Treatment of congenital penile curvature with penile torsion: a new twist

Penile Degloving and Dorsal Dartos Flap Rotation Surgery in the Management of Severe Isolated Penile Torsion in a 6-Year-Old Boy

Penile torsion is a rare congenital anomaly that is usually characterized by a counterclockwise rotation of the penile shaft or glans. Although several surgical techniques for its correction have been proposed, the consensus of choosing the most efficient technique remains controversial. Herein, we report our operational approach that successfully corrected a severe (>90 degrees) isolated penile torsion in the form of penile degloving and dorsal dartos flap rotation surgery.

Procedures used for correction of isolated penile torsion: are they competitive or complementary?

OBJECTIVES

To report our experience in starting the correction of penile torsion, whatever its degree (moderate or severe) with one or more simple procedures either separately or complementary in the same session.

PATIENTS AND METHODS

Between 2013 and 2018, 62 patients who have significant isolated penile torsion (> 45°) were involved in this study. Those patients were subjected to either simple degloving with skin reposition, degloving with skin overcorrection and/or dartos flap procedures. Those procedures were performed either separately or complementarily. All patients were examined postoperatively after 7 days and followed up at 3, 6, and 9 months postoperatively.

RESULTS

37 out of 62 patients had a moderate degree (45-90) of penile torsion; 21 of them were corrected using skin degloving-reattachment technique, 11 patients were corrected by degloving with skin overcorrection, and in the remaining 4 patients dartos flap technique was used for correction. In 25/62 patients who had severe degree (> 90°) of torsion; 9 patients were managed by degloving with skin overcorrection, while in 13 patients the procedure was shifted to dartos flap technique, and the remaining 3 patients, 2 of whom had 180° torsion, were managed by dartos flap with added skin overcorrection.

CONCLUSION

Performing degloving and skin reattachment with or without skin overcorrection procedure and dartos flap procedure either separately or complementarily in the same patient whatever the degree of torsion (moderate or severe) is associated with good results and can protect some patients from exposure to more difficult and extensive procedures as corporopexy and corporeal plication.

Penile degloving and dorsal dartos flap rotation approach for the management of isolated penile torsion

OBJECTIVE

Penile torsion is a counterclockwise rotational anomaly of the penile shaft or glans. We aimed to evaluate the outcomes of penile degloving and dorsal dartos flap rotation used for the repair of isolated penil torsion.

MATERIAL AND METHODS

During evaluation of the patients admitted to our polyclinic for circumcision between January 2013-December 2014, 5 cases of isolated penile torsion were determined. Following the circumcision procedure performed with bipolar cautery, patients undergoing penile degloving were checked whether penile torsion was relieved or not. In case of insufficient improvement, torsion was corrected with application of dorsal dartos flap. Penile torsion was corrected with dartos flap in 2, and penile degloving in 3 cases.

RESULTS

The mean age of the patients was 5.6 years (4-7), and the mean operative time 12 minutes (7-20), respectively. The mean operation time was 17.5 (15-20) minutes and 8.3 (7-10) minutes in the dorsal dartos flap and penile degloving groups, respectively. The preoperative mean degree of penile torsion was 50° (30°-70°). The mean degree of torsion was 65° and 40° in the dorsal dartos and penile degloving groups, respectively. During the postoperative follow up, 1 case of residual torsion (<10°) was observed in the dorsal dartos flap group. Residual torsion was not observed in other patients.

CONCLUSION

Exploration for isolated cases of penile torsion during the circumcision procedure should not be overlooked. Successful results can be obtained with penile degloving and dartos flap rotation in cases with low and moderate torsion.

Isolated penile torsion in newborns

INTRODUCTION

We reported on the incidence of isolated penile torsion among our healthy children and our approach to this anomaly.

METHODS

Between 2011 and 2014, newborn babies with penile torsion were classified according to the angle of torsion. Surgical correction (penile degloving and reattachment for moderate cases and dorsal dartos flap technique in case of resistance) after 6 months was advised to the babies with rotations more than 45°.

