Chordee correction by corporal rotation:The Split and Roll technique

0022-5347/99/1623-1152/0THE JOURNAL OF UROLOGYVol. 162, 1152–1155, September 1999Copyright © 1999 by AMERICAN UROLOGICAL ASSOCIATION, INC.Printed in U.S.A.CHORDEE CORRECTION BY CORPORAL ROTATION: THE SPLIT ANDROLL TECHNIQUEROSS M. DECTERFrom the Department of Surgery, Section of Urology, Milton S. Hershey Medical Center, Pennsylvania State Geisinger Health System,Hershey, PennsylvaniaABSTRACTPurpose: The optimal approach to correcting ventral chordee associated with severe hypospa-dias is controversial. Dorsal plication tends to shorten the phallus and ventrally positioned graftsoften mandate a staged procedure. An alternative approach is presented using corporal rotationto correct ventral chordee associated with hypospadias.Materials and Methods: In 6 boys with severe hypospadias the urethral plate was divided andthe septum between the corpora cavernosa was partially split with a ventral midline incision.This incision facilitates corporal rotation. Access to the dorsal aspect of the corpora cavernosawas achieved by dissecting Buck’s fascia with its encased neurovascular bundles, so that thebundles in the area of chordee were completely elevated and preserved. Using artificial erectionas a guide nonabsorbable sutures were placed in the area of maximal curvature from thedorsolateral aspect of 1 corpus cavernosum across the midline to the other side such that, as theknots were tied, the corpora rotated toward the dorsal midline. The knots were buried byapposition of the rotated corporal bodies.Results: Excellent straightening of the phallus was achieved intraoperatively in these patients.Conclusions: The split and roll technique for correcting severe chordee does not requireincisions into the corporal substance, involve use of grafts or cause shortening of the phallus. Theneurovascular bundles are preserved and are not compressed by the rotational sutures. Thesurgeon may perform 1-stage reconstruction while achieving maximal penile length.KEY WORDS: penis, urethra, hypospadias, abnormalitiesChordee associated with hypospadias is often readily cor-to the drop down position of the meatus, exposing a consid-rected by releasing the penile shaft skin and dissecting theerable length of the ventral aspect of the corpora (fig. 1, A).dysgenetic bands of tissue off of the corpora cavernosa, whichThe midline ventral septum between the corpora cavernosalie lateral to the corpus spongiosum and urethral plate.1These maneuvers may not adequately straighten the penis inpatients with more severe chordee. Most surgeons believethat residual chordee in these patients is due to corporaldisproportion. There are generally accepted techniques tocorrect this problem. The surgeon may choose to incise thedorsal aspect of the corpora and perform Nesbit plications,2which straighten the penis by shortening the dorsal side ofthe corpora. The alternative technique is to incise the ventralaspect of the corpora cavernosa at the point of maximumcurvature and place a graft in the defect created as the penisstraightens.3–6 For either procedure an incision into the cor-pora cavernosa is required, which is associated with thepossible risk of corporal damage or dysfunction. A techniqueis described using corporal rotation to correct ventral chordeeassociated with hypospadias that avoids corporal incisionsand penile shortening.MATERIALS AND METHODSThe split and roll technique of chordee correction was ini-FIG. 1. A, ventral corpus cavernosum is cleanly dissected to ex-tially used in 6 patients with penoscrotal or scrotal hypospa-pose midline ventral septum. When urethral plate is not divided, thisdias and severe chordee due to corporal disproportion. Inis achieved by simply dissecting corpus spongiosum and urethralthese patients dorsal plications would have been used previ-plate off of underlying corpora cavernosa. NVB, neurovascular bun-ously to treat this type of chordee. In these cases division ofdle. B, midline ventral incision into corporal septum need only causepartial separation of corpora to facilitate subsequent rotation. C,the urethral plate was required to correct chordee ade-plane of section under Buck’s fascia. This dissection allows neuro-quately.vascular bundles to be completely mobilized. D, neurovascular bun-To perform the split and roll technique the ventral aspectdle is elevated with vessel loops and dorsally positioned rotationalof the corpora cavernosa is exposed after the urethral plate issuture is placed. E, each dorsal corpus cavernosum is rotated inmidline. Artificial erection confirms adequate straightening of phal-divided. The urethral plate and distal corpus spongiosum arelus. Vessel loops are removed and Buck’s fascia drops back to normaldissected