Hypospadias-associated penile curvature assessment and management: A global survey of current practice

INTRODUCTION

Our goal was to assess how surgical management of hypospadias-associated penile curvature (HAPC) varies across continents, focusing on factors that influence assessment and decision-making.

METHODS

Members of the European Society of Pediatric Urology (ESPU), Society of Pediatric Urology (SPU), and Hypospadias International Society (HIS) participated in an anonymous, 34-question online survey addressing pre-, intra-, and postoperative elements of HAPC evaluation and management. A selection of intraoperative photos were included in the survey to investigate the prevailing surgical approaches and identify management patterns.

RESULTS

Out of the 267 participants, 38.4% of them are located in Europe. Visual estimation was the predominant approach for evaluating HAPC, although being regarded as the least dependable compared to other techniques. Surgeons who performed more than 40 cases per year were more inclined to use goniometers and had varying degrees of HAPC that were considered acceptable without requiring any correction (P < .001). Out of 58% of respondents, a significant number reported regular utilization of artificial erection tests for all categories of hypospadias. Surgeons with fewer than 10 years of expertise commonly utilized erection test as part of their regular practice. A tourniquet was employed to maintain sufficient intra-corporeal pressure, by134 (50%). 116 participants (43%) inject Saline through the corpora cavernosa through the glans, while 150 (56%) administer saline from the lateral aspect. Moreover, the decision-making process differed based on the intraoperative picture scenarios of mild to moderate penile curvature during erection testing. Contrary to temperatures ranging from 25o to 35o, decision-making in cases with less severe degrees of HAPC was uncomplicated.

CONCLUSION

This survey reveals a wide range of surgical practice patterns in the assessment and management of HAPC. To our knowledge, this global survey of HAPC practice is the largest to date and could aid in developing new guidelines in pediatric urology. These findings may also provide a foundation for future prospective multinational studies.

Urologist validation of an artificial intelligence-based tool for automated estimation of penile curvature

INTRODUCTION

Severity of penile curvature (PC) is commonly used to select the optimal surgical intervention for hypospadias, either alone or in conjunction with other phenotypic characteristics. Despite this, current literature on the accuracy and precision of different PC measurement techniques in hypospadias patients remains limited.

PURPOSE

Assess the feasibility and validity of an artificial intelligence (AI)-based model for automatic measurement of PC.

MATERIAL AND METHODS

Seven 3D-printed penile models with variable degrees of ventral PC were used to evaluate and compare interobserver agreement in estimation of penile curvatures using various measurement techniques (including visual inspection, goniometer, manual estimation via a mobile application, and an AI-based angle estimation app. In addition, each participant was required to complete a questionnaire about their background and experience.

RESULTS

Thirty-five clinical practitioners participated in the study, including pediatric urologists, pediatric surgeons, and urologists. For each PC assessment method, time required, mean absolute error (MAE), and inter-rater agreement were assessed. For goniometer-based measurement, the lowest MAE achieved was derived from a model featuring 86° PC. When using either UVI (unaid visual inspection), mobile apps, or AI-based measurement, MAE was lowest when assessing a model with 88° PC, indicating that high-grade cases can be quantified more reliably. Indeed, MAE was highest when PC angle ranged between 40° and 58° for all the investigated measurement tools. In fact, among these methodologies, AI-based assessment achieved the lowest MAE and highest level of inter-class correlation, with an average measurement time of only 22 s.

CONCLUSION

AI-based PC measurement models are more practical and consistent than the alternative curvature assessment tools already available. The AI method described in this study could help surgeons and hypospadiology researchers to measure PC more accurately.

New protocol in the treatment of Peyronie's disease by combining platelet-rich plasma, percutaneous needle tunneling, and penile modeling: Preliminary results

INTRODUCTION

Intra-lesional injections of collagenase (Xiapex®) were the only non-invasive treatment option for Peyronie's disease (PD), until their withdrawal from the European market.

OBJECTIVE

To evaluate the feasibility, efficacy, and safety of a combined treatment of percutaneous needle tunnelling (PNT) with penile modelling (PM) and the injection of platelet-rich plasma (PRP) under general anesthesia in the treatment of PD.

PATIENTS AND METHOD

A prospective case series study included patients with PD in a stable phase who underwent this procedure between March 2020 and January 2023. The main outcome was an improvement in curvature.

RESULT

Thirty-six patients underwent this novel approach for the treatment of PD. The pretreatment mean±standard deviation (SD) curvature degree was 57.5±20.61° (range 20-90°). After the protocol, the mean curvature degree was 40.86±25.13° (range 0-90°). The curvature angle improved significantly (P=0.0001), with a mean improvement difference of 16.85±14.81° (range 0-50°) and a mean improvement percentage of 47.7±40.29% (range 0-100%).

CONCLUSION

Our preliminary experience suggests that PNT and PRP injections with PM are effective and safe for the treatment of penile deformity of PD.

LEVEL OF EVIDENCE

4: case series study.

The Natural (non-invasive) Erection Test: Is it a reliable alternative to the artificial erection test?

AIM OF THE STUDY

To test the accuracy and reliability of the natural erection test (NET) as compared to the artificial erection test in assessing penile curvature in hypospadias.

MATERIALS AND METHODS

50 children underwent both natural and artificial erection tests intraoperatively between January 2020 and October 2021. These included 5 glandular, 26 distal, 9 proximal, and 10 perineal hypospadias patients with curvature. The mean follow up period was 20 months (range 16-37). Under anesthesia, the curvature was assessed before degloving, then after degloving using both the natural and the artificial erection test. The NET test was repeated after curvature correction (3 times per patient). The measurements were analyzed using paired t-test.

TECHNIQUE OF NATURAL ERECTION TEST

Two fingers of the left hand press just below the symphysis pubis to stop blood drainage from the penis and two fingers of the right hand massage the blood from the perineum distally into the penis until it becomes hard without tourniquet. The standard artificial erection test was performed using saline injected through a butterfly needle into the corporeal bodies without tourniquet. Photos were taken of both tests using the exact angle and angle of curvature was measured using Angle Meter App.

RESULTS

There was no statistically significant difference between both erection tests with a P value of 0.705. The Bland-Altman plot also showed that all studied children have a difference in their natural and artificial erection tests within the limits of agreements.

DISCUSSION

Erection is commonly induced using the artificial saline injected erection test first described by Gittes and less commonly using pharmaceutical erection test first described by Perovic. The severity of chordee apparent during artificial erection test varies with the amount of pressure used during injection. Also, it is difficult to place the tourniquet proximal enough to detect chordee at the base of the penis. It may be associated with hematoma formation, oedema, postoperative pain and the need for multiple punctures to assess the curvature before and after repair. Disadvantages of the pharmacological-induced erections in hypospadias include increased blood loss during erection, additional cost, and the need for a reversal agent. The natural erection test mimic the normal erection mechanism and may avoid all these potential disadvantages.

CONCLUSION

The study showed that the natural erection test is easy to perform, non-invasive, non-traumatic and can be repeated several times intraoperatively without the need of repeated puncturing of the corpora cavernosa and avoids the potential risks and complications of the artificial erection test.