RESULTS

Among 1000 newborn babies, 200 isolated penile torsions were found, and among these, 43 had torsions more than 45°, and 4 of these had angles greater than 90°. The mean angle of the rotations was found 30.45° (median: 20°). In total, 8 children with 60° torsions were previously circumcised. Surgery was performed on 19 patients, with a mean patient age of 12 ± 2 months. Of these 19, 13 babies were corrected with degloving and reattachment. This technique was not enough on the remaining 6 patients; therefore, derotational dorsal dartos flap was added to correct the torsion. After a mean of 15.6 ± 9.8 months, residual penile rotation, less than 15°, was found only in 2 children.

CONCLUSION

The incidence of isolated penile torsion is 20% in newborns. However, rotation more than 45° angles are seen in 4.3% of male babies. Correction is not necessary in mild degrees, and penile degloving with reattachment is enough in most cases. If the initial correction is insufficient, dorsal dartos flap rotation is easy and effective. Prior circumcision neither disturbs the operative procedure nor affects the outcomes.

Penile torsion repair in children following a ladder step: simpler steps are usually sufficient

OBJECTIVE

To evaluate the correction of different degrees of penile torsion following a ladder step so that simpler steps are used whenever possible. This can avoid the morbidity and complications of complex procedures.

PATIENTS AND METHODS

Cases of congenital and acquired penile torsion were repaired on a ladder step basis irrespective of the degree of torsion, starting with degloving and skin realignment, then a dorsal dartos flap and finally corporopexy. The torsion is checked with artificial erection after each step, and if corrected completely then the next step(s) is omitted.

RESULTS

Twenty-five cases of penile torsion (30-180°) were repaired over a 4-year period. Three cases were corrected by degloving only, 12 by degloving and skin realignment, five by a dartos flap and four required a corporopexy. Postoperative complications included five cases of penile edema, one case of hematoma and one case of dorsal skin gangrene. Residual torsion of <15° occurred in three cases. No cases required redo surgery.

CONCLUSION

A ladder step approach is a good option for penile torsion repair, starting with simpler techniques until complete correction is achieved. There is no need to plan a complex procedure in advance.

Dorsal dartos flap rotation versus suturing tunica albuginea to the pubic periosteum for correction of penile torsion: a prospective randomized study

PURPOSE

To compare the results of dorsal dartos flap rotation versus suturing tunica albuginea to the pubic periosteum for correction of congenital penile torsion.

PATIENTS AND METHODS

Seventeen patients with congenital penile torsion were evaluated and managed from 2006 to 2010. On a random basis, 9 patients underwent surgical repair using a dorsal dartos flap rotation technique (group 1), and 8 patients by suturing tunica albuginea to the pubic periosteum (group 2). All were followed up every 6 months.

RESULTS

The mean age in group 1 was 52.3 ± 24.8 months, while in group 2 it was 53.4 ± 33.6 months. Mean follow up was 22.3 ± 10.2 and 21.5 ± 7.2 months in group 1 and group 2 respectively. Torsion was corrected in 6 (66.7%) patients of group 1; 3 (33.3%) had residual torsion < 10°. In group 2, correction was achieved in 6 (75.0%) patients and 2 (25.0%) had residual torsion < 10°. The mean operative time was significantly less for group 1 than for group 2: 45.3 ± 7.1 and 74.5 ± 5.3 min, respectively (P < 0.0001).

CONCLUSIONS

In short-term prepubertal follow up, both dorsal dartos flap rotation and suturing tunica albuginea to the pubic periosteum are effective for correction of congenital penile torsion. The former technique is easier to perform as it requires much less dissection.

The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion

Objectives

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, 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 mobilisation 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 after conservative treatment. Massive oedema occurred in three patients and was treated conservatively. Urethral mobilisation did not correct the penile torsion completely. 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 important. 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 complete correction of penile torsion.

