The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion
The management of moderate and severe congenital penile torsion associated with hypospadias:...
Elbakry, Adel; Zakaria, Ahmed; Matar, Adel; El Nashar, Ahmed
2013-03-01 00:00:00
Arab Journal of Urology (2013) 11,1–7 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com PEDIATRIC UROLOGY ORIGINAL ARTICLE The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion Adel Elbakry , Ahmed Zakaria, Adel Matar, Ahmed El Nashar Department of Urology, Suez Canal University, Ismailia, Egypt Received 16 November 2012, Received in revised form 18 December 2012, Accepted 18 December 2012 Available online 24 January 2013 KEYWORDS Abstract Objectives: To evaluate the effectiveness of urethral mobilisation for cor- recting moderate and severe penile torsion associated with distal hypospadias. Hypospadias; Patients and methods: Nineteen patients with distal hypospadias and congenital Penile torsion; moderate and severe penile torsion were treated surgically. The hypospadias was Chordee; at the distal shaft, coronal and glanular in seven, eight and four patients, respec- Urethral mobilisation; tively, and six had mild chordee. The mean (SD, range) angle of torsion was 94.7 Urethral plate (19.9, 75–160). The urethra was mobilised down to the perineum. If the urethral mobilisation was insufficient the right border of the tunica albuginea was anchored to the pubic periosteum. The hypospadias was repaired using the urethral mobilisa- tion and advancement technique, with a triangular plate flap for meatoplasty. The patients were followed up for 12–18 months. Results: All patients had a successful functional and cosmetic outcome, with no residual torsion. Two patients had a small subcutaneous haematoma that resolved Corresponding author. Address: Paediatric Urology and Recon- structive Urological Surgery, Suez Canal University, Ismailia, P.O. Box 76, Mansoura 35511, Egypt. Tel.: +20 11 44224994/01067330881/ +20 50 2233600; fax: +20 50 2221442. E-mail addresses: adelelbakry@yahoo.com, adelelbakry1@gmail.- com (A. Elbakry). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2012.12.004 2 Elbakry et al. after conservative treatment. Massive oedema occurred in three patients and was treated conservatively. Urethral mobilisation did not correct the penile torsion com- pletely. Although the mean (SD, range) angle of torsion was reduced to 86.1 (14.3, 65–130), statistically significantly different (P = 0.001), it was not clinically impor- tant. The presence of chordee had no significant correlation with the reduction of penile torsion. Conclusion: Urethral mobilisation cannot completely correct moderate and severe penile torsion but it might only partly decrease the angle of torsion. Periosteal anchoring of the tunica albuginea might be the most reliable manoeuvre for the com- plete correction of penile torsion. ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction hypospadias repaired and penile torsion corrected in our department. Seven patients had distal shaft, eight had coronal and four had glanular hypospadias. Six pa- Penile torsion can be a congenital, or an acquired lesion tients had mild chordee. All patients had penile torsion after trauma, circumcision or urethral reconstruction. towards the left side. The angle of penile rotation was Congenital penile torsion can occur in association with measured from the midline using a protractor, giving a hypospadias or as a single deformity with no hypospa- mean (SD, range) of 94.7 (19.7, 75–160) (Fig. 1a). dias. The causes and pathogenesis of congenital penile The operative techniques of hypospadias repair and cor- torsion are not exactly known [1–3]. It might be due to rection of penile torsion were explained to the parents of abnormal skin attachment, or abnormal development the children. An informed signed consent was obtained of the dartos fascia that causes disorientation of the pe- from the parents of all the children and the study was nile shaft and corporeal rotation around its longitudinal approved by the local ethics committee. axis [1]. Extensive unilateral adhesions between the pubic bone and corpus cavernosa was proposed by Zhou et al. [2] as a cause of persistent penile torsion after Operative technique skin and fascial release. Several techniques have been de- scribed to correct penile torsion, but none of these tech- The angle of torsion was reconfirmed by inducing an niques has gained consensus as an optimal, ideal and artificial erection. A glans traction suture of 4/0 poly- versatile technique [1–3]. Bhat et al. [3] prospectively propylene was fixed and a suitably sized catheter was studied the effect of urethral mobilisation for correcting introduced into the urethra. A subcoronal circumferen- penile torsion, and concluded that extensive urethral tial incision was made 2 mm proximal to the hypospa- mobilisation from the corona to the perineum might diac orifice, and the penile shaft was degloved down to be a single and adequate corrective procedure in the the base of the penis. Complete penile degloving did cases of moderate and severe penile torsion. However, not change the angle of penile torsion. The urethral one of the effective techniques for repairing distal penile plate was dissected and mobilised, cutting any fibrovas- hypospadias is urethral mobilisation and advancement, cular bands of bifurcated spongiosum attached to the which has been used by several authors and given good glans. The urethra was mobilised by separating the cor- results [4–6]. Although these clinical reports have no pus spongiosum from the corpora cavernosum using a strong evidence-based conclusions they provoked us to small blunt-tipped and curved scissors that dissected explore the outcome of urethral mobilisation as correc- the corpus spongiosum from the corpus cavernosum tive surgery for both the repair of distal hypospadias safely and rapidly, with no injury to the spongiosal enve- and associated congenital moderate and severe penile lope. Urethral mobilisation proceeded down to the scro- torsion. We evaluated the outcome of urethral mobilisa- toperineal junction, using small vein retractors (Fig. 1b). tion and advancement for distal hypospadias repair, and An artificial erection was used to reassess the degree of estimated whether urethral mobilisation can effectively torsion and the angle was measured after urethral mobi- correct moderate and severe penile torsion and to what lisation. Because the improvement in torsion was partial extent. the pubic