Taping alone for persistent ventral curvature after urethral plate transection in hypospadias

INTRODUCTION

Ventral penile curvature is a key factor in determining the surgical approach to proximal hypospadias repair. However, there is limited evidence regarding the efficacy and long-term effects of the procedures used to address curvature. This study aimed to evaluate the effects of urethral plate transection alone with tissue traction therapy on penile curvature in two-stage repair of proximal hypospadias.

MATERIAL AND METHODS

This was a prospective study of primary hypospadias patients who underwent a two-stage repair with urethral plate transection as the sole straightening procedure. After stage 1, taping was applied as tissue traction therapy and continued until stage 2. Penile curvature was measured using a goniometer under artificial erection before and immediately after urethral plate transection and during the second stage of repair. The primary focus of this investigation is the angle of curvature after 6-month taping.

RESULTS

The study included 46 patients with a median age of 13 months at the start of treatment. The median angle of penile ventral curvature was 70° after degloving, 60° after urethral plate transection, and 0° during the second stage of repair. Full correction of ventral curvature was achieved in 42 patients (91 %).

DISCUSSION

This publication is the first of its kind to propose taping as a method for penile traction therapy in hypospadias. The study reveals that penile ventral lengthening can be achieved through tissue traction therapy following UP transection alone. These findings challenge the current consensus that complete straightening of the penis in the first stage is necessary to prevent recurrent curvature and that ventral lengthening is required to correct corporal disproportion. However, further validation and long-term data are needed to definitively confirm the effectiveness of tissue traction therapy after urethral plate transection.

CONCLUSIONS

This study demonstrated significant resolution rate of penile ventral curvature in proximal hypospadias following urethral plate transection alone with taping. Long-term follow-up studies are needed to confirm the sustainability of the results through puberty.

What is the angle of a banana? The difficulty in reliable assessment of hypospadias chordee

INTRODUCTION

The degree of chordee associated with hypospadias impacts operative management. Unfortunately, poor inter-observer reliability in assessing chordee by multiple methods in vitro has been demonstrated. This variability may be related to the fact that chordee is not a discrete angle, but rather an arc-like curvature similar to that of a banana. On an attempt to improve this variability, we assessed the inter-rater reliability of a novel method of chordee measurement and compared it to measurements with a goniometer both in vitro and in vivo.

MATERIALS AND METHODS

In vitro assessment of curvature was performed using 5 bananas. In vivo chordee measurement was performed during 43 hypospadias repairs. On in vitro and in vivo cases, chordee was assessed independently by faculty and resident physicians. Angle assessment was performed in a standard manner with a goniometer and with a smartphone app using ruler measurements of the length and width of the arc (Summary Figure). The proximal and distal aspect of the arc to be measured was marked on the bananas, whereas the penile measurements were taken from the penoscrotal to the sub-coronal junctions.

RESULTS

In vitro banana assessment demonstrated strong intra- and inter-rater reliability for length (0.89 and 0.88, respectively) and width measurements (0.97 and 0.96). The calculated angle demonstrated an intra- and inter-rater reliability of 0.67 and 0.67. The banana goniometer/protractor measurements were weak with an intra-rater and inter-rater reliability of 0.33 and 0.21. With hypospadias chordee, the inter-rater reliability was strong for length and width measurements (0.95 and 0.94) and 0.48 for calculated angle. The inter-rater reliability of the goniometer angle was 0.96. Further assessment of inter-rater goniometer reliability was performed relative to degree of chordee as characterized by faculty. The inter-rater reliability for ≤15°, 16-30, and ≥30° was 0.68 (n = 20), 0.34 (n = 14), and 0.90 (n = 9), respectively. When the goniometer angle was classified as ≤15, 16-30, or ≥30° by one physician, it was classified outside of this range by the other physician 23%, 47%, and 25% of the time, respectively.

DISCUSSION

Our data demonstrate significant limitations of the goniometer for assessing chordee in vitro and in vivo. We were unable to demonstrate significant improvement in chordee assessment using arc length and width measurements to calculate radians.

CONCLUSIONS

Reliable and precise techniques for measuring hypospadias chordee remain elusive and draw into question the validity and usability of management algorithms employing discrete values.

What Adults Teach Urologists About Hypospadias

Knowledge regarding the impact of hypospadias in adults helps inform decision-making in childhood and potentially answers the question if repair should be delayed until during or after puberty. Earlier studies suggested that men with uncorrected hypospadias were either not aware of their condition or not bothered by it. Recent reports disagree and find that those with hypospadias are concerned by their difference and experience more penile dysfunction that men without this birth defect.

A new method for measuring penile curvature based on digital images

INTRODUCTION AND OBJECTIVE

Accurate and objective assessment of penile curvature is considered a critical evaluation in patients with hypospadias, as it often determines if a 1 or 2-stage procedure should be done. Due to the ease of acquisition and reusability of digital images, more research is focused on digital images; however, the current method based on digital images is not an easily accurate and objective evaluation of penile curvature amongst surgeons. In scoliosis, the Cobb method is a standard method to quantify spinal curvature. Therefore, this study introduces a new accurate, and standardized method for measuring penile curvature based on the digital image concerning the Cobb method.

METHODS

Twenty-two subjects were randomly selected, including 11 pediatric urologists with experience in goniometry(professional group)and 11 non-pediatric urologists without experience in goniometry (non-professional group). A total of 9 two-dimensional images of penile curvatures from 10° to 90°were obtained and stored in the research project notebook. Subjects measured 9 digital images using the new method (fixed anatomical position method) and classical method (the angle created by the interception of two ideal lines, one passing along the proximal portion of the corpora and a second passing through the tip of the penis), respectively. Measurement error was calculated as the absolute difference between the true curvature and the subject estimation. A t-test was used to evaluate the significant differences between the methods.

RESULTS

A total of 22 subject measurement data were obtained. Mean errors using the new method ranged from 1.06° to 3.50°, compared to 3.84°to 11.83°for classical method. Mean errors were significantly lower (p < 0.05) when using the new method compared to the classical method. A subgroup comparing subjects with and without prior experience with goniometry showed a statistically significant difference only for the classical method when the penis curvature is 10-40°, the mean error range of the professional group was 7.8°-9.56°, compared to 10.34°-13.02°for nonprofessional group.

DISCUSSION

We emphasize the importance of penile curvature measurement and urgent need for an accurate measurement method, and then we focus on the new method compare with the previously described methods looking at mean errors and explain the reason that the new method why is accurate. Subsequently, we focus on explain the impact of experience measurement methods. Finally, the shortcomings of this paper and the prospective points are discussed:1) how to obtain more photos in practical situations; 2) using artificial intelligence methods for automatic marking of key points to achieve efficient measurement of penile curvature.

CONCLUSIONS

In this preliminary study, we demonstrated better penile curvature estimations using the new method compared to the classical methods currently used by pediatric urologists.