Correction of penile torsion by mobilization of urethral plate and urethra

OBJECTIVE

To assess the feasibility of correction of torsion by mobilization of the urethral plate with the corpus spongiosum and the proximal urethra.

PATIENTS AND METHODS

Of 27 cases of congenital penile torsion, 18 had hypospadias, seven were chordee without hypospadias, and two were isolated penile torsion. Age of patients varied from 2 to 26 years (mean 6 years, 8 months). Correction of torsion was performed: (1) penile skin de-gloving; (2) mobilization of the urethral plate with the corpus spongiosum up to the corona; (3) mobilization of the proximal urethra up to the perineum; and (4) mobilization of the hypoplastic urethra/urethral plate into the glans. Tubularized incised plate urethroplasty with spongioplasty was done in cases of hypospadias, as compared to spongioplasty alone in cases of chordee without hypospadias.

RESULTS

Degree of torsion varied from 45 to 180 degrees (mean 68.70); 74% of the patients had left and 26% had right penile torsion. Correction of torsion was possible by penile de-gloving (4%), mobilization of urethral plate and spongiosum (26%), mobilization of proximal urethra (22%), and mobilization of urethral plate/hypoplastic urethra with spongiosum into glans (48%).

CONCLUSIONS

Extended urethral mobilization corrected penile torsion in almost all cases. The technique is simple, safe, reproducible and effective for correction of both torsion and chordee.

Penile torsion correction by diagonal corporal plication sutures

Penile torsion is commonly encountered. It can be caused by skin and dartos adherence or Buck's fascia attachments. The authors suggest a new surgical approach to solve both problems. If Buck's fascia involvement is demonstrated by artificial erection then a new diagonal corporal plication suture is described to effectively solve this problem.

Modern technique for penile torsion repair

PURPOSE

Penile torsion is a congenital malformation that results in a rotational defect of the penile shaft. Various techniques have been described for correcting penile torsion, although there is no consensus on the best repair. We describe our experience using a dorsal dartos flap to correct penile torsion.

MATERIALS AND METHODS

We retrospectively reviewed the records of all 25 patients who underwent repair of significant penile torsion using a dorsal dartos flap at our institution between 2004 and 2007. A total of 17 repairs were performed in association with chordee repair, 7 with hypospadias and 1 with bilateral inguinal hernias. Patient age at the time of repair ranged from 6 to 19 months (mean 9). Of the patients 15 had torsion of at least 90 degrees, 8 had torsion of 60 to 90 degrees and 2 had torsion that was not recorded in degrees.

RESULTS

Mean followup was 4 months (range 1.5 to 19). Of the cases 16 demonstrated complete resolution of penile torsion, 7 had residual torsion less than 10 degrees and 2 had documented improvement that was not reported in degrees. No patient has undergone further repair for torsion.

CONCLUSIONS

Penile torsion is a challenging congenital anomaly. The dorsal dartos flap is familiar to pediatric urologists and can be varied for use in repair of penile torsion. The procedure results in successful repair of the torsion, has few complications and can easily be performed concurrently in the setting of other operative repairs. This approach provides excellent short-term results.

Degloving and realignment--simple repair of isolated penile torsion

OBJECTIVES

To present the results of repairing congenital or acquired penile torsion by means of a simple surgical procedure that does not involve resection of corporeal tissue.

METHODS

Forty-six circumcised patients (mean age 27 months, range 6 to 119) presented with isolated penile torsion of a greater than 30 degree rotation. The surgical technique involved degloving the penile skin to the penoscrotal junction. Residual torsion was corrected using 5-6/0 polyglactin absorbable suture applied to the desired 12-o'clock position of the penile skin adjacent to the glans and to a location counter to the direction of the torsion in the degloved penile skin sleeve. A wedge of loose ventral penile skin was usually resected. The resultant tightening of the skin allowed for proper alignment of the penis and better cosmesis. The rest of the circumferential incision was closed using the same suture material. The success of the procedure was evaluated according to physician and parental satisfaction with the final outcome.