periosteum was exposed and the right border of tunica albuginea was anchored to the pubic perios- Patients and methods teum using a 4/0 polypropylene suture to correct the anticlockwise torsion (Fig. 1c). The effectiveness of peri- osteal fixation was tested by a repeated artificial erec- In a prospective study, from 2004 to 2010, 19 patients tion. If there was under- or over-correction the suture (mean age 3.3 years, SD 1.3, range 1–6) with distal was readjusted or removed and replaced until the tor- hypospadias and congenital penile torsion had their The management of moderate and severe congenital penile torsion associated with hypospadias: 3 sion was optimally corrected, as assessed by an artificial erection (Fig. 1d). The chordee in 6 patients with distal penile and coronal hypospadias was corrected by com- plete excision of the fibrovascular tissue around the ure- thral plate at the level of the coronal sulcus; no dorsal tunical plication was needed. A V-shaped incision was made in the glanular part of the urethral plate to fashion a triangular or V-shaped flap which was not separated from the glans tissue. Glans wings were dissected later- ally to prepare the glans flaps. The hypospadiac orifice was trimmed to remove the distal few millimetres (3– 5 mm) of thin hypoplastic mucosa devoid of supportive spongiosum tissue. The dorsal aspect of the urethra was opened to the extent that was suitable for anastomosis with the V-shaped distal plate flap (Fig. 2a). Suturing of the mobilised urethra to the V-shaped flap was com- pleted using 6/0 polyglactin interrupted sutures. The urethra was fixed to the cavernosal bodies at the midline by a few stitches of 6/0 polyglactin suture (Fig. 2b). The glans flaps were closed at the midline in two layers using 6/0 polyglactin sutures (Fig. 2c). The distal edge of the urethra was fixed to the glans flaps by one stitch on each side. The prepuce was then circumcised and the penile skin closed. A silicone catheter (6–8 F) was inserted and removed after 48 h (Fig. 2d). Follow-up data Patients were followed up for a mean (SD, range) of 13.6 (1.9, 12–18) months. The patients were examined every 3 months during the follow-up to assess the site and diameter of the neomeatus and the direction and calibre of the urinary stream. The parents were asked to observe the orientation of the penile shaft and glans during a morning erection. The Wilcoxon signed-rank test was used to determine whether the urethral mobilisation significantly reduced and/or completely corrected moderate and severe penile torsion. The Mann–Whitney test was used to assess the effect of the presence of chordee on the degree of reduc- tion of the angle of penile torsion after urethral mobilisation. Results There were acute complications in 5 patients; three had massive oedema, relieved by a compressive dressing and ice-packs, and two had a small subcutaneous haema- toma that resolved spontaneously after conservative measures. The hypospadias was repaired successfully in all cases. The neomeatus was vertical and in the mid- Figure 1 a, Coronal hypospadias with a penile torsion of 100; line at the glans tip. There were no urethrocutaneous fis- b, The urethra is mobilised down to the level of the scrotoperineal tulae, meatal stenosis or penile curvature. junction using vein retractors; c, A 4/0 polypropylene suture is Urethral mobilisation decreased the angle of penile taken in the lateral border of the right corpus cavernosum and the pubic periosteum to rotate the penile shaft in a clockwise torsion in 12 patients and did not change it in the direction, correcting the torsion; and d, An artificial erection remaining seven, as indicated by an artificial erection. showing the corrected torsion. 4 Elbakry et al. Figure 3 The optimal correction of penile torsion and a successful hypospadias repair at 3 months after surgery. The mean (SD, range) reduction in the angle of torsion was 8.7 (7.6, 0–30). Thus, after urethral mobilisation the angle of penile torsion decreased from 94.7 (19.7, 75–160) to 86.1 (14.3, 65–130), a statistically signifi- cant difference (P = 0.001). However, the difference be- tween the angles of torsion before and after urethral mobilisation was trivial in practice and of no clinical sig- nificance. The presence of chordee had no significant correlation with the degree of reduction of the angle of penile torsion after urethral mobilisation (P = 0.961). Fixation of the lateral border of the right tunica albu- ginea to the pubic periosteum (periosteal anchoring of the tunica albuginea) was necessary for the optimal and complete correction of penile torsion in all patients. This manoeuvre was repeated once or twice in nine pa- tients to avoid the over- or under-correction of penile torsion. Based on our extensive experience in hypospa- dias surgery and drug records in the patients’ files, the periosteal anchoring suture did not cause significant pain after surgery, and no extra doses of analgesia were required. The corrected position of the penile shaft and glans penis was maintained throughout the follow-up, either when flaccid (Fig. 3) or during a morning erec- tion, as noted by the parents. Discussion Figure 2 a, The mobilised urethra is spatulated dorsally to be Our study indicates that urethral mobilisation extended anastomosed to the triangular distal plate; b, Urethral advance- to the scrotoperineal angle is insufficient for the com- ment and anastomosis to the urethral plate up to the glans tip; c, Glanular flaps are approximated and glanuloplasty is completed; plete correction of moderate and severe penile torsion, and d, Skin closure; the glans closure line is in the midline with the but statistically it significantly reduced the angle of tor- scrotal median raphe. sion. Periosteal anchoring of the tunica albuginea was The management of moderate and severe congenital penile torsion associated with hypospadias: 5 necessary for the complete adjustment of penile torsion. act cause and pathogenesis of penile torsion is unknown, The study also confirmed the reliability of the urethral there are several anti-torsion techniques that have been mobilisation and advancement technique with a glans used for correction. Degloving and re-attachment of pe- triangular flap in the repair of distal hypospadias. nile skin is a simple technique used by several authors Urethral mobilisation and advancement is an old [1,10,11]. Others advocated dissection and re-attach- technique used for glanular, coronal and distal penile ment of dorsal dartos