Penile Autophotography Underestimates the Degree of Penile Curvature in Peyronie's Disease

BACKGROUND

Penile curvature is the most debilitating symptom of Peyronie's disease (PD); the evaluation of the degree of angulation is essential for planning treatment strategy. However, the most used method of penile at-home autophotography (AHP) is associated with some potential pitfalls and discrepancies compared with different assessment methods.

OBJECTIVE

To compare the degree of penile curvature quantified by AHP and in-office intracavernosal alprostadil injection (ICI) prior to therapy.

DESIGN, SETTING, AND PARTICIPANTS

Data from 55 PD patients of a single tertiary referral center were analyzed. All patients provided standardized AHP of the erect phallus. Clinic-based assessment included ICI with curvature measurement and completion of the International Index of Erectile Function (IIEF-15).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The Wilcoxon and/or chi-square test was used to compare the degree of curvature obtained using AHP and ICI, and to evaluate whether erectile dysfunction was a predictor of a relevant difference of >10° in curvature assessment between AHP and ICI.

RESULTS AND LIMITATIONS

Our study showed a significant (p < 0.001) difference in the degree of penile curvature between AHP (48° [38°; 55°]) and ICI (50° [40°; 65°]). Patients suffering from erectile dysfunction tend to have a higher difference in the degree of penile curvature between AHP and ICI than patients with good erectile function (p < 0.001). Our study is not devoid of limitations. First, we did not use Peyronie's Disease Questionnaire, as suggested by the European Association of Urology guidelines. Second, we did not evaluate inter- and intraobserver variations in the measurements.

CONCLUSIONS

AHP tends to underestimate the extent of penile curvature compared to ICI. Erectile dysfunction is an independent predictor of measurement differences of >10° between AHP and ICI.

PATIENT SUMMARY

It is necessary to evaluate the degree of penile curvature in Peyronie's disease prior to therapy decision. The at-home self-photography underestimates the real degree of penile curvature compared with an erection by in-office penile drug injection. Especially men suffering from erectile dysfunction carry the risk of a high difference in the measured degree of penile curvature, with a potential impact on the further treatment.

Is there any advantage in the use of absorbable sutures in congenital penile curvature surgery performed in childhood?

OBJECTIVE

To compare the long-term outcomes of corporeal plication using absorbable versus nonabsorbable sutures for the treatment of congenital penile curvature in childhood.

MATERIALS AND METHODS

Forty seven children who underwent congenital penile curvature repair between 11 and 140 months of age were included in the study. All children were operated on using the incisional plication technique and were divided into two groups: Absorbable-polyglactine (PLG, n=23, 48.93%) and nonabsorbable-polypropilen (PP, n=24, 51.06%) according to the suture material used for plication. Surgical outcomes were compared between groups.

RESULTS

Mean follow-up period was 19.02±4.66 months. There was no significant difference between the mean age of the children in two groups included in the study (PLG=41.39±34.63 months vs PP=53.66±37.42 months, p=0.250). There was no significant difference in penile straightening degree between the two groups in the postoperative follow-up (PLG=27.39±6.88 vs PP=31.08±6.38, p=0.06). Similarly, there was no significant difference between two groups in terms of postoperative curvature recurrence (p=0.681). However, palpable suture knots in the plication area was significantly higher in the PP group in the postoperative period (25.0% vs 4.3%, p=0.047).

CONCLUSION

The use of absorbable sutures in congenital penile curvature surgery in childhood has similar success rates with the use of nonabsorbable sutures and provides lower complications that are secondary to nonabsorbable sutures.

Evaluation of penile curvature in patients with hypospadias; gaps in the current practice and future perspectives

BACKGROUND/PURPOSE

Penile curvature (PC) is a significant phenotypic anomaly associated with hypospadias that can affect hypospadias repair post-operative outcomes and impact on long-term quality of life as well as psychosexual wellbeing of affected patients. While several previous studies have attempted to define PC assessment criteria, there is still no accurate, reproducible, and reliable tool for quantifying severity. Our goal was to review the pros and cons of the current tools utilized for assessing the degree of PC in children, stressing on both strengths and limitations of each method.

METHODS

A wide and deliberate review of the literature discussing the assessment of PC in hypospadias patients was conducted. We also draw on relevant methods employed in adults with PC and Peyronie's disease where a greater breadth of studies has been conducted.

RESULTS

The appraisal outcomes combined with our recommendations were presented in a structured approach discussing the pre-, intra-, and post-operative evaluation of PC in patients with hypospadias. Critical appraisal of the evaluation tools in terms of availability, cost, objectivity, and potential reproducibility was presented.

CONCLUSION

This review reflects on current tools used for assessing the degree of PC in children, highlighting both strengths and limitations of each method. A wide variety of approaches are currently being practiced or investigated, with each method displaying particular utility and reliability characteristics. Several approaches are currently being explored with high potential to overcome the current difficulties encountered when measuring PC both in clinical practice and research studies.

Long term complications of penile fracture repair: Erectile dysfunction and penile curvature

OBJECTIVE

To determine the factors that cause erectile dysfunction and penile curvature after repair of penile fracture (PF).

METHODS

Data from 25 patients who underwent PF repair was retrospectively analyzed. PF was diagnosed by examining patients' medical histories and performing physical examinations. All patients underwent immediate PF repair. All patients filled out the International Index of Erectile Function (IIEF-5) form and penile curvature was examined.

RESULTS

The median age of patients at the time of surgery and the median follow-up duration were 46 years (22-60 years) and 95 months (12-156 months), respectively. Two of the patients had concomitant urethral injury. At the final follow up, erectile dysfunction (ED) was present in 13 patients (52%). Among these patients, 9 patients (36%) had mild ED and 4 patients (16%) had moderate ED. With a univariate analysis, age and penile curvature were significantly associated with ED (p=0.008 and p=0.039, respectively). With a multivariate analysis, age was independently associated with ED (p=0.048, odds ratio=1.104, 95% confidence interval 1.000-1.218). The IIEF-5 scores correlated with age (p=0.009, r=0.510). Seven patients (28%) had penile curvature and one patient underwent penile plication surgery.

CONCLUSION

After PF repair, age is the only risk factor for ED and penile curvature rarely requires surgical treatment.

Expression of mRNA vascular endothelial growth factor in hypospadias patients

Background

Hypospadias is a relatively common genital anomaly in humans, usually followed by inelastic dartos that causes penile chordee. Vascular endothelial growth factor (VEGF) is strongly linked to the viscoelasticity of tissues and their elastic phase. This study aimed to evaluate VEGF expressions in (1) fascia dartos between hypospadias and controls and (2) chordee severity.

Methods

This prospective cohort study involved 65 specimens from patients with hypospadias and ten specimens from controls. The samples were analyzed by quantitative real-time polymerase chain reaction (qPCR) for VEGF expression.

Results

The expressions of VEGF were not different between proximal and distal hypospadias patients and controls (fold change: distal − 0.25; fold change: proximal − 0.2; p = 0.664). The scaled expressions related to chordee severity were mild − 0.1; moderate 0.1; severe − 0.25 (p = 0.660).

