albuginea being brought together with a continuous, blood-tight, intratunical suture, and the end knots buried.

Results

The early results (<6 months) were comparable in both groups, with correction of the curvature in 94% and 95%, and postoperative complications in 14% and 15%. There were fewer postoperative haematomas in those undergoing modified corporoplasty (6% vs 18%). The late results (>6 months) also showed that these patients developed fewer palpable indurations (16% vs 44%).

Conclusion

The modified corporoplasty reduced the incidence of postoperative haematoma and late complications (e.g. palpable indurations) after the surgical correction of congenital penile curvature.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

It is difficult to estimate how many patients require treatment for congenital penile angulation. The prevalence of this condition is probably higher than the 0.4–6 per 1000 previously reported [1,2]. Penile curvature is diagnosed with increasing frequency, possibly as a result of raised public awareness of sexual problems and less reluctance to consult a physician when they appear [3]. Penile angulation not only causes sexual dysfunction, e.g. substantial difficulty and pain on intercourse or even total coital incapacity, but also severe psychological problems. Surgical intervention to cure penile curvature is required when coital function is impaired [4,5].

Different surgical techniques have been described; Nesbit performed the first operative correction in 1965 [6] and this procedure was modified by Kelâmi in 1985 [7,8]. The surgical correction of congenital penile curvature generally involved shortening the convex side of the organ by direct excision [6], closing a longitudinal incision transversely [9] or a plication of the tunica albuginea [10[11]–12]. Penile induration, which can disturb the functional and cosmetic results of these procedures, is a common complication. Thus, the aim of the present study was to reduce the incidence of postoperative palpable induration after treating congenital penile curvature, using a modified corporoplasty technique.

Patients and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

In all, 105 patients with congenital penile curvature of >30° and without hypospadias or chordee, but with difficulty or pain on intercourse, were treated by corporoplasty. All patients were asked to document their penile angle before operation by photography, as described by Kelâmi [13]. To be able to assess the degree of angulation and the anticipated postoperative success during the operation, an artificial erection was established by infusing normal saline into one corpus cavernosum through a butterfly needle. Directly above the point of maximum curvature on the convex side of the organ, the skin was incised or the sleeve technique with circumcision carried out. After that, Buck’s and Colles’ fasciae were cut through, thus providing a clean exposure of the tunica albuginea. Special care was taken to avoid large veins, the dorsal neurovascular bundle and the corpus spongiosum. In cases of dorsal or ventral curvature, these structures were mobilized precisely. Holding sutures were inserted at the site of the corporoplasty.

Of the 105 patients, 55 underwent the Nesbit–Kelâmi procedure. Using Allis clamps, as many ‘bites’ were taken from the convex side of the corpora cavernosa as were necessary to straighten the penis and the resulting diamond-shaped area was then removed completely with a scalpel. The edges of the tunica albuginea were then brought together with interrupted absorbable sutures (polydioxanone 2–0, Fig. 1). The remaining 50 patients underwent the modified corporoplasty. The diamond-shaped defect of the tunica albuginea was closed with a continuous intratunical suture of slow absorbable material (3–0 polyglactin) and the end knots buried (Fig. 2).

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Figure 1. The Nesbit-Kelâmi technique for corporoplasty, showing closure of the tunica albuginea with single sutures.

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Figure 2. The modified corporoplasty, showing closure of the tunica albuginea with a continuous blood-tight intratunical suture (a, b) with buried end knots (c).

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After completing the corporoplasty, Colles’ and Buck’s fasciae and the penile skin were closed accurately in layers with single sutures. Moderate compression was applied and no indwelling catheter was required. No antiandrogen or sedative medication was given; the patients remained in hospital for 2–7 days.

The outcome was assessed every 3 months for the first year and thereafter yearly, estimating the objective and subjective results of penile correction by physical examination and interview. In cases of residual curvature, patients were requested to record these by photography.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

The characteristics of the patients and the outcome are given in Table 1. The incidence of the direction of penile curvature was the same in both groups, with most being ventral and left lateral curvatures. The mean (range) number of ‘bites’ which were taken from the convex side of the tunica albuginea was 2 (1–4) in both groups.

