Superficial tunica albuginea excision, using geometric principles, for the correction of congenital penile curvature

Authors

  • Franklin Emmanuel Kuehhas,

    Corresponding author
    1. Department of Urology, Medical University of Vienna, Austria
      Franklin Emmanuel Kuehhas, Department of Urology, Medical University of Vienna, Waehringer Guertel 18-20/ Eben 8, 1090 Vienna, Austria. e-mail: fkuehhas@hotmail.com
    Search for more papers by this author
  • Paulo Henrique Egydio

    1. Specialized Center of Penile Curvature, Sao Paulo, Brazil
    Search for more papers by this author

Franklin Emmanuel Kuehhas, Department of Urology, Medical University of Vienna, Waehringer Guertel 18-20/ Eben 8, 1090 Vienna, Austria. e-mail: fkuehhas@hotmail.com

Abstract

Study Type – Therapy (practise pattern survey)

Level of Evidence 3b

What's known on the subject? and What does the study add?

Congenital penile deviation has become a relatively frequent finding due to a greater awareness of the problem among patients and physicians. Since the first surgical correction for congenital penile curvature was performed, many modifications have been implemented to overcome the disadvantages of the standard procedure and to improve functional results. Among the possible side effects of the original technique are postoperative erectile dysfunction, the development of painful nodules at the suture sites (‘dog ears’), alteration of cutaneous sensibility and significant penile shortening.

This study presents a novel approach for the correction of congenital penile curvature. We modified the conventional Nesbit technique by applying superficial tunica albuginea excisions, according to the geometric principles of the Egydio technique.

OBJECTIVE

  • • To report our experience with a new technique for the correction of congenital penile curvature based on geometric principles.

PATIENTS AND METHODS

  • • Between January 2006 and March 2011, 211 men with congenital penile curvature underwent our modified Nesbit technique.
  • • The technique consists of an objectivation of the degree of curvature and distribution of the bending force by multiple, small, superficial, elliptical excisions of the tunica albuginea.

RESULTS

  • • The overall success rate was 99.1%.
  • • A residual curvature of less than 20° was reported in 5% (n= 11) of the cases; none of these patients opted for further surgical correction.
  • • Residual curvature of up to 30° was observed in 0.9% (n= 2); these patients underwent a reoperation.
  • • Acquiring or regaining the ability to perform sexual intercourse brought major relief and high rates of satisfaction and self-esteem.
  • • No recurrence of a ventral curvature occurred.

CONCLUSIONS

  • • Our modified Nesbit technique, consisting of superficial tunica albuginea excision according to the geometric principles of the Egydio technique, leads to rapid and excellent results due to an objectivation of the curvature.
  • • It is a safe and valid alternative for the treatment of congenital ventral or ventro-lateral penile deviation.

INTRODUCTION

Penile curvature is a common urological problem, estimated to affect 3–5% of the male population [1]. Abnormal penile deviations are divided into a congenital form, which is less frequent (37/100 000 men), and an acquired form, due to Peyronie's disease, which affects a larger proportion of the male population (388/100 000) [2]. Peyronie's disease manifests as a fibrous inelastic scar of the tunica albuginea, leading to penile deformity, shortening, narrowing and painful erections. It was first described by Francois Gigot de la Peyronie, the personal physician of King Louis XV of France in 1743 [3]. Modern autopsy studies suggest that 22% of men have some degree of subclinical Peyronie's lesions on their penile tunica albuginea [4].

Several reconstructive surgical techniques have been proposed for the correction of acquired penile curvature, including lengthening the concave side by grafting with different tissues or synthetic materials [3,5–8]. Congenital penile deviation, however, has generally been treated with a slightly different approach. Nesbit [9] originally described a more conservative treatment modality for congenital deviations by simply shortening the convex side of the curvature. This is achieved by excision of paired ellipses of the tunica albuginea from the dorsal surface of the corpora cavernosa. Since its description in 1965 several modifications have been proposed to simplify the technique and to increase its success rate and degree of patient satisfaction. Ebbehoj and Metz [10] reported a modification that consisted of transverse plication of the tunica albuginea, with a possible variation of intracavernous embedding of the plications, to reduce the incidence of palpable indurations [11]. Yachia [12] proposed longitudinal incisions of the tunica, which were then sutured transversally. In all cases, the correction of congenital ventral curvatures implies an important and delicate step consisting of the isolation of the dorsal neurovascular bundle to expose the tunical surface to be incised for corporoplasty.