Conclusions

VEGF expressions might not affect the severity of hypospadias and chordee, implying the pathogenesis is complex involving many growth factors. Further study with a larger sample size is necessary to clarify and confirm our findings.

Peyronie disease: Our first experience with Ducket Baskin tunica albuginea plication (TAP) technique

INTRODUCTION

Peyronie's Disease is a deformity of the penis. Surgical procedure options for Peyronie's disease treatment include grafting (curvature >60°) or plication (curvature <60°). This case report emphasizes the curvature degree and therapy options chosen, such as tunica albuginea plication instead of grafting.

CASE PRESENTATION

A 55-year-old male complains about a curved penis during erection. Examination shows penile bending 70° ventrally with ±15 cm length and 2x4cm size. The patient underwent Ducket-Baskin tunica albuginea placation (TAP). Postoperative unbent penis size decrement of ±3 cm, neither pain nor erectile dysfunction felt.

CLINICAL DISCUSSION

Tunica plication is usually recommended in Peyronie's disease patients with curvature less than 60°, without an hourglass or hinge if grafting is not available. This technique is more simple, safe, the higher success rate of curvature correction (> 80%), low recurrency, low complication rate of penile hypoesthesia (approximately 10%), as well as low risk for postoperative erectile dysfunction.

CONCLUSION

In our case, the tunica albuginea plication technique gives a good outcome in Peyronie's disease reconstruction.

Peyronie Disease as a Marker of Inflammation-Is There Hope on the Horizon?

Although the description of Peyronie disease, a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis, is attributed to François de la Peyronie, surgeon to Louis XV of France, there are reports previous to that time. Over the intervening 450 years, a variety of empiric treatments, varying in barbarity, have been proposed. The frequency of this condition and the etiology of the fibrosis are unknown. Quality of life for affected men and their partners is adversely impacted. In this review, the authors summarize the history of the discovery of this condition, review contemporary management approaches, and address the pathophysiology leading to the underlying disordered fibrosis. The potential immunomodulatory role of testosterone as well as inflammatory conditions and environmental stimuli that may provoke fibrosis are also considered. Peyronie disease may be part of a spectrum of fibrotic conditions, including Dupuytren contracture. Treatment strategies to date have focused on reversing fibrosis; work is needed to prevent fibrosis and to accurately document disease prevalence.

Single-stage versus staged interposition urethroplasty for glandular hypospadias with severe penile curvature: 15-year experience

Purpose

Our study examined the benefit of an alternative interposition urethroplasty (IU) procedure for glandular hypospadias (GH) with severe penile curvature (SPC). The technique involved transecting and reconstructing the urethra to preserve the distal glandular and coronal urethra and correct the curvature. We compared procedural characteristics, outcomes, and surgical complications for the single-stage and staged IU techniques.

Methods

We retrospectively studied 44 patients with GH with SPC who underwent single-stage or staged IU between March 2005 and June 2020. Demographics, operative details, complications, and uroflometry findings were analyzed.

Results

The median age at initial surgery was 37.5 months. Ten patients underwent single-stage IU repair, and 34 patients underwent staged IU repair. The median length of the interposition neourethra was 3.2 cm (2.2–4.3). The median follow-up duration was 58 months, and the overall complication rate was 13.6%. Complications were noted in 30% (3/10) and 8.8% (3/34) of patients in the single-stage and staged IU groups, respectively (p > 0.05). Fistula formation was noted in one and three patients in the single-stage and staged groups, respectively (8.8% vs. 10%, p > 0.05). Two cases of urethral stricture were documented in the single-stage group only. No chordee recurrence or urethral diverticula was noted in any of the patients.

Conclusion

IU is a reliable and durable technique for GH with SPC. It avoided penile shortening, preserved the distal urethra, and reduced the risk of chordee recurrence. The staged IU technique had more superior outcomes compared to the single-stage IU technique.

Standardization of penile angle estimation with a semi-automated algorithm

INTRODUCTION

Penile curvature (PC) refers to an abnormal bending of the main longitudinal axis of the penis. It is frequently associated to hypospadias. To date, accurate and objective evaluation of PC is not easily reproducible amongst surgeons and there are no stablished protocols on how to measure PC in a standard way and in real-time to guide intraoperative decision making. For this reason, we want to present the results of creating a semi-automated algorithm to establish a reproducible and objective assessment of PC and propose it as a standard protocol for clinical applicability using inanimate 3-D penile models.

METHODS

This project consisted in two different phases. 1. Creation of an automated algorithm to estimate penile angle based on digital images. 2 Use of the algorithm to estimate penile angle on 3-D models and estimate interrater agreement using the algorithm. The algorithm was created to initially identify the geometrical centerline of the penile model to establish an automated output for angle estimation. 3-D printed penile models with known curvature angles ranging from 10 to 90° were used to test the algorithm (total of 9 penile models. These models were curved at one hinge as opposed to an arc type model. For each inanimate model, a set of 5 pictures were obtained from a lateral view at different camera angles (0⁰, 15⁰, 30⁰, 45⁰ and 60⁰) at a standard distance of 75 cm. Angle estimation using our designed PC algorithm was performed by a total of 10 different evaluators. Inter-rater reliability analysis in using the semiautomated algorithm was performed using the inter-class correlation coefficient (ICC) with two-way mixed effect model.

RESULTS

If the camera angle was greater than 30°, the absolute angle mean difference was greater than 10°. Camera angle with the smallest mean difference was at 0⁰ with a mean difference of 7.83°. Agreement between raters showed greater variability towards the higher camera angles. Nonetheless, a high degree of between evaluator reliability was found between the measurements at different camera angles. Single measures ICC ranges from .873 to .946, p-values were all <.0001.

CONCLUSION

Our results help standardize PC assessment using digital images and reduce subjectivity using an algorithm for PC estimation. Optimal camera position between 0⁰ to 30⁰ vertical from the penis gives the least variable and most accurate angle estimation. Future studies using algorithms will help define predictive PC cutoff values and evaluate postoperative outcomes.