cleanly off of the corpora cavernosa from the glansanatomical position.1152CHORDEE CORRECTION BY CORPORAL ROTATION1153is identified and incised using a microsurgical knife. Thecase artificial erection revealed a straight phallus intraoper-incision partially separates the 2 corpora cavernosa (fig. 1,atively.B). This incision extends along the length of the intracorporalseptum from the glans to the meatus. It is deepest in the areaof maximum ventral curvature. Care must be taken to avoidDISCUSSIONaccidental entry into either corporal body. The septum is aVarious techniques are available to the reconstructive sur-thin structure and dissection must proceed carefully or thegeon for correcting chordee associated with hypospadias. It iscorpora will be entered and bleeding will be excessive. Pre-clear that in the majority of boys with hypospadias releasingcise placement of the incision is facilitated by rolling thethe ventral skin and its associated dartos fascia straightenscorpora away from the ventral midline and instilling inject-the phallus.1 Some patients have persistent chordee evenable saline into the corpora using the artificial erection tech-after the skin is released, and the dysgenetic tissue on thenique to aid in identifying the appropriate plane. It is notventral aspect of the corpora cavernosa adjacent to the cor-necessary to separate the corpora cavernosa completely, butpus spongiosum and urethral plate is dissected. Mollard andonly to incise the septum partially. Splitting the septumCastagnola suggested that excising the fibrous tissue underfacilitates corporal rotation, which is done subsequently tothe urethral plate almost invariably results in straighteningstraighten the penis.this chordee7 but this has not been my experience. EvenRepeat artificial erection testing at this point reveals per-when the urethral plate has been completely divided andsistent ventral curvature due to corporal disproportion anddissection is performed on the ventrum to clean the tunicapoints out the area of maximum deformity. Access to thealbuginea of the corpora cavernosa, chordee persists in somedorsal aspect of the corpora cavernosa is achieved by dissect-patients. The persistent curvature appears to be due to cor-ing Buck’s fascia with its encased neurovascular bundlesporal disproportion.starting at the ventrolateral aspect of the corpora cavernosaPerhaps the most widely used techniques to correct thison each side and proceeding toward the dorsum (fig. 1, C).problem are variations of the Nesbit plication.2, 8, 9 PlicatingThis dissection is performed with fine tenotomy scissors andthe dorsum of the corpora obviously shortens that aspect ofit mobilizes the neurovascular bundles from the glans dis-the penis to correct curvature. In most patients shortening istally to an appropriate position proximally on the penilenot significant enough to prevent using the technique. Someshaft. After Buck’s fascia and the neurovascular bundles aresurgeons incise directly through Buck’s fascia to place themobilized they are elevated with vessel loops to allow easyplicating sutures.8 This approach risks inadvertent injury toaccess to the dorsum (fig. 1, D). Each corpus cavernosum isthe neurovascular bundles, which are located on either sidethen rotated toward the dorsal midline by positioning aof the dorsal midline with branches ramifying distallytransverse nonabsorbable suture on the dorsal aspect of 1around the corpora cavernosa to the ventral side of the phal-corpus across the midline to the other corpus. The suture islus.10 When the corpora cavernosa are plicated, Buck’s fasciaplaced so that, as it is tied, the knot is buried between theis elevated with its encased neurovascular bundle as de-corpora as they roll toward each other (fig. 1, E). Usually 2 orscribed in the split and roll technique to avoid any direct3 such sutures placed in the region of maximum curvatureinjury to these nerves. To my knowledge it is not knownsuffice. Repeat artificial erection guides suture placementwhether there are perforating branches of the bundles intoand confirms penile straightening (fig. 2). Urethroplasty thenthe corpora along the length of the mobilized Buck’s fasciaproceeds according to surgeon preference.but none is discernible with loupe magnification. Other po-Initially the split and roll technique was performed intential pitfalls of the technique are that the incision throughpatients who required division of the urethral plate to correctthe tunica albuginea may enter the erectile tissue and ad-chordee. This technique now has been applied to patients inversely affect its function. Although this risk may be consid-whom the urethral plate has not been divided. In these casesered only theoretical, to my knowledge there are no publishedthe