Table 1.  Patient characteristics and results of the Nesbit-Kelâmi technique or modified corporoplasty for the treatment of congenital penile curvature Thumbnail image of

The early results (at <6 months) showed comparable results in both groups for normal erection, erectile deformity <15°, normal penetration and satisfactory coitus (94% vs 95%). The complication rate (e.g. oedema, disturbances of sensitivity of shaft or glans) was the same in both groups (15% vs 14%). In five patients (two undergoing modified corporoplasty and three the Nesbit-Kelâmi technique) with incomplete correction of penile curvature (i.e. a residual angulation of >30°) the preoperative curvature was >70°. Because of difficulties on intercourse, two of these five underwent a further corporoplasty, with good results. There were fewer postoperative haematomas in those undergoing modified corporoplasty (4% vs 18%).

The late results (>6 months) showed that patients treated by modified corporoplasty had fewer palpable indurations (Table 1). There were no differences in the incidence of residual penile curvature (>15°) and penile shortening between the groups after 6 and 12 months. None of the patients had postoperative erectile dysfunction.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References

Since the introduction of surgery for penile curvature by Nesbit in 1965, various approaches and variations on the theme of corporoplasty have been reported. These include plication, segmental resection and the transverse closure of a longitudinal incision of the tunica albuginea. The procedure described by Yachia [9] (i.e. the transverse closure of a longitudinal incision in the longer portion of the tunica albuginea) is a simple and minimally invasive technique which has the advantage of leaving the cavernosal tissue intact. The Nesbit procedure (i.e. segmental resection of the tunica albuginea) is more time-consuming and requires greater surgical experience. In cases of severe angulation, penile shortening can be significant [6,7]. Both techniques require closure of the tunica albuginea for the correction of penile angulation. Plication of the tunica albuginea on the convex side of the corpora cavernosa is an easy operation, but opinions differ on the long-term results of this modification [3,11,14,15].

Functional and cosmetic success rates after these different types of corporoplasty have been estimated at 60–100% [1,8,16,17], depending on the aetiology of the curvature. Patients with Peyronie’s disease, often accompanied by erectile impairment and erectile pain due to cavernosal fibrosis, have worse results than patients with congenital penile angulation [17[18][19]–20].

Postoperative complications, e.g. residual curvature, sensory disturbances of the shaft or glans, oedema, wound infection, haematomas, penile shortening or induration, have been reported in 10–64% of patients [3,16,17,20[21]–22]. Postoperative haematomas caused by leakage through the tunica albuginea seem to be more frequent after the Nesbit procedure than after plication of the tunica albuginea [23]. In the present patients undergoing modified corporoplasty, there were fewer postoperative haematomas, probably because of the blood-tight suturing of the tunica albuginea.

Penile shortening is caused by segmental resection or plication of the tunica albuginea and in general, a decrease of 1–2 mm per 10° angulation is to be expected. With severe angulation, penile shortening can be significant. In the present series, there was subjectively inconvenient penile shortening in both groups (27% and 22%, respectively). The phenomenon of penile shortening after corporoplasty is more often a problem in patients with Peyronie’s disease than with congenital penile curvature.

Oedema and sensory disturbances arise through irritation or damage of the dorsal neurovascular bundle. These can be avoided by careful dissection and do not depend upon the procedure used. Sensory disturbances at the penile shaft or the glans occurred in both groups (4% and 2%, respectively).

Palpable induration has been described after segmental resection of the tunica albuginea, the transverse closure of a longitudinal incision and plication of the tunica albuginea. In the present series, 45% of those treated by the Nesbit-Kelâmi technique complained of induration at the site of the corporoplasty. Having found by experience that less scar tissue is formed after intradermal suturing, we used intratunical sutures for closing the tunica albuginea. With this technique, significantly fewer (16%) postoperative indurations were reported by patients. The intratunical suture with buried end-knots used in the modified corporoplasty can be used for all techniques in which the tunica albuginea is incised.

In conclusion, the modified corporoplasty proved to be at least as effective as the other standard procedures for correcting congenital penile angulation. It also reduced the incidence of postoperative haematomas and late complications such as palpable indurations.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. References