[Study on the effect of simple incision of ventral tunica albuginea on the correction of penile curvature in hypospadias]

Objective: To investigate the therapeutic effect of simple tunica albugineaincision and ventral penile lengthening surgery on the correction of penile curvature due to asymmetry of the cavernous bodies in hypospadias. Methods: A retrospective analysis was performed in 39 children with hypospadias who underwent simple tunica albuginea incision and ventral penile lengthening surgery for correcting asymmetry of the cavernous bodies from January 2016 to December 2018(36 of them were from Department of Pediatric Urology surgery, The Children's Hospital, Zhejiang University School of Medicine, and 3 from Department of Urology surgery, Affiliated Hospital ofJiaxing University), all of whom aged from 0.5 to 5, with a median age of 1.1 years. During the first stage of the operation, firstly penile skin and sarcoma was released by completely degloving the skin and fascia of penis, secondly the factor of short urethral plate was solved by transection of urethral plate, and then the dorsal length of penis (A), the ventral length of the penis before and after straightening by incision of tunica albuginea (B and C) were measured and recorded; onto the second stage of the operation, an artificial erection test was performed to observe the curvature of the penis, the dorsal and ventral length of the penis (D and E) were measured. The dorsal and ventral length of the penis before and after straightening were compared. Results: The dorsal length of penis (A) was 33-39(35.6±3.2) mm, the length of ventral length of penis before straightening (B) was 28-35 (29.8±2.8) mm and the length of ventral length of penis after straightening (C) was 32-38 (34.3±2.1) mm, which were measured during the first stage of operation, and the difference between B and C was statistically significant (P<0.05), while the difference between A and C was not statistically significant (P>0.05). The dorsal length of penis (D) was34-41 (36.4±2.5) mm and the ventral length of penis (E) was 33-40 (35.7±3.6) mm, which were measured during the second stage of operation, and there was no significant difference between D and E (P>0.05). The degree of penile curvature at the time of erection was less than 15° by measuring with the side photos in all patients during 0.5 to 2.5 years of follow-ups with an average of 1.7 years. Conclusions: Penile curvature due to the asymmetry of the cavernous bodies could be effectively corrected by simple incision of ventral tunica albuginea, which showed a good result of early follow-up. The effect of this surgery on ventral penile straightening could be verified by measuring and comparing the ventral and dorsal length of penis during surgery.

Ventral penile curvature estimation using an app

INTRODUCTION AND OBJECTIVE

The assessment of penile curvature is a key component of hypospadias surgery, as it often determines if a 1 or 2-stage procedure should be done. The objective of this study was to test the accuracy of penile curvature measurements using an App-based method among non-urologists.

METHODS

Lateral pictures of six plastic 3-dimensional penile models representing each decile of curvature from 20 to 70° were obtained and stored on the research project iPad. Each picture was labeled with a name (i.e. Jim). Non-urology medical professionals were recruited to estimate the curvature of the six pictures with an App-based method consisting of the Photoblend Pro App and 9 provided graded 2-dimensional penile curvature images (representing each decile of curvature from 10 to 90°). Curvature estimations were done by merging the picture of the 3-dimensional penile model with one of the 9 provided graded 2-dimensional penile curvature images inside the App in an iterative process until the penile model picture matched the graded image (see figure). A research associate taught the research subjects the App-based method and then the subjects were asked to estimate the ventral penile curvature of each of the six penile model pictures. Measurement error was calculated as the absolute difference in between the measured value and the true value for the 6 models. A comparison was then made with previous research where pediatric urologists used either a goniometer or unaided visual inspection (UVI) to measure the ventral curvature of the same plastic 3-dimensional penile models used for the pictures of this study.

RESULTS

Twenty-one subjects were recruited, and all completed the study. Mean errors using the App ranged from 1.9° to 7.1°, compared to 6.5°-15° for UVI and 4.4°-15.9° for goniometry. The median error for the App was 0° compared to 5-10° for both UVI and goniometry. Mean errors were significantly lower (p < 0.05) when using the app compared to UVI/goniometry for all except the 30° and 50° models. Assuming patients with VC ≤ 30° would have had a one stage repair versus a 2-stage repair if curvature was >30°, the number of measurements that could have resulted in the unintended operation was calculated. There was a statistically significant difference in number of potential unintended surgeries in between App (17%) versus UVI + Goniometer (37%) (p = 0.0133).

CONCLUSION

This pilot study demonstrated better penile curvature estimations using the App compared to the two most common methods currently used by pediatric urologists. Plastic models provide an avenue to test and compare penile curvature measurement techniques.

New insights into the pathogenesis of Peyronie's disease: A narrative review

Peyronie's disease (PD) is a benign, progressive fibrotic disorder characterized by scar or plaques within the tunica albuginea (TA) of the penis. This study provides new insights into the pathogenesis of PD based on data from different studies regarding the roles of cytokines, cell signaling pathways, biochemical mechanisms, genetic factors responsible for fibrogenesis. A growing body of literature has shown that PD is a chronically impaired, localized, wound healing process within the TA and the Smith space. It is caused by the influence of different pathological stimuli, most often the effects of mechanical stress during sexual intercourse in genetically sensitive individuals with unusual anatomical TA features, imbalanced matrix metalloproteinase/tissue inhibitor of metalloproteinase (MMP/TIMP), and suppressed antioxidant systems during chronic inflammation. Other intracellular signal cascades are activated during fibrosis along with low expression levels of their negative regulators and transforming growth factor-β1 signaling. The development of multikinase agents with minimal side effects that can block several signal cell pathways would significantly improve fibrosis in PD tissues by acting on common downstream mediators.

Laser Therapy for Peyronie's Disease: A Randomized Control Double-Blind Pilot Study

Introduction: The management of Peyronie's disease (PD) has remained a therapeutic dilemma for physicians and there is no gold standard treatment. In this paper, we decided to investigate the beneficial effect of the intralesional administration of verapamil compared with the intralesional administration of verapamil plus a low-intensity laser (LIL). Methods: Research was activated from May 2016 to May 2018 and a total of 38 men aged 18 years and older completed the investigation. The subjects were randomly divided into 2 groups. Group 1 was composed of 22 patients that were treated only by verapamil (5 mg) plus a sham laser weekly for 6 weeks, and group 2 consisted of 22 patients that received a laser, using the BTL-6000 HIGH-INTENSITY LASER 12 W machine and the same protocol of intralesional verapamil injection. The visual analogue scale (VAS) was used to evaluate pain during an erection, penile ultrasonography was used to measure plaque size, the penile curvature angle degree was measured using the photographs taken during an erection, and the International Index of Erectile Function questionnaire was used to assess erectile function. The follow-up treatment lasted for nine months, with visits performed in the 3rd and 9th months. Results: All study parameters decreased significantly after treatment in both arms, but the reduction in pain and penile curvature improvements in combination therapy revealed more significant changes in 3 months (p = .035, p=.032). Nevertheless, these improvements were not seen in the follow-up session after 9 months. Conclusion: A laser appears to be safe treatment modality in carefully-selected patients with PD. It has moderate efficacy in the short term.

Comparison of Intralesional Hyaluronic Acid vs. Verapamil for the Treatment of Acute Phase Peyronie's Disease: A Prospective, Open-Label Non-Randomized Clinical Study

Purpose

To compare the efficacy and safety of intralesional hyaluronic acid (HA) as compared with verapamil injection in patients with Peyronie's disease (PD).

Materials and Methods

Between January 2015 and December 2018, men in PD acute phase were prospectively recruited. This open-label, prospective study included 2 different protocols. Group A: 8-week cycle of weekly intraplaque injections with HA; Group B: 8-week cycle of weekly intraplaque injections with verapamil. Penile curvature, plaque size, International Index of Erectile Function (IIEF)-15 score and visual analogue scale (VAS) were assessed at baseline and after 3 months.