corpus spongiosum proximal to the meatus and the ure-studies describing the long-term followup of patients withthral plate distal to the meatus are elevated off of the under-severe chordee who underwent plication.lying corpora cavernosa using sharp dissection. This dissec-An alternative to plicating or shortening the long side oftion allows access to the ventral midline and the septum maythe curved penis is to increase the length of the short orbe split. Elevation of the neurovascular bundles and rota-ventral aspect of the corpora cavernosa. The surgeon incisestional suture placement then proceed as described. In eachthe tunica albuginea of the ventral corpus cavernosum in theregion of maximum curvature and places a graft into thedefect that is created as the penis straightens. Various ma-terials have been used as the grafting material, althoughdermal grafts have probably been used most frequently.3–6, 11Most suggest that this technique necessitates staged hypos-padias repair,6 although Hendren and Keating noted that a1-stage procedure may be performed in certain cases.4The concept of corporal rotation to correct ventral chordeeassociated with hypospadias has been described in thepast.12–14 Koff and Eakins noted that an incision along theventral corporal septum allows the corpora to rotate andstraighten during erection.12 Snow described a technique ofmaking an initial ventral midline incision in the corporacavernosa and placing sutures into the dorsal lateral corpuscavernosum to rotate the corpora.13 Kass also placed dorsallypositioned sutures to rotate the corpora, which straightenedthe phallus.14 The dorsal rotational sutures of Snow13 andKass14 were positioned so that the neurovascular bundles layunder the sutures when the knots were tied. In this situationthe neurovascular bundles are subject to the risk of compres-FIG. 2. Artificial erection. A, chordee persists after division ofsion injury caused by these sutures. The split and roll tech-urethral plate, splitting of septum and clean dissection of corpusnique involves a ventral septal incision, which facilitates thespongiosum off of corpus cavernosum. B, straight phallus after place-ment of dorsal rotational sutures.corporal rotation provided by the dorsally positioned suture.1154CHORDEE CORRECTION BY CORPORAL ROTATIONCorporal rotation created by straightening the ventral penile4. Hendren, W. H. and Keating, M. A.: Use of dermal graft and freecurvature allows the penis to achieve its full potential length.urethral graft in penile reconstruction. J. Urol., 140: 1265,In the technique described the dorsal rotational sutures lie1988.under the neurovascular bundles and the knots are buried5. Horton, C. E., Jr., Gearhart, J. P. and Jeffs, R. D.: Dermal graftsbetween the corpora cavernosa when tied. These factorsfor correction of severe chordee associated with hypospadias.J. Urol., 150: 452, 1993.should obviate the risk of injury to the neurovascular bundles6. Pope, J. C., IV, Kropp, B. P., McLaughlin, K. P., Adams, M. C.,in the long term.Rink, R. C., Keating, M. A. and Brock, J. W., III.: Penileorthoplasty using dermal grafts in the outpatient setting.CONCLUSIONSUrology, 48: 124, 1996.The split and roll technique allows the correction of chor-7. Mollard, P. and Castagnola, C.: Hypospadias: the release ofchordee without dividing the urethral plate and onlay islanddee due to corporal disproportion without requiring incisionsflap (92 cases). J. Urol., 152: 1238, 1994.into the corporal substance. It avoids the penile shortening8. Daskalopoulos, E. I., Baskin, L., Duckett, J. W. and Snyder,that may be caused by dorsal plication, and during erection itH. M., III.: Congenital penile curvature (chordee without hy-allows the shortened ventral aspect of the corpora to stretchpospadias). Urology, 42: 708, 1993.to the length of the dorsal corpus. The technique avoids the9. Rehman, J., Benet, A., Minsky, L. S. and Melman, A.: Results ofuse of grafts and allows the surgeon to proceed with 1-stagesurgical treatment for abnormal penile curvature: Peyronie’srepair. Good intraoperative results have been achieved butdisease and congenital deviation by modified Nesbit plicationfurther followup is required to confirm long-term outcomes.