Management of Penile Curvature (Chordee) at CHOP Christopher

Management of Penile Curvature (Chordee) at CHOP Christopher

Management of Penile Curvature (Chordee) at CHOP Christopher J. Long, MD Hypospadias World Congress Moscow, Russia August 30, 2017 Hypospadiology: Noun. hypo-spayd-ee-ah-low-gee 1. The study of boys with hypospadias and the outcomes we witness.

2. A difficult science1 that is humbling and energy consuming John Warner Duckett Jr. 1936 -1996 Duckett, JW: The current hype in hypospadiology. Br J Urol, 1995 76:1 Doug Canning Mark Zaontz

Mike Carr Steve Zderic Howard Snyder Tom Kolon Constellation of hypospadias: Ectopic urethral meatus Dorsal hooded foreskin Ventral penile curvature

Constellation of hypospadias: Ectopic urethral meatus Dorsal hooded foreskin Ventral penile curvature The key to a satisfactory (and lifelong) repair 1. Correct curvature 2. Ensure that there is good growth potential for long term outcome through adulthood a. Supple ventral shaft skin b. A urethral plate that is not going to tether the penis

c. Correct any corporal body disproportion 3. There is significant morbidity associated with poorly corrected curvature as boys age Correcting ventral penile curvature: How? 1. Penile shortening procedure Dorsal plication 2. Penile lengthening procedure Corporal lengthening Correcting ventral penile curvature: How?

Dorsal plication Nesbit plication3 Baskin plication4 Zaontz modification of the Nesbit plication5 Nesbit RM, 1965 4 Baskin LS et al, 1998 5 Dean GE et al, 2000 3

Dorsal plication: Baskin Technique (midline plication) Midline incision through the tunica Absorbable vs non-absorbable suture Dartos is closed over permanent sutures Curvature is re-assessed to confirm correction

Correcting ventral penile curvature: How? Corporal lengthening Autologous tissue6 Dermal graft Tunica vaginalis flap Tunica vaginalis graft Non-autologous tissue Small intestinal submucosa (SIS) graft Single-ply vs 4-ply7

Multiple ventral corporal incisions (Fairy cuts)8 Braga LH et al, 2007 7 Weiser AC et al, 2003 8 Devine CJ, 1983 6 Correcting penile curvature: Dorsal plication vs lengthening procedure

Limited data on a direct comparison of the two approaches Higher risk of recurrent curvature when plication is used in the absence of urethral plate division6 Decreased complication rates when 2-stage repair used vs single stage repair (plication)9 Braga LH et al, 2007 9 Pippi Salle JL et al, 2016 6 Correcting ventral penile curvature:

Corporal lengthening vs Plication Repair Pros Dorsal plication -Quicker procedure -Single stage repair -Minimal/non risk for ED Penile lengthening

-More effective for severe curvature -Results in longer penis Cons -Risk for recurrence of curvature if incorrectly utilized -? Long term effectiveness -? Risk for erectile dysfunction

-Longer procedure -Commits the patients to a 2-stage procedure No residual curvature Urethroplasty Mild curvature, <30 Concern for proximal hypospadias

Division of urethral plate Dorsal plication Single stage repair Penis is degloved, chordee tissue is resected Consider corporal lengthening procedure

Moderate-severe curvature, 30 Division of urethral plate Dorsal plication Single stage repair Corporal lengthening, 2-stage repair Determining the degree of curvature

Curvature is assessed after complete degloving Artificial erection is performed with a penile tourniquet Goniometer to obtain an objective measurement Persistent ventral curvature >30 after urethral plate division Corporoplasty with dermal graft

Tunica albuginea incised horizontally on the ventrum of the penis, opposite the point of maximal curvature Incision should be carried laterally so the penis is unhinged Care must be taken to avoid injury to the neurovascular bundle Defect is measured so an appropriately sized graft can be harvested (either dermal or tunica vaginalis) Corporoplasty with dermal graft Excess graft is excised then secured in place with a running, water tight

anastomosis Groin incision is closed with minimal scar Corporoplasty with dermal graft Repeat artificial erection is performed to confirm that curvature has been completely corrected Correcting penile curvature: Concerns Potential long-term efficacy (adulthood) of penile straightening

procedures Recurrent curvature Erectile dysfunction What degree of curvature should be the dividing line for pursuing plication vs a lengthening procedure? 20, 30, 45, 60? Which technique is best for penile lengthening? Should chordee even be corrected, i.e. at what point is it worthwhile to fix penile curvature?

THANK YOU

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