Results

Two-hundred forty-four patients were enrolled. Of these, 125 received intralesional HA (Group A), 119 received intralesional verapamil (Group B). At enrollment, median age was 56.0 years (interquartile range [IQR]=47.0–63.0 years), median curvature 35.0° (IQR=25.0°–45.0°), median IIEF-15 score 19.0 (IQR=16.0–23.0), median VAS 4.0 (IQR=4.0–5.0). Median difference for IIEF-15 was 1.0 (95% confidence interval [CI]=1.12–1.94) in Group A and 0.0 (95% CI=−0.04–0.14) in Group B (p<0.05) and median difference for VAS score was −4.0 (95% CI=−4.11–−3.65) in Group A and −1.0 (95% CI=−0.50–2.01) in Group B (p<0.05). Plaque size decreased by −1.50 mm (IQR=1.60–2.10 mm) in Group A and −1.20 in Group B (p=0.10), while penile curvature decreased by −9.50° (IQR=4.50°–13.00°) in group A and −4.50 (IQR=2.50–7.50) in Group B (p<0.01).

Conclusions

Intralesional HA injections could represent a reliable treatment option for the conservative management of patients with acute phase of PD.

Goniometer not better than unaided visual inspection at estimating ventral penile curvature on plastic models

INTRODUCTION AND OBJECTIVE

The assessment of penile curvature is a key component of hypospadias surgery, as it often determines if a one- or two-stage procedure should be performed. The objective of this study was to compare unaided visual inspection (UVI) against goniometry estimations of ventral penile curvature (VC) among pediatric urologists.

METHODS

A total of nine different penile models (1.5 cm wide and 5-6 cm long) representing each decile of curvature from 10° to 90° were created. The nine models were divided in two groups: one with five models (group 1: 10°, 30°, 50°, 70°, and 90°) and the other with four models (group 2: 20°, 40°, 60°, and 80°). Each subject measured the VC of each model in group 1 using one method (i.e. UVI) and the curvature of each model in group 2 using the other method (i.e. goniometry). The next subject then used the opposite method for group 1 (goniometry) and group 2 (UVI), and so on, alternating the methods used to measure each group in between the subjects (Figure). The mean error (difference in between the true curvature and the subject estimation) was compared in between the two measurement methods (UVI and goniometry). A statistician calculated that 20-30 subjects would be needed to detect more than 10° difference in between the methods.

RESULTS

A total of 25 subjects were recruited for the study (24 pediatric urologists and 1 adult urologist). Mean errors for all degrees of penile curvature and methods ranged from 3.5° (90° model) to 13.6° (30° model). The mean error was not statistically different in between UVI and goniometry methods for any degree of curvature. A subgroup analysis of only goniometry estimations comparing subjects with and without prior experience with goniometry showed a statistically significant difference only for the 60° model. If choosing the correct surgery depended on determining if the curvature was ≤30° or >30°, all subjects would have chosen the right surgery for all except the 20°, 30°, and 40° models, where wrong surgery was chosen in 6/25, 15/25, and 7/25, respectively.

CONCLUSIONS

In this preliminary study, goniometry was not superior to UVI at estimating VC. There is pressing need in the field of hypospadias surgery to develop a tool that can measure VC in a reproducible and reliable fashion.

Prevalence, assessment and surgical correction of penile curvature in hypospadias patients treated at one European Referral Center: description of the technique and surgical outcomes

PURPOSE

Penile curvature (PC) is a common component of hypospadias, but its presence is inconstantly assessed. We aim to report prevalence of PC in hypospadias patients, as well as to report our method to assess and correct PC, with the associated postoperative outcomes.

METHODS

We scrutinized 303 pediatric hypospadias patients operated (2013-2018) at our referral center. PC was routinely assessed and eventually corrected with dorsal plications (DP) as one-stage procedure, or ventral tunica attenuations ± DP as two-stage repair. PC severity and surgical treatment of PC were compared between primary and failed hypospadias. Finally, PC severity, failed repair and PC treatment were tested as predictors of perioperative complications.

RESULTS

PC (> 10°) was identified in 274/303 (90.4%) patients, 86.1% with distal, 91.8% with midshaft, and 100% with proximal hypospadias, respectively. PC was found in 51/64 (79.7%) of failed hypospadias. One-stage and two-stage procedures were adopted in 211/274 (77%) and 63/274 (23%) children, respectively. PC severity (p = 0.1) and PC treatment (p = 0.4) did not differ between primary and failed hypospadias. PC severity (all p > 0.2), failed repair (p = 0.8), and PC treatment (all p > 0.09) were not predictors of perioperative complications. 95.6% of patients achieved a straight penis.

CONCLUSION

Less than 1/10 patients did not require PC correction. High rate of residual PC in failed hypospadias and similar severity between failed and primary suggest that PC was usually under-corrected. It is possible to correct PC completely and the resulting complication would not be associated with PC severity, failed repair or treatment adopted.

Use of small intestinal submucosa for corporal body grafting in cases of epispadias and epispadias/exstrophy complex

BACKGROUND

Male epispadias is a rare congenital urogenital anomaly in which the meatus is ectopically located along the dorsal midline of the penile shaft. In cases associated with severe curvature, functional and cosmetic outcomes could be accomplished by lengthening the shorter dorsal surface with the use of corporal grafting. Various graft materials have been used in the past for hypospadias repair including tunica vaginalis, dermis, and small intestinal submucosa (SIS). The use of SIS grafting for corporoplasty during epispadias repair has rarely been described in the literature.

OBJECTIVE

To report the experience in the management of dorsal corporal body grafting using SIS in children with severe penile curvature due to epispadias.

STUDY DESIGN

The authors retrospectively reviewed the charts of all patients with epispadias or bladder exstrophy/epispadias complex and severe dorsal chordee (>40°) who underwent epispadias repair with single-layer SIS for corporal body grafting. Clinical variables, surgical technique, and outcomes were analyzed.

RESULTS

A total of nine consecutive patients underwent staged epispadias repair with dorsal corporal single-layer SIS grafting (summary figure). Of these, four (44.4%) had primary penopubic epispadias, one (11.1%) had mid-shaft epispadias, and four (44.4%) had bladder exstrophy/epispadias complex. The mean age at surgery was 13.4 ± 6 months. After phalloplasty with SIS grafting, there were no reported complications related to the graft during the post-operative period or follow-up visits.

DISCUSSION

Although traditional techniques for epispadias repair allow some degree of corporal lengthening, they also result in abrupt medial rotation of the corporal bodies leading to torqueing and potential unsatisfactory cosmetic results. In contrast, the authors use single-layer SIS for corporal body grafting, and this study technique results in a more gradual inward rotation thus allowing more anatomical accuracy. Furthermore, an advantage of the use of SIS over other grafting materials is that there is no need to harvest an autologous graft such as tunica vaginalis or dermis.

CONCLUSION

Epispadias repair using single-layer SIS corporal body grafting is an effective, safe, and feasible method, which provides satisfactory cosmesis and correction of dorsal curvature in congenital epispadias in children. Furthermore, a more normal penis appearance, without a decrease in the corporal length or diameter, is achieved with this technique.