We modified the conventional Nesbit technique by applying superficial tunica albuginea excisions, according to the geometric principles of the Egydio technique [13,14], which can be applied to any kind of penile deviation. We report our 5-year experience with this modified surgical technique for the treatment of congenital ventral and ventro-lateral penile deviations.

PATIENTS AND METHODS

PATIENT POPULATION

Between January 2006 and March 2011, 211 patients with disabling, congenital ventral and ventro-lateral curvature of the penis underwent our modified Nesbit surgical procedure. The mean age of the patients at the time of treatment was 22.5 years (range 14–45 years). A detailed medical and sexual history was obtained, including the duration and progression of symptoms, erectile function, medication use, history of trauma and family history of Peyronie's disease. Patients reported difficult vaginal penetration during sexual intercourse or that their partners had dyspareunia.

During outpatient, preoperative evaluation, the patients each received an intracavernous injection of 20 µg of prostaglandin E1 to objectively assess the degree of curvature and to classify the curvature as either ventral or ventro-lateral. In addition, erectile function was assessed using dynamic duplex sonography. The indication for surgical intervention was a congenital penile curvature greater than 45° (varying from 45° to 90°, mean of 60°), associated with loss of axial rigidity and stability. The patients provided informed consent after being informed about the operation and possible side effects, including hypercorrection, penile shortening, loss of sensitivity, erectile dysfunction and residual curvature. All patients underwent antibiotic prophylaxis with a cephalosporin.

SURGICAL TECHNIQUE

Surgical corrections of ventral and ventro-lateral congenital deviations were performed under slight sedation and a local anaesthesia (2% lidocaine and 0.5% bupivacaine). Magnifying lenses (2.5×) were used for better visualization of the surgical field. A circumferential sub-coronal incision was made and the penis was degloved to the penile base, followed by dissection and resection of the paraurethral and periurethral chordee. An artificial erection was induced by intracavernous injection of papaverine or prostaglandin E1 using a 21-gauge needle into a cavernous body. If the erection was not sufficient, a transglandular infusion of saline was also administered to obtain maximal rigidity during the operation. The Buck's fascia was longitudinally incised paraurethrally to free it from the urethra from the penile base to the beginning of the glans penis. This step was only done on one side of the penis. After that step, the Buck's fascia and the neurovascular bundle were easily mobilized with blunt dissection to the midline of the dorsal convex side of the penis. From the point of maximum curvature (P), located at the intersection of the lines a-a' and b-b', a circumferential line was drawn at the bisection of the angle formed by these lines (Fig. 1). The point at which this circumferential line crossed the midline of the dorsal concave side of the penis, the intercavernous septum for ventral deviations and slightly more lateral for ventro-lateral deviations, determined the location of the superficial, elliptical excision of the outer layer of the tunica albuginea (Fig. 2). A small, 3 × 2 mm ellipse of the outer layer of the tunica albuginea was excised (Fig. 3). The inner layer of the tunica was not incised. The newly generated tissue defect was closed with three absorbable 3-0 polydioxanone sutures.

Figure 1.

The geometrical principle: from the point of maximum curvature (P) located at the intersection of the lines a-a' and b-b', a circumferential line is drawn at the bisection of the angle formed by these lines. The point at which this circumferential line crosses the midline of the dorsal concave side of the penis determines the location of the superficial elliptical excision of the outer layer of the tunica albuginea.

Figure 2.

After neurovascular bundle mobilization (yellow arrow), the tunica albuginea is exposed. Small 3 × 2 mm elliptical excisions are made in the tunica albuginea where marked (blue arrows).

Figure 3.

Elliptical excisions of the superficial layer of the tunica albuginea (blue arrow) are followed by three absorbable sutures to close each tissue defect.

At this point, a new erection was induced and the newly formed tangential lines to the penile axis, a-a' and b-b', determined where the new point of maximum curvature was located. A circumferential line was again drawn from P to the bisection of the angle formed by lines a-a' and b-b'. The location for a new ellipse was thereby identified at the midline of the dorsal concave side of the penis. Another superficial excision was performed and closed with absorbable 3-0 polydioxanone sutures. These steps were repeated until full correction of the deviation was accomplished. The degloving of the penis was reversed and the foreskin, when present, was removed. The circumcision incision, when required, was closed with 5-0 poliglecaprone sutures in two layers, first the dartos and then the skin (Fig. 4). The mean surgical time required to complete a curvature correction was 90 min.

Figure 4.

Initial and final appearance of the corrected penis.

