Midline dorsal plication technique for penile curvature repair.

Abstract

Most penile curvature repair techniques involve excision of the tunica albuginea and mobilization of the neurovascular bundles. Recent neuroanatomical studies of the neurovascular bundles have demonstrated the distribution of nerve fibers and identified the 12 o'clock position as the only nerve-free position. We present the results of penile curvature repair with the midline dorsal penile plication technique.
A total of 45 penile plication procedures were performed in 43 pediatric patients, of whom 39 had mild to moderate and 4 had severe curvature. Eight patients had previously undergone penile curvature repair. After the induction of an artificial erection test a 4 or 5-zero polypropylene plication suture was placed at the point of maximal curvature at the 12 o'clock position.
Of patients with mild to moderate curvature 97% underwent a successful initial procedure. Satisfactory results were achieved in only 2 of the 4 patients with severe curvature. Two of the 3 initial failures were successfully reoperated using the same technique. The procedure was successful in all 8 patients who had previously undergone operation for curvature repair.
Midline dorsal penile plication is a safe, simple to perform procedure that achieves excellent results in patients with mild to moderate curvature. It is a useful technique in patients in who previous repairs have failed. We suggest other repair techniques for severe curvature.

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MIDLINE DORSAL PLICATION TECHNIQUE FOR PENILE
CURVATURE REPAIR
YUVAL BAR YOSEF, JOSEPH BINYAMINI, HAIM MATZKIN AND JACOB BEN-CHAIM
From the Pediatric Urology Unit, Department of Urology, Tel-Aviv Souraski Medical Center, Affiliated with Sackler School of Medicine,
Tel-Aviv University, Tel-Aviv, Israel
ABSTRACT
Purpose: Most penile curvature repair techniques involve excision of the tunica albuginea and
mobilization of the neurovascular bundles. Recent neuroanatomical studies of the neurovascular
bundles have demonstrated the distribution of nerve fibers and identified the 12 o’clock position
as the only nerve-free position. We present the results of penile curvature repair with the midline
dorsal penile plication technique.
Materials and Methods: A total of 45 penile plication procedures were performed in 43 pediatric
patients, of whom 39 had mild to moderate and 4 had severe curvature. Eight patients had
previously undergone penile curvature repair. After the induction of an artificial erection test a
4 or 5-zero polypropylene plication suture was placed at the point of maximal curvature at the 12
o’clock position.
Results: Of patients with mild to moderate curvature 97% underwent a successful initial
procedure. Satisfactory results were achieved in only 2 of the 4 patients with severe curvature.
Two of the 3 initial failures were successfully reoperated using the same technique. The proce-
dure was successful in all 8 patients who had previously undergone operation for curvature
repair.
Conclusions: Midline dorsal penile plication is a safe, simple to perform procedure that
achieves excellent results in patients with mild to moderate curvature. It is a useful technique in
patients in who previous repairs have failed. We suggest other repair techniques for severe
curvature.
KEY WORDS: penis, abnormalities, reconstructive surgical procedures
Most penile curvature repair (orthoplasty) techniques,
such as the Nesbit procedure1and tunica albuginea plication
technique,2involve varying degrees of dissection or excision
of the tunica albuginea. Recent neuroanatomical studies
demonstrated the distribution of nerve fibers and identified
the 12 o’clock, midline dorsal position as the only nerve-free
position. In addition, the thickness and strength of the tunica
albuginea was found to be greatest at the 12 o’clock posi-
tion.3,4Based on these findings the midline dorsal plication
technique has been advocated to repair hypospadiac and
nonhypospadiac penile curvature. This is a simple and brief
technique that avoids the potential of neurovascular bundle
(NVB) damage and decreases the chances of potential post-
operative hematoma.
MATERIALS AND METHODS
A total of 45 midline dorsal plication procedures were per-
formed in 43 pediatric patients at a median age of 25 months
(range 6 to 163). Of the patients 37 underwent hypospadias
repair and penile curvature repair, while 6 underwent cur-
vature repair only.
Eight of the 37 patients who underwent hypospadias and
curvature repair had previously undergone operation for cur-
vature and hypospadias repair. A total of 20 patients (47%)
had mild curvature (less than 30 degrees of deviation), 19
(44%) had medium curvature and 4 (9%) had severe curva-
ture (greater than 45 degrees).
The surgical method used involves skin degloving to the
penile base, induction of an artificial erection test and place-
ment of 1 or 2 polypropylene 4 or 5-zero plication sutures at
the midline dorsal aspect of the point of maximal curvature
(fig. 1). A satisfactory on-site result was verified by repeating
the artificial erection test (fig. 2). The incision was closed
with 4-zero polyglecaprone monofilament absorbable su-
tures, with the plication suture covered with natural skin
and subcutaneous tissue. No attempt was made to cover
plication sutures with a subcutaneous flap. Successful repair
was judged according to physician and parental satisfaction
by the final result during followup. Median followup was 16
months (range 3 to 34).
Accepted for publication May 21, 2004.FIG. 1. Erection test demonstrates mild curvature
0022-5347/04/1724-1368/0
THE JOURNAL OF UROLOGY®
Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 172, 1368–1369, October 2004
Printed in U.S.A.
DOI: 10.1097/01.ju.0000138341.68365.b6
1368