Evolution of the surgical sealing patch TachoSil® in Peyronie's disease reconstructive surgery: technique and contemporary literature review

PURPOSE

The aim of this study is to review the current literature that reports outcomes of Peyronie's disease (PD) reconstructive surgery using the collagen fleece TachoSil^® (Baxter, CA, USA), a novel graft that has self-adhesive properties and gained popularity in recent years.

METHODS

A literature review was performed through PubMed between 2013 and 2018 regarding the use of TachoSil^® in PD penile reconstructive surgery. Keywords used for the search were: Peyronie's disease, surgical therapy, surgical outcomes, grafting techniques, graft materials, collagen fleece, surgical patch, and TachoSil.

RESULTS

Grafting procedures are indicated for men with PD and preserved erectile function. TachoSil^® is a novel graft used for defect closure after tunical incision or partial plaque excision. Long-term results of this technique are encouraging and reliable. One major advantage over other grafts is that the TachoSil^® does not require suture fixation leading to significantly decreased operative times. Another indication is residual curvature correction by plaque incision and grafting/sealing with TachoSil^® during penile prosthesis implantation in patients with PD and severe erectile dysfunction. Besides reduced operative times, the major advantage is that there is no risk of device puncture because of the self-adhesive properties of the TachoSil^®.

CONCLUSIONS

The TachoSil^® has emerged as a safe, reliable, and promising graft in PD reconstructive surgery. Until now, this graft has met the expectations as a durable and effective graft, not only for grafting techniques but also for residual curvature correction during penile prosthesis implantation. However, future research is encouraged, preferably within prospective multicenter studies.

Twenty Years of Plaque Incision and Grafting for Peyronie's Disease: A Review of Literature

Introduction

Plaque incision and grafting (PIG) is indicated for men with complex or severe penile curvature and, despite a multitude of incision types and grafting materials having been used, no individual technique has proven superiority.

Aim

To assess outcomes following PIG and to understand the operative technique.

Methods

A systematic review was performed to find all relevant studies reporting on use of the PIG technique to correct curvature resulting from Peyronie’s disease. Studies were included if they had >40 participants, were written in the English language, and no penile prosthesis was implanted.

Main Outcome Measures

Primary outcome measures included deformity correction, erectile dysfunction, and degree of penile lengthening/shortening. Secondary outcome measures included satisfaction, reoperation rate, and complications.

Results

Twelve studies were included in the quantitative synthesis, which overall report on the results of 1,025 patients. Careful patient selection was critical, with erectile function requiring assessment with the International Index of Erectile Function (IIEF), subjective patient reports, and consideration of whether erections are pharmacologically aided. There was no evidence of superiority in favor of any particular incision type or grafting material, and absorbable sutures were clearly favored. Postoperatively, 4.6%–67.4% required pharmacologically aided erections and 0–11.8% were completely unable to achieve erections. Successful straightening occurred in 80.0%–96.4%, although there was no consistent definition of success. Penile length was unchanged in 44.2%–95.0%; 88.0%–92.0% of the patients were satisfied, and .7%–4.7% required reoperation. Altered sensation occurred in 2.0%–22.5% of patients, of which 80.0%–100.0% was only a transient loss. All outcomes were heterogeneously reported. There are no clear predictive factors for erectile dysfunction following PIG surgery. No single incision type or grafting material has proven superiority.

Conclusion

PIG is an effective and safe technique for correction of complex or severe penile curvature in terms of satisfaction, length change, straightening, and complications.

Rice PG, Somani BK, Rees RW. Twenty Years of Plaque Incision and Grafting for Peyronie’s Disease: A Review of Literature. Sex Med 2019;7:115–128.

Peyronie's disease and testosterone deficiency: Is there a link?

INTRODUCTION

Peyronie's disease (PD) and testosterone deficiency (TD) impact men at the same stage of life and can ultimately contribute to erectile dysfunction. There is speculation that low levels of testosterone (T) may predispose men to penile fibrosis; however, there is no published, up-to-date review summarizing the current evidence. Therefore, we conducted a narrative review of the literature exploring the relationship between PD and TD.

METHODS

A comprehensive systematic search of existing literature of five online databases from June 1990 to June 2018 examining the relationship between PD and TD was conducted. The Cochrane risk-of-bias tool for randomized trials and the risk-of-bias assessment tool for cohort studies were used to evaluate the quality of studies.

RESULTS

Six studies were identified (n = 675). Overall, five studies supported the link between PD and TD by demonstrating relationships in PD patients with low total T, free T, bioavailable T, greater penile curvature, and plaque development. However, one study demonstrated no connection between the conditions. The literature is restricted by small studies with methodological flaws.

CONCLUSION

There are a number of mechanisms to support the link between TD and PD. The literature on the topic is limited by small studies which are overall conflicting. The findings of this work suggest the need for larger, prospective studies to clarify the role of TD in the development, evaluation, and treatment of PD. Establishing such a relationship could change management of PD as a diagnosis of PD may encourage clinicians to evaluate a patient's testosterone levels.

Buccal mucosa graft for simultaneous correction of severe chordee and urethroplasty as a one-stage repair of scrotal hypospadias (watch technique)

PURPOSE

Severe hypospadias repair still presents a great challenge. We evaluated a novel approach of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and new urethral plate creation, in combination with longitudinal dorsal island skin flap, as a one-stage repair of severe hypospadias.

METHODS

Between July 2014 and September 2017, 26 patients (aged from 12 to 22 months) underwent scrotal hypospadias repair. Short and non-elastic urethral plate is divided. Buccal mucosa graft is harvested from the inner cheek, and designed in a special "watch" shape, with the spherical part in the middle and two rectangular parts on both sides. Tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the "watch-shaped" buccal mucosa with 6-8 "U-shape" stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally. Longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with buccal graft. Penile skin reconstruction is performed using available penile skin.

RESULTS

The mean follow-up was 22 months (range from 9 to 46 months). Satisfactory results were achieved in 22 patients. Two urethral fistulas were successfully repaired by minor surgery after 3 months, while one meatal stenosis and one urethral diverticulum were successfully treated by temporary urethral dilation. There were no cases of residual curvature.

CONCLUSION

Specially shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty could be a good choice for single-stage repair of scrotal hypospadias with severe curvature.

Repeated Micro-Trauma of the Penile Tunica Albuginea: A New Animal Model of Peyronie's Disease

OBJECTIVES

To compare effects of repairing injured tunica albuginea (PTA) of rat penis by single or repeated local injections of chlorhexidine ethanol (ChE) into the PTA and to establish a new animal model of Peyronie's disease (PD).

MATERIALS AND METHODS

Forty-two rats were divided into 7 groups. Rats either served as the normal control group with 1-5 injections of 0.9% saline or they received a single injection, 2, 3, 4, or 5 injections of ChE (0.1% chlorhexidine gluconate plus 15% ethanol dissolved in saline); rats in the positive control group were injected with TGF-β1. At 60 days after the last injection, the intracavernous pressure, degree of penile curvature, and histology were evaluated.