fascial flaps to counter-rotate hypospadias repair. It has several advantages over other the shaft and correct penile torsion [12,13]. Skin deglov- techniques, mainly because of a very low incidence of fis- ing and fascial flap re-attachment techniques give good tula and/or stricture formation, an effect which is logical results in mild cases of penile torsion, but residual due to obviating the reconstruction of a neourethra and/or recurrent torsion usually occurs because of the ‘hypospadias repair without neourethra’ [4–7]. How- unsustainable effect of these techniques, in which the ever, the two disadvantages of that technique are the core problem of corporeal rotation is not actually cor- demanding dissection and the separation of the corpus rected [1,10–13]. Another group of corrective methods spongiosum from corpora cavernosa, which can be a for penile torsion is that dealing with the corporeal bloody manoeuvre, and the significant rates of meatal problem directly. Hsieh et al. [14] described an obliquely stenosis due to circumferential sutures around the orientated plication of the tunica albuginea, and diago- neomeatus [4–6]. The former problem can be avoided nal tunical plication was advocated by Snow [15]. Slawin by meticulous sharp dissection through the correct plane and Nagler [16] described the technique of angular tuni- between the spongiosal and cavernous bodies, using a cal excision in the direction that can counter-rotate the small and curved blunt-tipped scissors. We have found corpora cavernosa. However, these techniques cannot this method to be easy and rapid, and bleeding is a min- gain wide acceptance due to the risk of injury to the neu- or problem. The use of acutely sharp-tipped scissors rovascular bundles and/or erectile tissue. Moreover, might cause injury to the spongiosal and/or cavernous these techniques might not be effective in severe penile bodies, causing significant bleeding and postoperative torsion. haematoma. The use of the distal triangular flap of the Baht et al. [3] used extensive mobilisation of the ure- urethral plate avoids circular fixation of the neomeatus thral plate and urethra for correcting moderate and se- to the glanular tissue, and minimises the possibility of vere penile torsion in 27 patients; 18 of them had meatal stenosis. The use of a triangular flap at the distal hypospadias. They reported the complete correction of part of the urethral plate for creating a neomeatus and penile torsion by skin degloving in one patient, by mobi- distal neourethra is an old technique. It was advocated lisation of the fibrovascular spongiosum and urethral in 1973 by Horton et al. [7] in the ‘flip-flap’ technique plate into the glans in 13 (48%), by mobilisation of for hypospadias repair. Mollaeian et al. [8] used a trian- the urethral plate and penile urethra in seven (26%), gular distal plate flap and urethral mobilisation to man- and by mobilisation of the proximal urethra down to age a large series of distal and midpenile hypospadias; the bulbar urethra in six (22%). they had no cases of meatal stenosis. Our results for Our findings differ from those reported by Baht et al. hypospadias repair are similar to those reported by Mol- [3]. This discrepancy might be explained by the heteroge- laeian et al. [8]. Although the technique of urethral neity in the pathogenesis and underlying causal factors mobilisation and a distal plate triangular flap has a good of the condition. In about half of their patients the pe- outcome in distal hypospadias, it can result in meatal nile torsion was due to an asymmetrical attachment of retraction and/or ventral curvature if it is used to repair the divergent hypoplastic spongiosum to the glans. midpenile hypospadias, because mobilisation of the ure- More extensive urethral mobilisation down to the bul- thra cannot bridge the deficient length without tension bous urethra might release adhesions condensed under [9]. For an objective judgement of the required extent the pubic bone [2]. The present patients responded min- of urethral mobilisation in relation to the length of the imally to urethral mobilisation, and this was evident on deficient urethra, Atala [6] found that the length of the induction of an artificial erection. Although the dif- mobilised urethra should be four to five times the length ference between the angles of torsion before and after of the deficient segment. Others concluded that mobili- urethral mobilisation was statistically significant, the sation of the entire penile and bulbar urethra can pro- mean reduction was 8.7, which was not clinically vide up to 2.5 cm of tension-free extra length in important. This might indicate an intrinsic longitudinal children [10]. disorientation of the corpora cavernosa around the lon- Penile torsion is a relatively rare but well-known con- gitudinal axis of the penile shaft. Zhou et al. [2] found genital deformity, but its specific cause and pathogenesis that the left corpus cavernosum is relatively hypoplastic are not known [1,2]. Unlike chordee, which is deviation in cases of penile torsion. Asymmetrical development of of a part of penile shaft from the straight longitudinal the corpora cavernosa around the longitudinal axis of axis, penile torsion is a right or left rotation of the penile the penis, and/or a fibrous band that tightly attaches shaft around its longitudinal axis [1–3]. Because the ex- the left corpus cavernosum to the pubic periosteum, 6 Elbakry et al. might cause persistent penile torsion. Zhou et al. found als assessing the cause(s) of the anticlockwise direction that releasing that fibrous band was not successful in of torsion in all of our patients. correcting the penile torsion, because the adhesions were We recommend that when hypospadias is associated too dense, tough and difficult to dissect and release. with moderate and severe penile torsion, then degloving Those authors used tunical fixation to the pubic perios- and the release of all fascial attachments should be the teum and concluded that this manoeuvre is the most first manoeuvres. If the torsion persists totally or partly, reliable treatment for such cases of penile torsion. In then anchoring the tunica albuginea to the pubic perios- the present patients the penile torsion was corrected teum is the most reliable and effective method for cor- completely using the same technique as that described recting torsion. Extensive urethral mobilisation causes by Zhou et al. [2]; the outcome was optimal and sus- a minimal reduction of the