(tunical shaving and plication). J. Urol., 157: 1288, 1997.10. Baskin, L. S., Erol, A., Ying, W. L. and Cunha, G. R.: Anatomicalstudies of hypospadias. J. Urol., 160: 1108, 1998.REFERENCES11. Perlmutter, A. D., Montgomery, B. T. and Steinhardt, G. F.:1. King, L. R.: Hypospadias: a one-stage repair without skin graftTunica vaginalis free graft for the correction of chordee.based on a new principle: chordee is sometimes produced byJ. Urol., 134: 311, 1985.skin alone. J. Urol., 103: 660, 1970.12. Koff, S. A. and Eakins, M.: The treatment of penile chordee using2. Nesbit, R. M.: Congenital curvature of the phallus: report ofcorporal rotation. J. Urol., 131: 931, 1984.three cases with description of corrective operation. J. Urol.,13. Snow, B. W.: Transverse corporal plication for persistent chor-93: 230, 1965.dee. Urology, 34: 360, 1989.3. Devine, C. J., Jr. and Horton, C. E.: Use of dermal graft to correct14. Kass, E. J.: Dorsal corporal rotation: an alternative technique forchordee. J. Urol., 113: 56, 1975.the management of severe chordee. J. Urol., 150: 635, 1993.DISCUSSIONDr. Antoine E. Khoury. Are you concerned about lifting the neurovascular bundle along the lateral edges? Arethere no nerve perforators that enter the corpora at that point, which may impact on sensation or erectilefunction on a long-term basis?Dr. Ross M. Decter. The technique that we use, wherein we start our dissection ventrolaterally, basically allowsus to lift up the neurovascular bundles even as they spread around the lateral aspects of the phallus. You do notsee perforating nerves when you are doing the dissection. There may well be some tiny ones but you do not seethem. You can do the dissection atraumatically and get nice access to the dorsum of the penis.Doctor Khoury. Those lateral nerve endings coming around the sides are entering the tunica albuginea andcorpora?Doctor Decter. They may be but you do not perceive it when you are doing it.Dr. Sava V. Perovic. In my hands the split and roll technique in the septal region is a good method anddecreases the severity of penile chordee. Rotation of the corpora cavernosa in my hands is not successful. Whatdo you do when chordee is in the distal part of the corpora cavernosa near the glans?Doctor Decter. We have limited experience but we have straightened the phallus in each situation that Imentioned using dorsal rotational sutures. In all cases that I described the main part of the curvature was in theshaft of the phallus. There was not as much in the way of distal curvature under the glans. Two weeks ago I hada case in which there was some glans tilt that I was not happy with after I put in some dorsal rotational sutures.In fact, I applied your technique. I mobilized the glans completely off of the corpora cavernosa with the bloodsupply coming from the neurovascular bundle and urethral plate which exposed the end of the corpora cavernosa.Then I put a rotational suture in the distal end of the glans, which resolved the situation.Dr. Laurence S. Baskin. I want to comment about this concept of lifting up the neurovascular bundle. Theneurovascular bundle does something. It does not just innervate the glans. There are all these piercing nervesthat specifically go into the tunica. Dr. John Duckett showed me how to do the tunica albuginea plicationprocedure, which I did for many years. When we lifted up the neurovascular bundle, I am convinced that we werecutting these little perforating nerves. Does it make a difference? We do not know but I think that we shouldprobably try to minimize it. I would not advocate lifting the neurovascular bundle.Doctor Decter. When you did that procedure, you incised Buck’s fascia right over the major part of theneurovascular bundles. I think that this procedure has a much greater chance of not injuring the bundles becausewe are elevating them and not incising through them. I advocate a technique starting with dissection ventro-laterally to try to preserve all of Buck’s fascia with its encased neurovascular bundle.Dr. Mark Zaontz. I agree with Doctor Baskin. The nerves span out all over the dorsum of the penis andlaterally. When we make a lateral incision, we tend to cut 1 or 2 nerves but so what? My colleagues who treatPeyronie’s disease in adults have told me that these patients have no functional or sensory deficits. Severaladults have been referred to me for hypospadias repair with chordee release. I have probably nicked a few nervesCHORDEE CORRECTION BY CORPORAL ROTATION1155myself and have not seen any deficit. I think that a few nerves cut here and there is not going to make adifference.Doctor Baskin. It makes a difference in San Francisco. The technique that we are using in children is takenfrom observations made by Dr. Tom Lue in adults. He started his technique because of complaints of patientswho underwent a plication or Nesbit type procedure that was done laterally. These patients had decreasedsensation in the glans and skin. Doctor Lue, a penile anatomist, started to put sutures in the dorsal midline ornear the urethra. Based on fetal studies that made a lot of sense. When I showed him my fetal studies, heindicated that he had had similar findings in adult cadaver penises. We do not know what the long-term outcomewill be of placing midline sutures but I think that it is going to be good.