After the surgery, a light compressive dressing was applied for 7 days, but urethral catheterization was not required. The patients were discharged on the same day that the surgery occurred. The use of ciproterone citrate (50 mg in the morning and 150 mg at night) was recommended for the first 20 days to reduce the frequency of nocturnal erections. A 6-week period of sexual abstinence was also recommended. During the first 3 months after surgery, the patients were instructed to perform penile physiotherapy for 5 min, 10 times throughout the day. This involved the patient in pulling his penis along the anatomical penile axis and helped to ensure correct axial healing.

All patients were regularly followed up, after the surgical correction, for a mean of 19 months (range 6–60 months). The follow-up included self-photography using Kelami [15] latero-lateral projections during a fully turgid erection. If necessary, a pharmacologically induced erection was performed during an office visit.

RESULTS

An overview of the study is given in Table 1. Intraoperative complications, such as neurovascular lesions, bleeding or infections were not observed and revision operations were not required for any patient. Palpable dog-ears were not seen after the operation and post-surgical infections were absent.

Table 1. Overview
Study periodJanuary 2006 to March 2011
Study population n= 211
Age, yearsMean 22.5 (range 14–45)
Degree of curvatureMean of 60° (range 45°–60°)
Follow-up, monthsMean of 19 (range 6–60)
Success rate99.1% (209/211)
Residual curvature requiring re-correction0.9% (2/211)

Significant penile shortening was not perceived by the patients and none were dissatisfied by the outcome of the surgery. The acquisition or regaining of the ability to perform sexual intercourse brought significant psychosexual and/or psychological relief to the patients, accompanied by a high rate of satisfaction and improved self-esteem. In addition, none of the patients reported a loss of genital sensation, and all of the patients maintained normal erectile function. None of the patients reported painful sexual intercourse after the operation, and reports of patient/partner dyspareunia disappeared completely. None of the patients exhibited a recurrence of a ventral curvature over the course of the follow-up visits.

Residual curvature of less than 20° was reported in 5% (n= 11) of the cases. However, none of these patients opted for a second surgical correction since their sexual life was normal and they were satisfied with the correction achieved during the first surgery. Residual curvature of up to 30° was observed in two patients (0.9%). Despite good axial rigidity these patients chose a second surgery to correct the residual curvature. Hypercorrection was not observed to result from any of the surgeries.

DISCUSSION

Congenital penile deviation is a relatively frequent finding. In recent years, reports of congenital curvature have increased due to a greater awareness of the problem among patients and physicians. Since the first surgical correction for congenital penile curvature was performed [9], many modifications have been implemented to overcome the disadvantages of the standard procedure and to improve functional results. Among the possible side effects of the original technique are postoperative erectile dysfunction, the development of painful nodules at the suture sites (‘dog ears’), alteration of cutaneous sensibility and significant penile shortening [16,17]. Currently, the most widespread therapeutic modalities for ventral curvature are aimed at shortening the convex side, while techniques to lengthen the concave side have been abandoned due to the potential for scar retraction and the consequent relapse of the curvature [1].

As noted previously, a number of modifications of the original Nesbit technique have been described. Essed and Schroeder [18] published a modification that consisted of tunica albuginea reeving with non-resorbable sutures but without tunica excision. Yachia [12] showed how longitudinal incisions on the convex side of the penis, with horizontal closure, lead to penile straightening. More recently Giammusso et al. [19] and Rolle et al. [20] introduced interesting modifications. The first technique consists of a corporoplasty, as described by Yachia [12], accomplished in the bed of the deep dorsal vein, without manipulation of the neurovascular bundle. The second technique involves a ‘U’ stitch, positioned under the Allis forceps, and the excision of an area of the albuginea. All of these modifications were performed with the goal of reducing the morbidity associated with the original Nesbit technique. However, any kind of albuginea plication can be detected when the penis is palpated, in some cases even leading to a slight deformity of the surface of the erect penis caused by small, paired balloonings that emerge on either side of any suture [16]. In some cases, patients complain about discomfort due to these ‘dog-ears’, especially when non-absorbable suture material is used. Plication procedures are also not as durable as other techniques because the penile straightening relies on the sutures to mediate the correction, rather than on the natural healing process of the tunica [19]. Recurrent curvature has been observed in up to 15.8% of cases corrected with these types of technique [1].