angle of penile torsion and tained during the follow-up. Bauer and Kogan [13] ret- should be avoided as an anti-torsion technique. rospectively analysed the correction of penile torsion In conclusion, urethral mobilisation down to the in 25 patients. They concluded that persistent torsion scrotoperineal region is insufficient for the complete cor- after the release of chordee is due to fibrosis of Buck’s rection of moderate and severe penile torsion. It can fascia, but their finding lacked histological evidence. only reduce the angle of torsion. Periosteal anchoring Mobilisation of the urethral plate and corpus spong- of the tunica albuginea is the most reliable and sustain- iosum, and resection of the underlying fibrous bands, able method for correcting moderate and severe penile might contribute to correcting chordee, with or without torsion. This study also confirmed the reliability of the division of the urethral plate [3,17]. In 1966, Culp [18] urethral mobilisation and advancement technique with reported 17 cases of hypospadias with chordee and pe- a glans triangular flap in the repair of distal hypospa- nile torsion. He found that penile torsion was persistent dias. Further studies are needed to understand the path- despite the complete removal of chordee. However, ogenesis of congenital penile torsion. Mobley [19] reported that the complete removal of chor- dee in one case decreased the angle of torsion from 180 Conflict of interest to 120. We found that the presence of chordee had no significant correlation with the degree of reduction of None. the angle of penile torsion after urethral mobilisation. These data confirm our findings that urethral mobilisa- Source of funding tion alone might be insufficient for the complete correc- tion of moderate and severe penile torsion. Thus, tunical None. fixation to the pubic periosteum is the simplest and most reliable technique for correcting the original pathology References that causes corporeal rotation. All of the present patients had penile torsion to the [1] Bar-Yosef Y, Binyamini J, Matzikin H, Ben-Chaim J. Degloving and realignment – simple repair of isolated penile torsion. Urology left side. Previous published data indicate that penile 2007;69:369–71. torsion is mostly towards the left [2,3,14]. In an epidemi- [2] Zhou L, Mei H, Hwang AH, Xie HW, Hardy BE. Penile torsion ological study of the incidence of penile torsion in neo- repair by suturing tunica albuginea to the pubic periosteum. J Ped nates, Sarkis and Sadasivam [20] found that penile Surg 2006;41:E7–9. torsion was counter-clockwise in 99% of affected in- [3] Bhat A, Bhat MP, Saxena G. Correction of penile torsion by mobilization of urethral plate and urethra. J Ped Urol fants. This phenomenon is not fully understood, but fur- 2009;5:451–7. ther studies of the embryogenesis of the penile shaft and [4] Koff SA. Mobilization of the urethra in the surgical treatment of genital tubercle, and the intrauterine factors that might hypospadias. J Urol 1981;125:394–7. induce cavernosal disorientation and penile torsion, [5] Nasrallah PF, Minott HB. Distal hypospadias repair. J Urol should be designed and carried out. 1984;131:928–30. [6] Atala A. Urethral mobilization and advancement for midshaft to There are several limitations to the present study. distal hypospadias. J Urol 2002;168:1738–41. There were relatively few patients, and not all degrees 7 Horton CE, Devine CJ, Baran N. Pictorial history of hypospadias of penile torsion were included. Cases of hypospadias repair techniques. In: Horton CE, editor. Plastic and Reconstructive with mild torsion were not included because the required Surgery of the Genital Area. Boston: Little Brown; 1973. p. correction is too simple, and it is not ethical to dissect 237–48. [8] Mollaeian M, Sheikh M, Tarlan S, Shojaei H. Urethral mobili- and mobilise a long urethral segment for these cases. zation and advancement with distal triangular urethral plate flap Such mild torsion could be corrected by skin degloving, for distal and select cases of mid shaft hypospadias: experience fascial dissection and reattachment, or by cutting the with 251 cases. J Urol 2008;180:290–4. fanned spongiosum that is asymmetrically attached to [9] Warwick RT, Parkhouse H, Chapple CR. Bulbar elongation the glans [8]. The outcome of the correction of torsion anastomotic meatoplasty (BEAM) or subterminal and hypospa- diac urethroplasty. J Urol 1997;158:1160–7. was assessed subjectively by the parents on a morning [10] Redman JF, Bissada NK. One-stage correction of chordee and erection in the child. Another limitation is the lack of tri- 180-degree penile torsion. Urology 1976;7:632–3. The management of moderate and severe congenital penile torsion associated with hypospadias: 7 [11] Azmy A, Eckstein HB. Surgical correction of torsion of penis. [16] Slawin KM, Nagler HM. Treatment of congenital penile curva- BJU Int 1981;53:378–9. ture with penile torsion: a new twist. J Urol 1992;147:152–4. [12] Fisher PC, Park JM. Penile torsion repair using dorsal dartos flap [17] Acimi S. Proximal hypospadias. Effect of urethral mobilization rotation. J Urol 2004;171:1903–4. on release of chordee. Urology 2012;80:894–8. [13] Bauer R, Kogan BA. Modern technique for penile torsion repair. [18] Culp OS. Struggles and triumphs with hypospadias and associ- J Urol 2009;182:286–91. ated anomalies: review of 400 cases. J Urol 1966;96:339–51. [14] Hsieh JT, Wong WY, Chen J, Chang HJ, Liu SP. Congenital [19] Mobley JE. Congenital torsion of the penis. J Urol isolated penile torsion in adults: untwist with placation. Urology 1973;109:517–9. 2002;59:438–40. [20] Sarkis PE, Sadasivam M. Incidence and predictive factors of [15] Snow BW. Penile torsion correction by diagonal corporal isolated neonatal penile torsion. J Ped Urol 2007;3:495–9. plication sutures. Int Braz J Urol 2009;35:56–9.
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The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion
The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion
Abstract
AbstractObjectives:To evaluate the effectiveness of urethral mobilisation for correcting moderate and severe penile torsion associated with distal hypospadias.Patients and methods:Nineteen patients with distal hypospadias and congenital moderate and severe penile torsion were treated surgically. The hypospadias was at the distal shaft, coronal and glanular in seven, eight and four patients, respectively, and six had mild chordee. The mean (SD, range) angle of torsion was 94.7 (19.9,...