RESULTS

Compared with the single injection of the ChE group, we found the following in the repeat ChE injections groups: an increase in the degree of penile curvature, fibrous plaques in the PTA and/or corpus cavernosum, broken elastic fibers, slightly decreased erectile function, and an increased expression of TGF-β1 and αSMA.

CONCLUSIONS

Repeated ChE injuries of PTA may lead to fibrosis. This represents an excellent model of PD that involves repeated injections of ChE into the local PTA as well as reveals the pathophysiologic mechanism of PD.

Correction of Residual Ventral Penile Curvature After Division of the Urethral Plate in the First Stage of a 2-Stage Proximal Hypospadias Repair

PURPOSE OF REVIEW

The first stage of a 2-stage proximal hypospadias repair involves division of the urethral plate and correction of any residual ventral penile curvature (VPC). Options to correct residual VPC include dorsal corporal shortening or ventral corporal lengthening techniques. This review discusses these options and suggests an approach to management.

RECENT FINDINGS

Recent reports of 2-stage proximal hypospadias repairs indicate low rates of recurrent VPC with either dorsal corporal shortening or ventral corporal lengthening. Dorsal corporal shortening with dorsal plication may be preferentially used for mild to moderate residual VPC after division of urethral plate and ventral corporal lengthening reserved for severe residual VPC. Ventral corporal lengthening with grafts has been associated with urethroplasty complications after the second stage hypospadias surgery. Ventral corporal lengthening with relaxing incisions of corpora has been reported, but concerns about adverse effects require longer term studies. Little guidance exists to choose the best technique for VPC correction during first stage hypospadias repair after division of urethral plate. Reported literature suggests good results with dorsal plication techniques and ventral corporal lengthening. A practical approach is to use dorsal plication techniques for mild to moderate residual VPC after division of urethral plate (<45°) and reserve ventral corporal lengthening for severe residual VPC (>45°).

Bicentric prospective evaluation of corporoplasty with porcine small intestinal submucosa (SIS) in patients with severe Peyronie's disease

INTRODUCTION

Advanced Peyronie's disease (PD) with severe penile deviation demands grafting procedures following plaque incision or partial plaque excision in order to avoid penile shortening and to improve quality of life of affected patients. Small intestinal submucosa (SIS) is an established xenograft. The objective of the present study was to validate external results in a bicentric prospective manner.

METHODS

Patient selection criteria, surgical technique and standards for pre- and postoperative care were defined. Consecutively, patients with severe penile deviation in stable disease and sufficient erectile function were included between 2007 and 2015. After plaque incision, grafting was performed using SIS in a standardized manner. The postoperative evaluation using a non-validated questionnaire included complications, correction of curvature, pre- and postoperative erectile function, change in penile length and general satisfaction with the procedure.

RESULTS

Forty-three patients underwent surgery between 2007 and 2015. The mean degree of preoperative curvature was 73.8° (range 60-90°). No intraoperative or major postoperative complications were reported. After a mean follow-up of 33.0 months (range 10-59), complete straightening of the penis was achieved in 74.4%. 88.4% of all patients were able to achieve satisfying sexual intercourse (67.4% unaided, 21.0% with assistance). The IIEF-5 score was improved in 69.8% (mean improvement 4.0 points). Overall 86.0% were satisfied with the surgical treatment.

CONCLUSION

Corporoplasty with SIS in patients with PD and severe penile curvature is a safe approach and shows good long-term results. A thorough patient selection and a standardized pre-, intra- and postoperative procedure are decisive for a satisfying outcome.

Imperforate Anus with Fistula Exiting at the Penile Skin

We present the case of a male neonate with imperforate anus and a fistula exiting on the penile skin. Anorectal malformations in boys often present themselves with an entero-perineal or entero-urinary tract fistula, the type of which is a key feature for the classification and the treatment plan. A fistula exiting in front of the scrotum, such as described in our case, is very rare and is not incorporated in the current classification and treatment algorithms. Scarce reports on misjudgment concerning the position of the blind rectal pouch in similar cases, led us to perform a colostomy instead of a one-stage correction. A posterior sagittal anorectoplasty was performed eight months later and the rectal pouch was found inside the levator sling, justifying the cautious approach. The colostomy was closed three months later and after six months the distal part of the fistula was excised. We believe that in cases with a rare fistula presentation, the position of the rectal pouch is not predictable and the surgeon should proceed with caution.

The Egydio geometrical procedure for managing penile curvature using a single relaxing incision: A single-centre experience with 330 patients

Objective

To present our 3-year experience with the Egydio’s geometrical procedure for managing penile curvature with some modifications.

Patients and methods

In all, 330 patients (mean age 51 years) that underwent the Egydio’s procedure as day cases were included in this study.

Results

The mean penile curvature was 45° and 27.3% of the patients reported mild erectile dysfunction (ED) preoperatively. Partial excision of the calcified plaque was performed in 12.1% of the patients. Partial glans necrosis was recorded in one patient, while haematoma was recorded in 9%, and delayed wound healing in 3%. There was residual curvature (mean 20°) requiring reoperation in 8.2% of the patients. In all, 10% of the patients were dissatisfied with their results, while of the remainder, 75.2% were totally satisfied and 14.8% partially satisfied. ED was reported in 31.8% of the patients (moderate: 17.3% and significant: 2.7%).

Conclusions

The Egydio geometrical technique for the treatment of penile curvature seems to be a simple, reproducible, safe, and efficient operation.

Do adult men with untreated hypospadias have adverse outcomes? A pilot study using a social media advertised survey

OBJECTIVE

Hypospadias is usually treated in childhood. Therefore, the natural history of untreated mild hypospadias is unknown. We hypothesized that men with untreated hypospadias, especially mild, do not have adverse outcomes.

MATERIALS

Facebook was used to advertise an electronic survey to men older than 18 years. Men with untreated hypospadias identified themselves and indicated the severity of hypospadias with a series of questions. Outcomes included: Sexual Health Inventory for Men (SHIM), penile curvature and difficulty with intercourse, International Prostate Symptom Score (IPSS), Penile Perception Score (PPS), psychosexual milestones, paternity, infertility, sitting to urinate, and the CDC HRQOL-4 module.

RESULTS

736 men completed self-anatomy questions and 52 (7.1%) self-identified with untreated hypospadias. Untreated hypospadias participants reported worse SHIM (p < 0.001) and IPSS scores (p = 0.05), more ventral penile curvature (p = 0.003) and resulting difficulty with intercourse (p < 0.001), worse satisfaction with meatus (p = 0.011) and penile curvature (p = 0.048), and more sitting to urinate (p = 0.07). When stratified by mild and severe hypospadias, severe hypospadias was associated with more adverse outcomes than mild hypospadias.

CONCLUSION

Men with untreated hypospadias reported worse outcomes compared with non-hypospadiac men. Mild untreated hypospadias had fewer adverse outcomes than severe hypospadias. Research is needed to determine if treatment of childhood hypospadias improves outcomes in adults, especially for mild hypospadias.