The present technique overcomes these potential problems. Key factors for the success of this technique are the use of absorbable sutures that distribute the bending force with multiple superficial tunica albuginea excisions. Furthermore, the superficial tunica excisions lead to a better natural healing process, since the integrity of the tunica albuginea is not compromised by incisions of the inner layer. Experience has demonstrated that it is important to use absorbable suture material to prevent the development of dog-ears, which affect the functional outcome and patient satisfaction. This is particularly important in the current era, as young males pay remarkably high attention to penile cosmesis. The use of non-absorbable knots can cause massive patient dissatisfaction resulting from poor cosmesis and pain. Although data show that absorbable suture material may be associated with recurrent curvature [1], such outcomes were not observed in the present study. As already stated, this is a result of the better distribution of the bending force provided by the multiple, small, superficial tunica excisions. Furthermore, the superficial tunica excisions lead to better stability within the corpora cavernosa, since the integrity of the tunica albuginea is not compromised.

Surgical procedures that correct ventral deviations require greater technical ability than those required for the ventral approach due to the delicate surgical step of neurovascular bundle mobilization. Anatomical studies have shown that the dorsal nerves of the penis wrap extensively around the tunica albuginea [21]. Baskin et al. [21] stated that the only nerve-free zone on the penis is at the 12 o'clock position. In order to prevent neurovascular bundle damage, a paraurethral longitudinal incision was made in the Buck's fascia to allow easy, and minimal, mobilization of the neurovascular bundle by blunt dissection. Doppler ultrasound defines the side on which the mobilization should occur since no collateral arteries are located between dorsal and cavernous arteries at the point of the curvature. Additionally, mobilization of the neurovascular bundle should be limited to a single side of the penis. The contralateral side of the penis is not touched during the operation, thereby preventing any damage to or unnecessary stress on the neurovascular bundle of that side.

The present modification of the Nesbit technique, making use of geometric principles [13,14], simplifies the surgical correction of ventral penile deviation and provides additional precision to the correction of the curvature. The geometric principles also help to achieve an objective assessment and correction of the deviation while avoiding any damage to the tunica albuginea by the Allis clamps. Congenital penile deviations, which are mostly ventral, should be corrected surgically once they are associated with loss of axial rigidity and dyspareunia. With the new technique, an upper limit does not need to be established for the angle of curvature to be corrected. The geometric principles can easily be applied to any kind of penile deviation, regardless of the degree of curvature, and are associated with a better penile shape outcome since the point of maximum deviation is objectified.

The application of geometric principles also allows the surgeon to make the correction step by step until a satisfying result is achieved. During the operation, an erection is maintained throughout all of the steps to ensure that the result achieved resembles a natural erection to the greatest extent possible. These features yield a simplified procedure that improves the cosmetic outcome. To this end, a recent study reported on the importance of penile reconstructive surgery for congenital penile deviation. Surgical correction was found to result in a significant improvement in the patient's overall relationship, as well as his sexual relationship, confidence, libido and general satisfaction [22]. The highest rates of complete penile straightening, preservation of erectile function and overall satisfaction with our technique are in accordance with results of other published series [16,19,23,24].

Penile shortening due to the conventional Nesbit procedure is a common side effect that should be addressed preoperatively, although patients with congenital ventral penile deviation usually have a satisfactory penile length. In our experience, the excision of a small 3 × 2 mm superficial ellipse in the tunica albuginea, without damage to the inner layer of the tunica, and the use of absorbable suture material provides a more physiological penile straightening with limited shortening and better healing. The stitches used to close the newly formed tissue defect are covered by the fascia and skin until they are absorbed. Thus, even before the stitches are completely absorbed they are almost imperceptible in the flaccid or rigid penis.

Another advantage of our technique is the provision of better bending force distribution through the sutures. The technique also minimizes tissue damage associated with the use of Allis clamps and, since mobilization of the neurovascular bundle occurs only on one side of the penis, unnecessary stress and potential damage to the neurovascular bundles is prevented. Furthermore, the integrity of the tunica albuginea is not compromised and the use of absorbable suture material prevents the development of painful, palpable indurations. For these reasons we recommend deviation correction via our modified Nesbit technique as the primary option for patients requiring surgical correction.

Thus, our modified Nesbit technique, consisting of superficial tunica albuginea excisions, leads to rapid and excellent results due to objectivation of the curvature. In our opinion, this is an optimal treatment for congenital ventral or ventro-lateral penile deviation. The excellent functional outcomes and lack of significant postoperative complications resulted in a high level of patient satisfaction, including improved self-esteem, relationships, libido and sexual intercourse.

CONFLICT OF INTEREST

None declared.

Ancillary