Arab Journal of Urology (2013) 11,1–7 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com PEDIATRIC UROLOGY ORIGINAL ARTICLE The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion Adel Elbakry , Ahmed Zakaria, Adel Matar, Ahmed El Nashar Department of Urology, Suez Canal University, Ismailia, Egypt Received 16 November 2012, Received in revised form 18 December 2012, Accepted 18 December 2012 Available online 24 January 2013 KEYWORDS Abstract Objectives: To evaluate the effectiveness of urethral mobilisation for cor- recting moderate and severe penile torsion associated with distal hypospadias. Hypospadias; Patients and methods: Nineteen patients with distal hypospadias and congenital Penile torsion; moderate and severe penile torsion were treated surgically. The hypospadias was Chordee; at the distal shaft, coronal and glanular in seven, eight and four patients, respec- Urethral mobilisation; tively, and six had mild chordee. The mean (SD, range) angle of torsion was 94.7 Urethral plate (19.9, 75–160). The urethra was mobilised down to the perineum. If the urethral mobilisation was insufficient the right border of the tunica albuginea was anchored to the pubic periosteum. The hypospadias was repaired using the urethral mobilisa- tion and advancement technique, with a triangular plate flap for meatoplasty. The patients were followed up for 12–18 months. Results: All patients had a successful functional and cosmetic outcome, with no residual torsion. Two patients had a small subcutaneous haematoma that resolved Corresponding author. Address: Paediatric Urology and Recon- structive Urological Surgery, Suez Canal University, Ismailia, P.O. Box 76, Mansoura 35511, Egypt. Tel.: +20 11 44224994/01067330881/ +20 50 2233600; fax: +20 50 2221442. E-mail addresses: adelelbakry@yahoo.com, adelelbakry1@gmail.- com (A. Elbakry). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2012.12.004 2 Elbakry et al. after conservative treatment. Massive oedema occurred in three patients and was treated conservatively. Urethral mobilisation did not correct the penile torsion com- pletely. Although the mean (SD, range) angle of torsion was reduced to 86.1 (14.3, 65–130), statistically significantly different (P = 0.001), it was not clinically impor- tant. The presence of chordee had no significant correlation with the reduction of penile torsion. Conclusion: Urethral mobilisation cannot completely correct moderate and severe penile torsion but it might only partly decrease the angle of torsion. Periosteal anchoring of the tunica albuginea might be the most reliable manoeuvre for the com- plete correction of penile torsion. ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction hypospadias repaired and penile torsion corrected in our department. Seven patients had distal shaft, eight had coronal and four had glanular hypospadias. Six pa- Penile torsion can be a congenital, or an acquired lesion tients had mild chordee. All patients had penile torsion after trauma, circumcision or urethral reconstruction. towards the left side. The angle of penile rotation was Congenital penile torsion can occur in association with measured from the midline using a protractor, giving a hypospadias or as a single deformity with no hypospa- mean (SD, range) of 94.7 (19.7, 75–160) (Fig. 1a). dias. The causes and pathogenesis of congenital penile The operative techniques of hypospadias repair and cor- torsion are not exactly known [1–3]. It might be due to rection of penile torsion were explained to the parents of abnormal skin attachment, or abnormal development the children. An informed signed consent was obtained of the dartos fascia that causes disorientation of the pe- from the parents of all the children and the study was nile shaft and corporeal rotation around its longitudinal approved by the local ethics committee. axis [1]. Extensive unilateral adhesions between the pubic bone and corpus cavernosa was proposed by Zhou et al. [2] as a cause of persistent penile torsion after Operative technique skin and fascial release. Several techniques have been de- scribed to correct penile torsion, but none of these tech- The angle of torsion was reconfirmed by inducing an niques has gained consensus as an optimal, ideal and artificial erection. A glans traction suture of 4/0 poly- versatile technique [1–3]. Bhat et al. [3] prospectively propylene was fixed and a suitably sized catheter was studied the effect of urethral mobilisation for correcting introduced into the urethra. A subcoronal circumferen- penile torsion, and concluded that extensive urethral tial incision was made 2 mm proximal to the hypospa- mobilisation from the corona to the perineum might diac orifice, and the penile shaft was degloved down to be a single and adequate corrective procedure in the the base of the penis. Complete penile degloving did cases of moderate and severe penile torsion. However, not change the angle of penile torsion. The urethral one of the effective techniques for repairing distal penile plate was dissected and mobilised, cutting any fibrovas- hypospadias is urethral mobilisation and advancement, cular bands of bifurcated spongiosum attached to the which has been used by several authors and given good glans. The urethra was mobilised by separating the cor- results [4–6]. Although these clinical reports have no pus spongiosum from the corpora cavernosum using a strong evidence-based conclusions they provoked us to small blunt-tipped and curved scissors that dissected explore the outcome of urethral mobilisation as correc- the corpus spongiosum from the corpus cavernosum tive surgery for both the repair of distal hypospadias safely and rapidly, with no injury to the spongiosal enve- and associated congenital moderate and severe penile lope. Urethral mobilisation proceeded down to the scro- torsion. We evaluated the outcome of urethral mobilisa- toperineal junction, using small vein retractors (Fig. 1b). tion and advancement for distal hypospadias repair, and An artificial erection was used to reassess the degree of estimated whether urethral mobilisation can effectively torsion and the angle was measured after urethral mobi- correct moderate and severe penile torsion and to what lisation. Because the improvement in torsion was partial extent. the pubic periosteum was exposed and the right border of tunica albuginea was anchored to the pubic perios- Patients and methods teum using a 4/0 polypropylene suture to correct the anticlockwise torsion (Fig. 1c). The effectiveness of peri- osteal fixation was tested by a repeated artificial erec- In a prospective study, from 2004 to 2010, 19 patients tion. If there was