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RESULTS
In 40 children (93%) a completely straight penis was
achieved after the initial procedure. Of the 39 patients with
mild to moderate curvature 38 (97%) underwent successful
initial procedures. The results of the initial procedures were
satisfactory in only 2 of 4 patients (50%) with severe curva-
ture. In 3 patients (7%) residual curvature was observed, of
whom 1 had moderate and 2 had severe curvature. Two of
these initial failed cases were successfully reoperated using
the same method. The third patient with initial severe cur-
vature was lost to followup. All 8 patients who had previously
undergone operation for curvature and hypospadias repair
had satisfactory results after the initial procedure.
DISCUSSION
Some cases of penile curvature are caused by skin tether-
ing and they can be successfully managed by circumferential
dissection along Buck’s fascia to the level of the penoscrotal
junction. When possible, the release of spongiosal tissue
causing chordee achieves additional straightening. However,
in the remaining cases a satisfactory result is not achieved
and an additional procedure is required. According to our
experience in many cases an ancillary procedure is required,
although in a previous report it was necessary in only 13% of
the patients.5
Most current penile curvature repair techniques involve
dissection or excision of the tunica albuginea, requiring NVB
mobilization. Several studies of NVB anatomy have demon-
strated the distribution of nerve fibers, which run from the 11
and 1 o’clock positions around the corporeal bodies to the 7
and 5 o’clock positions, leaving the 12 o’clock position as the
only nerve-free position.3,4These findings led to changing the
previous recommendation for curvature repair with the tu-
nica albuginea plication technique. The proposed technique,
namely the midline dorsal plication technique, involves no
NVB dissection or tunica albuginea excision. In these studies
the dorsal midline position was identified as the thickest and
strongest position of the tunica albuginea, facilitating repair
with the proposed method. Further study used human fetal
penile specimens to examine the feasibility of NVB mobiliza-
tion and led to the conclusion that safe mobilization is theo-
retically possible.6No evidence of perforating branches from
the dorsal lateral nerve complex into the corporeal bodies
was identified. Although theoretically possible, practically
mobilization is often difficult due to the small distance be-
tween nerve fibers and the tunica albuginea. Therefore,
Baskin et al have continued to advocate the midline dorsal
plication technique.6
To our knowledge the results of midline dorsal penile pli-
cation technique in the pediatric population have not yet
been published. A modified technique was successfully per-
formed in 10 patients.7Modification included a transverse
incision in the midline position, thus, risking damage to the
nerves, which are just of the midline.8
Since data on the long-term results of penile curvature
repair in pediatric patients are lacking, the clinical signifi-
cance of NVB dissection or tunica albuginea mobilization is
unclear. To our knowledge the potential for neuronal damage
has not yet been evaluated. Concerns have been raised re-
garding possible ligation of the dorsal vein. Visualization of
the dorsal vein in the pediatric population may be difficult.
We currently make no effort to identify the vein. This ap-
proach is based on the results of dorsal vein excision in adults
with Peyronie’s disease who have no adverse effects.6,8
The midline dorsal penile plication technique is simple to
perform, requires minimal operative time and achieves ex-
cellent results in patients with mild to moderate curvature.
As long as the clinical significance of NVB dissection is un-
clear, a procedure that avoids it seems preferable. According
to our results with the repair of severe curvature greater
than 45 degrees we recommend other techniques in these
patients.
CONCLUSIONS
The midline dorsal penile plication technique is a safe,
anatomically sound method. It requires minimal operative
time and achieves excellent results in patients with mild to
moderate penile curvature in those with and without hypos-
padias. The technique may also be successfully used for re-
sidual curvature after previous repair.
REFERENCES
1. Nesbit, R. M.: Congenital curvature of the phallus: report of
three cases with description of corrective operation. J Urol, 93:
230, 1965
2. Baskin, L. S. and Duckett, J. W.: Dorsal tunica albuginea plica-
tion for hypospadias curvature. J Urol, 151: 1668, 1994
3. Baskin, L. S., Lee, Y. T. and Cunha, G. R.: Neuroanatomical
ontogeny of the human fetal penis. Br J Urol, 79: 628, 1997
4. Baskin, L. S., Erol, A., Li, Y. W. and Cunha, G. R.: Anatomical
studies of hypospadias. J Urol, 160: 1108, 1998
5. Baskin, L. S., Ducket, J. W., Ueoka, K., Seibold, J. and Snyder,
H. M.: Changing concepts of hypospadias curvature lead to
more onlay island flap procedures. J Urol, 151: 191, 1994
6. Baskin, L. S., Erol, A., Li, Y. W. and Liu, W. H.: Anatomy of the
neurovascular bundle: is safe mobilization possible? J Urol,
164: 977, 2000
7. Hayashi, Y., Kojima, Y., Mizuno, K., Tozawa, K., Sasaki, S. and
Kohri, K.: Modified technique of dorsal plication for penile
curvature with or without hypospadias. Urology, 59: 584, 2002
8. Baskin, L. S.: Editorial comment. Urology, 59: 586, 2002
FIG. 2. After placement of plication suture artificial erection was
repeated, showing straight penis.
MIDLINE DORSAL PLICATION FOR PENILE CURVATURE REPAIR
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