RESULTS

Thirty-seven patients were available for follow-up (mean 31 months, range 8 to 68). Satisfactory results were achieved in 35 (95%) of the 37 patients; the other 2 had residual torsion. Complications were minor and consisted of postoperative fever and a subcutaneous hematoma in 1 patient that resolved with conservative treatment.

CONCLUSIONS

The degloving and realignment procedure is a simple technique that may be applied safely and successfully in most cases of penile torsion.

Penile torsion repair by suturing tunica albuginea to the pubic periosteum

PURPOSE

The aim of the study was to evaluate the effectiveness of a new technique to repair penile torsion in children.

METHODS

Eighteen boys with penile torsion were evaluated in our department from 1989 to 2003. Eleven had associated hypospadias, 4 had chordee without hypospadias, and 3 had torsion only. The direction of rotation was counterclockwise in 16 cases and clockwise in 2 cases. Torsion was repaired in 6 patients by degloving the penis and reattaching the dartos and the skin (comparative group). In 11 patients (1 with prior repair), the torsion was corrected by suturing the lateral edge of the corpus cavernosum to the pubic periosteum (study group). Two patients were not treated.

RESULT

Follow-up ranges from 6 months to 7 years. All of the 11 cases in the study group had satisfactory correction of the penile torsion. All of the urethroplasties for hypospadias were successful. In the comparative group, none of 6 patients had satisfactory correction of the rotation.

CONCLUSION

The technique of degloving the penis and reattaching the skin cannot reliably correct penile torsion in our experience. Lateral suturing of tunica albuginea to the pubic periosteum to repair penile torsion appears to be a better technique.

Penile torsion repair using dorsal dartos flap rotation

PURPOSE

Counterclockwise penile torsion is a frequently noted congenital deformity. Previously proposed techniques of torsion repair are ineffective or pose significant operative risks. We introduce a novel technique using dorsal dartos flap rotation.

MATERIALS AND METHODS

The penis is first degloved completely and a broad based dartos flap is mobilized from the dorsal penile skin. The flap is rotated around the right side of the penile shaft and attached to the ventral aspect, causing clockwise penile rotation. Final slight adjustments are made during skin closure. We applied this technique in 8 patients undergoing circumcision (2), chordee (4) or hypospadias (2) repair.

RESULTS

This technique was effective for correcting penile torsion in all patients. At a mean followup of 8.3 months the cosmetic outcome was satisfactory with the complete correction of penile torsion.

CONCLUSIONS

Rotational repositioning of a dorsal dartos flap is an effective technique for correcting penile torsion and it is easily applicable with other penile reconstruction procedures.

[Corrective surgery of penile inward curvature]

OBJECTIVE

To evaluate the corporoplasty techniques performed on 59 patients to correct congenital penile curvature and Peyronie's disease.

PATIENTS AND METHOD

From april 1991 to december 2001, 39 Nesbit technique, 12 Ruiz-Castañé method and 8 Essed-Schröeder procedure were performed on forty-four congenital curvatures and fifteen Peyronie's diseases. The mean age was 24 years old. Trying to hide the knots, in all patients except five a nonabsorbable inverting sutures were placed.

RESULTS

The mean follow-up was 12 months. Postoperatively, 53 patients (86%) had satisfactory cosmetic and functional results. Four patients of five with absorbable sutures had residual curvature which needed another successful surgical correction. One patient complained of penile shortening, one of glans hypoaesthesia, one of foreskin oedema and five of palpable plication sutures. No differences were found depending on the applied surgical technique.

CONCLUSIONS

The results reported are in accordance with the literature showing a higher recurrence rate with the absorbable sutures. The outcome is very similar with the three described techniques.

Congenital isolated penile torsion in adults: untwist with plication

To correct congenital isolated penile torsion, we delineated a parabolic curve as a counterdirection to the torsion after artificial erection was induced. Two areas along the curve were chosen and plicated with two interrupted U-shaped sutures. Satisfactory functional and cosmetic results were achieved in 3 patients.