under- or over-correction the suture (mean age 3.3 years, SD 1.3, range 1–6) with distal was readjusted or removed and replaced until the tor- hypospadias and congenital penile torsion had their The management of moderate and severe congenital penile torsion associated with hypospadias: 3 sion was optimally corrected, as assessed by an artificial erection (Fig. 1d). The chordee in 6 patients with distal penile and coronal hypospadias was corrected by com- plete excision of the fibrovascular tissue around the ure- thral plate at the level of the coronal sulcus; no dorsal tunical plication was needed. A V-shaped incision was made in the glanular part of the urethral plate to fashion a triangular or V-shaped flap which was not separated from the glans tissue. Glans wings were dissected later- ally to prepare the glans flaps. The hypospadiac orifice was trimmed to remove the distal few millimetres (3– 5 mm) of thin hypoplastic mucosa devoid of supportive spongiosum tissue. The dorsal aspect of the urethra was opened to the extent that was suitable for anastomosis with the V-shaped distal plate flap (Fig. 2a). Suturing of the mobilised urethra to the V-shaped flap was com- pleted using 6/0 polyglactin interrupted sutures. The urethra was fixed to the cavernosal bodies at the midline by a few stitches of 6/0 polyglactin suture (Fig. 2b). The glans flaps were closed at the midline in two layers using 6/0 polyglactin sutures (Fig. 2c). The distal edge of the urethra was fixed to the glans flaps by one stitch on each side. The prepuce was then circumcised and the penile skin closed. A silicone catheter (6–8 F) was inserted and removed after 48 h (Fig. 2d). Follow-up data Patients were followed up for a mean (SD, range) of 13.6 (1.9, 12–18) months. The patients were examined every 3 months during the follow-up to assess the site and diameter of the neomeatus and the direction and calibre of the urinary stream. The parents were asked to observe the orientation of the penile shaft and glans during a morning erection. The Wilcoxon signed-rank test was used to determine whether the urethral mobilisation significantly reduced and/or completely corrected moderate and severe penile torsion. The Mann–Whitney test was used to assess the effect of the presence of chordee on the degree of reduc- tion of the angle of penile torsion after urethral mobilisation. Results There were acute complications in 5 patients; three had massive oedema, relieved by a compressive dressing and ice-packs, and two had a small subcutaneous haema- toma that resolved spontaneously after conservative measures. The hypospadias was repaired successfully in all cases. The neomeatus was vertical and in the mid- Figure 1 a, Coronal hypospadias with a penile torsion of 100; line at the glans tip. There were no urethrocutaneous fis- b, The urethra is mobilised down to the level of the scrotoperineal tulae, meatal stenosis or penile curvature. junction using vein retractors; c, A 4/0 polypropylene suture is Urethral mobilisation decreased the angle of penile taken in the lateral border of the right corpus cavernosum and the pubic periosteum to rotate the penile shaft in a clockwise torsion in 12 patients and did not change it in the direction, correcting the torsion; and d, An artificial erection remaining seven, as indicated by an artificial erection. showing the corrected torsion. 4 Elbakry et al. Figure 3 The optimal correction of penile torsion and a successful hypospadias repair at 3 months after surgery. The mean (SD, range) reduction in the angle of torsion was 8.7 (7.6, 0–30). Thus, after urethral mobilisation the angle of penile torsion decreased from 94.7 (19.7, 75–160) to 86.1 (14.3, 65–130), a statistically signifi- cant difference (P = 0.001). However, the difference be- tween the angles of torsion before and after urethral mobilisation was trivial in practice and of no clinical sig- nificance. The presence of chordee had no significant correlation with the degree of reduction of the angle of penile torsion after urethral mobilisation (P = 0.961). Fixation of the lateral border of the right tunica albu- ginea to the pubic periosteum (periosteal anchoring of the tunica albuginea) was necessary for the optimal and complete correction of penile torsion in all patients. This manoeuvre was repeated once or twice in nine pa- tients to avoid the over- or under-correction of penile torsion. Based on our extensive experience in hypospa- dias surgery and drug records in the patients’ files, the periosteal anchoring suture did not cause significant pain after surgery, and no extra doses of analgesia were required. The corrected position of the penile shaft and glans penis was maintained throughout the follow-up, either when flaccid (Fig. 3) or during a morning erec- tion, as noted by the parents. Discussion Figure 2 a, The mobilised urethra is spatulated dorsally to be Our study indicates that urethral mobilisation extended anastomosed to the triangular distal plate; b, Urethral advance- to the scrotoperineal angle is insufficient for the com- ment and anastomosis to the urethral plate up to the glans tip; c, Glanular flaps are approximated and glanuloplasty is completed; plete correction of moderate and severe penile torsion, and d, Skin closure; the glans closure line is in the midline with the but statistically it significantly reduced the angle of tor- scrotal median raphe. sion. Periosteal anchoring of the tunica albuginea was The management of moderate and severe congenital penile torsion associated with hypospadias: 5 necessary for the complete adjustment of penile torsion. act cause and pathogenesis of penile torsion is unknown, The study also confirmed the reliability of the urethral there are several anti-torsion techniques that have been mobilisation and advancement technique with a glans used for correction. Degloving and re-attachment of pe- triangular flap in the repair of distal hypospadias. nile skin is a simple technique used by several authors Urethral mobilisation and advancement is an old [1,10,11]. Others advocated dissection and re-attach- technique used for glanular, coronal and distal penile ment of dorsal dartos fascial flaps to counter-rotate hypospadias repair. It has several advantages over other the shaft and correct penile torsion [12,13]. Skin deglov- techniques, mainly because of a very low incidence of fis- ing and fascial flap re-attachment techniques give good tula and/or stricture formation, an effect which is logical results in mild cases of penile torsion, but residual due to obviating the reconstruction of a neourethra and/or recurrent torsion usually occurs because of the ‘hypospadias repair without neourethra’ [4–7]. How- unsustainable effect of these techniques, in which the ever, the two disadvantages of that technique are the core problem of corporeal rotation is not actually cor- demanding dissection and the separation of the corpus rected [1,10–13]. Another group of corrective methods spongiosum from corpora cavernosa, which can be a for penile torsion is that dealing with the corporeal bloody manoeuvre, and the significant rates of meatal problem directly. Hsieh et al. [14] described an obliquely stenosis due to circumferential sutures around the orientated plication of the tunica albuginea, and diago- neomeatus [4–6]. The former problem can be avoided nal tunical plication was advocated by Snow [15]. Slawin by meticulous sharp dissection through the correct plane and Nagler [16] described the technique of angular tuni- between the spongiosal and cavernous bodies, using a cal excision in the direction that can counter-rotate the small and curved blunt-tipped scissors. We have found corpora cavernosa. However, these techniques cannot this method to be easy and rapid, and bleeding is a min- gain wide acceptance due to the risk of injury to the neu- or problem. The use of acutely sharp-tipped scissors rovascular bundles and/or erectile tissue. Moreover, might cause injury to the spongiosal and/or cavernous these techniques might not be effective in severe penile bodies, causing significant bleeding and postoperative torsion. haematoma. The use of the distal triangular flap of the Baht et al. [3] used extensive mobilisation of the ure- urethral plate avoids circular fixation of the neomeatus thral plate and urethra for correcting moderate and se- to the glanular tissue, and minimises the possibility of vere penile torsion in 27 patients; 18 of them had meatal stenosis. The use of a triangular flap at the distal hypospadias. They reported the complete correction of part of the urethral plate for creating a neomeatus and penile torsion by skin degloving in one patient, by mobi- distal neourethra is an old technique. It was advocated lisation of the fibrovascular spongiosum and urethral in 1973 by Horton et al. [7] in the ‘flip-flap’ technique plate into the glans in 13 (48%), by mobilisation of for hypospadias repair. Mollaeian et al. [8] used a trian- the urethral plate and penile urethra in seven (26%), gular distal plate flap and urethral mobilisation to man- and by mobilisation of the proximal urethra down to age a large series of distal and midpenile hypospadias; the bulbar urethra in six (22%). they had no cases of meatal stenosis. Our results for Our findings differ from those reported by Baht et al. hypospadias repair are similar to those reported by Mol- [3]. This discrepancy might be explained by the heteroge- laeian et al. [8]. Although the technique of urethral neity in the pathogenesis and underlying causal factors mobilisation and a distal plate triangular flap has a good of the condition. In about half of their patients the pe- outcome in distal hypospadias, it can result in meatal nile torsion was due to an asymmetrical attachment of retraction and/or ventral curvature if it is used to repair the divergent hypoplastic spongiosum to the glans. midpenile hypospadias, because mobilisation of the ure- More extensive urethral mobilisation down to the bul- thra cannot bridge the deficient length without tension bous urethra might release adhesions condensed under [9]. For an objective judgement of the required extent the pubic bone [2]. The present patients responded min- of urethral mobilisation in relation to the length of the imally to urethral mobilisation, and this was evident on deficient urethra, Atala [6] found that the length of the induction of an artificial erection. Although the dif- mobilised urethra should be four to five times the length ference between the angles of torsion before and after of the deficient segment. Others concluded that mobili- urethral mobilisation was statistically significant, the sation of the entire penile and bulbar urethra can pro- mean reduction was 8.7, which was not clinically vide up to 2.5 cm of tension-free extra length in important. This might indicate an intrinsic longitudinal children [10]. disorientation of the corpora cavernosa around the lon- Penile torsion is a relatively rare but well-known con- gitudinal axis of the penile shaft. Zhou et al. [2] found genital deformity, but its specific cause and pathogenesis that the left corpus cavernosum is relatively hypoplastic are not known [1,2]. Unlike chordee, which is deviation in cases of penile torsion. Asymmetrical development of of a part of penile shaft from the straight longitudinal the corpora cavernosa around the longitudinal axis of axis, penile torsion is a right or left rotation of the penile the penis, and/or a fibrous band that tightly attaches shaft around its longitudinal axis [1–3]. Because the ex- the left corpus cavernosum to the pubic periosteum, 6 Elbakry et al. might cause persistent penile torsion. Zhou et al. found als assessing the cause(s) of the anticlockwise direction that releasing that fibrous band was not successful in of torsion in all of our patients. correcting the penile torsion, because the adhesions were We recommend that when hypospadias is associated too dense, tough and difficult to dissect and release. with moderate and severe penile torsion, then degloving Those authors used tunical fixation to the pubic perios- and the release of all fascial attachments should be the teum and concluded that this manoeuvre is the most first manoeuvres. If the torsion persists totally or partly, reliable treatment for such cases of penile torsion. In then anchoring the tunica albuginea to the pubic perios- the present patients the penile torsion was corrected teum is the most reliable and effective method for cor- completely using the same technique as that described recting torsion. Extensive urethral mobilisation causes by Zhou et al. [2]; the outcome was optimal and sus- a minimal reduction of the angle of penile torsion and tained during the follow-up. Bauer and Kogan [13] ret- should be avoided as an anti-torsion technique. rospectively analysed the correction of penile torsion In conclusion, urethral mobilisation down to the in 25 patients. They concluded that persistent torsion scrotoperineal region is insufficient for the complete cor- after the release of chordee is due to fibrosis of Buck’s rection of moderate and severe penile torsion. It can fascia, but their finding lacked histological evidence. only reduce the angle of torsion. Periosteal anchoring Mobilisation of the urethral plate and corpus spong- of the tunica albuginea is the most reliable and sustain- iosum, and resection of the underlying fibrous bands, able method for correcting moderate and severe penile might contribute to correcting chordee, with or without torsion. This study also confirmed the reliability of the division of the urethral plate [3,17]. In 1966, Culp [18] urethral mobilisation and advancement technique with reported 17 cases of hypospadias with chordee and pe- a glans triangular flap in the repair of distal hypospa- nile torsion. He found that penile torsion was persistent dias. Further studies are needed to understand the path- despite the complete removal of chordee. However, ogenesis of congenital penile torsion. Mobley [19] reported that the complete removal of chor- dee in one case decreased the angle of torsion from 180 Conflict of interest to 120. We found that the presence of chordee had no significant correlation with the degree of reduction of None. the angle of penile torsion after urethral mobilisation. These data confirm our findings that urethral mobilisa- Source of funding tion alone might be insufficient for the complete correc- tion of moderate and severe penile torsion. Thus, tunical None. fixation to the pubic periosteum is the simplest and most reliable technique for correcting the original pathology References that causes corporeal rotation. All of the present patients had penile torsion to the [1] Bar-Yosef Y, Binyamini J, Matzikin H, Ben-Chaim J. Degloving and realignment – simple repair of isolated penile torsion. Urology left side. Previous published data indicate that penile 2007;69:369–71. torsion is mostly towards the left [2,3,14]. In an epidemi- [2] Zhou L, Mei H, Hwang AH, Xie HW, Hardy BE. Penile torsion ological study of the incidence of penile torsion in neo- repair by suturing tunica albuginea to the pubic periosteum. J Ped nates, Sarkis and Sadasivam [20] found that penile Surg 2006;41:E7–9. torsion was counter-clockwise in 99% of affected in- [3] Bhat A, Bhat MP, Saxena G. Correction of penile torsion by mobilization of urethral plate and urethra. J Ped Urol fants. This phenomenon is not fully understood, but fur- 2009;5:451–7. ther studies of the embryogenesis of the penile shaft and [4] Koff SA. Mobilization of the urethra in the surgical treatment of genital tubercle, and the intrauterine factors that might hypospadias. J Urol 1981;125:394–7. induce cavernosal disorientation and penile torsion, [5] Nasrallah PF, Minott HB. Distal hypospadias repair. J Urol should be designed and carried out. 1984;131:928–30. [6] Atala A. Urethral mobilization and advancement for midshaft to There are several limitations to the present study. distal hypospadias. J Urol 2002;168:1738–41. There were relatively few patients, and not all degrees 7 Horton CE, Devine CJ, Baran N. Pictorial history of hypospadias of penile torsion were included. Cases of hypospadias repair techniques. In: Horton CE, editor. Plastic and Reconstructive with mild torsion were not included because the required Surgery of the Genital Area. Boston: Little Brown; 1973. p. correction is too simple, and it is not ethical to dissect 237–48. [8] Mollaeian M, Sheikh M, Tarlan S, Shojaei H. Urethral mobili- and mobilise a long urethral segment for these cases. zation and advancement with distal triangular urethral plate flap Such mild torsion could be corrected by skin degloving, for distal and select cases of mid shaft hypospadias: experience fascial dissection and reattachment, or by cutting the with 251 cases. J Urol 2008;180:290–4. fanned spongiosum that is asymmetrically attached to [9] Warwick RT, Parkhouse H, Chapple CR. Bulbar elongation the glans [8]. The outcome of the correction of torsion anastomotic meatoplasty (BEAM) or subterminal and hypospa- diac urethroplasty. J Urol 1997;158:1160–7. was assessed subjectively by the parents on a morning [10] Redman JF, Bissada NK. One-stage correction of chordee and erection in the child. Another limitation is the lack of tri- 180-degree penile torsion. Urology 1976;7:632–3. The management of moderate and severe congenital penile torsion associated with hypospadias: 7 [11] Azmy A, Eckstein HB. Surgical correction of torsion of penis. [16] Slawin KM, Nagler HM. Treatment of congenital penile curva- BJU Int 1981;53:378–9. ture with penile torsion: a new twist. J Urol 1992;147:152–4. [12] Fisher PC, Park JM. Penile torsion repair using dorsal dartos flap [17] Acimi S. Proximal hypospadias. Effect of urethral mobilization rotation. J Urol 2004;171:1903–4. on release of chordee. Urology 2012;80:894–8. [13] Bauer R, Kogan BA. Modern technique for penile torsion repair. [18] Culp OS. Struggles and triumphs with hypospadias and associ- J Urol 2009;182:286–91. ated anomalies: review of 400 cases. J Urol 1966;96:339–51. [14] Hsieh JT, Wong WY, Chen J, Chang HJ, Liu SP. Congenital [19] Mobley JE. Congenital torsion of the penis. J Urol isolated penile torsion in adults: untwist with placation. Urology 1973;109:517–9. 2002;59:438–40. [20] Sarkis PE, Sadasivam M. Incidence and predictive factors of [15] Snow BW. Penile torsion correction by diagonal corporal isolated neonatal penile torsion. J Ped Urol 2007;3:495–9. plication sutures. Int Braz J Urol 2009;35:56–9.
Degloving and realignment – simple repair of isolated penile torsion
Penile torsion repair by suturing tunica albuginea to the pubic periosteum
Correction of penile torsion by mobilization of urethral plate and urethra
Mobilization of the urethra in the surgical treatment of hypospadias
Distal hypospadias repair
Urethral mobilization and advancement for midshaft to distal hypospadias
Pictorial history of hypospadias repair techniques
Urethral mobilization and advancement with distal triangular urethral plate flap for distal and select cases of mid shaft hypospadias: experience with 251 cases
Bulbar elongation anastomotic meatoplasty (BEAM) or subterminal and hypospadiac urethroplasty
One-stage correction of chordee and 180-degree penile torsion
Surgical correction of torsion of penis
Penile torsion repair using dorsal dartos flap rotation
Modern technique for penile torsion repair
Congenital isolated penile torsion in adults: untwist with placation
Penile torsion correction by diagonal corporal plication sutures
Treatment of congenital penile curvature with penile torsion: a new twist
Proximal hypospadias. Effect of urethral mobilization on release of chordee
Struggles and triumphs with hypospadias and associated anomalies: review of 400 cases
Congenital torsion of the penis
Incidence and predictive factors of isolated neonatal penile torsion
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