Congenital penile curvature (CPC) is the term used to describe bending of the penis that has been present since birth. Curvature that arises later in life is usually called Peyronie’s disease. Although some of the treatments used for Peyronie’s disease are also used for CPC, these conditions are often treated differently. This article will focus solely on the surgical treatment of CPC and not on Peyronie’s disease.
In 2/3 of cases of CPC, the bending is directed straight downwards — ventral. In the other 1/3 of cases, there is either lateral or dorsal bending of the penis. In this article I will only discuss the surgical management of the most common ventral curvature:
Types of procedures to correct ventral curvature
There are 2 types of procedures used to correct ventral curvature:
- Procedures that shorten the convex (dorsal) side of the penis.
- Procedures that lengthen the concave (ventral) side of the penis
Procedures that shorten the convex side of the penis
There are 3 main groups of procedures that shorten the convex or dorsal side of the penis:
- Excisional plication, such as the Nesbit procedure.
- Incisional plication, such as the Yachia procedure.
- Incisionless plication, such as the 16 dot procedure.
For the excisional plication, ellipses of tunica albuginea — the outer strong layer of the penis– are excised and then the gap is closed with sutures:
For the incisional plication, longitudinal incisions are made in between the dorsal vein and the paired dorsal arteries that are closed transversely as described by Heineke–Mikulicz:
Lastly, with incisionless plications, permanent sutures are used to plicate the dorsal side of the penis:
The problems with shortening procedures
The main problem shared by all the shortening procedures is that they shorten the penis! Studies have shown penile length loss of 1-3 cm. The amount of shortening appears to be unrelated to the degree of curvature —some patients with severe curvature end up with little shortening and vice-versa. Thankfully, the majority of men are not bothered by the 1-3 cm loss in length — only around 10% of men are troubled by it.
Other problems can be specific to the type of surgery. Excisional plication can result in damage to the penile nerves — which course longitudinally along the penis. To decrease the risk of this complication, the nerves and vessels are mobilized of the tunica albuginea before excision of the ellipse. Incisional and incisionless plication have less chance of damaging the nerves due to the fact that the incision and sutures are placed parallel to the direction of the penile nerves.
Another common issue is bother related to the suture knots. This is particularly a problem with incisionless plication where permanent sutures are used — with absorbable sutures the problem with the knots is usually transitory.
The following table — extracted from an excellent review paper by Sokolakis et al — summarizes and compares all these techniques from studies done solely on CPC (Peyronie’s patients were excluded):
|Excisional plication (Nesbit)||Incisional plication (Yachia)||Incisionless Plication||Grafting (ventral lengthening)|
|Number of studies||14||7||16||3|
|Number of patients||1204||262||668||21|
|% with ventral curvature||70||75||69||>40|
|Transient loss of glans sensation||5%||0.5%||12%||–|
|Bothersome palpable sutures or granulomas||8%||28%||27%||–|
Procedures that lengthen the concave (ventral) side of the penis
When discussing lengthening procedures in the case of ventral penile curvature, the urethra plays a pivotal role. Since the lengthening has to be done under the urethra, the urethra has to be either:
- Elevated and dissected distally and proximally from the point of maximal curvature
- Divided and dissected distally and proximally from the point of maximal curvature.
Surgeons that believe that ventral curvature is due to a shortened urethra will recommend dividing the urethra. Surgeons who contend that the urethra only plays a role in a minority of cases will have you elevate the urethra instead. In this article by Donnahoo et al from Riley Hospital for Children in Indianapolis, a congenital short urethra was thought to be the cause of only 7% of cases of CPC. In this article that includes a video, Dr. Zaontz from CHOP demonstrates the technique for the correction of ventral CPC by elevation of the urethra and ventral corporotomy with a graft.
Dividing the urethra adds a whole layer of complexity to the repair of CPC. If the urethra is elevated, the patient will only need one procedure –assuming it works. On the other hand, if the urethra is divided, at least 2-3 procedures will be needed to correct the problem:
- In the first procedure, the urethra is divided and the curvature is corrected. If the lengthening of the penis was done using no grafts (see below) then the gap in between the 2 urethral stumps is covered by a graft –using foreskin or buccal mucosa — to later use it to reconstruct the urethra. If the lengthening of the penis was done using itself a graft of flap, the urethra reconstruction would have to wait 6 months –since it would be unwise to place a graft over another graft.
- In the second surgery 6 months later, if a graft was laid out for the urethra, it gets tubularized, and as long as the procedure works that would be the second and last procedure. If no graft was laid down for the urethra on the first stage, then a graft of foreskin or buccal mucosa is laid down to be tubulirized on the third stage
- A 3rd surgery is only necessary for when both the urethra was divided and the lengthening was done using a graft. In the 3rd stage, the graft placed on the second stage is tubularized.
Now let me explain the 2 main ways to lengthen the ventral urethra (one without a graft and one with a graft):
- No graft: 3 full-thickness corporotomies — horizontal incisions that go from 3 to 9 o’clock– at the point of maximal curvature
- Graft: 1 single corporotomy covered with a graft or a flap:
When doing 3 corporotomies, no graft is placed to fill in the defect. One could technically then place a buccal/foreskin graft over the corporotomies to reconstruct the urethra and finish the procedure in a second stage 6 months later. On the other hand, if a single corporotomy with graft is done, no graft could be placed on top of the urethra, submitting the patient to at least 3 procedures 6 months apart if the urethra was divided. If the urethra is not divided, either way of lengthening the urethra can be done in one surgery.
Types of grafts to cover corporotomies
Most of the literature on ventral grafting comes from hypospadias patients and not from CPC patients. Almost all of the data concerns covering a single large ventral corporal defect — sometimes greater than 180 degrees– with either a graft or a flap. Papers describing long-term outcomes with 3 ungrafted corporotomies are rare.
With regards to the different grafts, the Miami group had great success with a 1 layer SIS, but the Indiana group had issues with the 4 layers SIS. Braga reported bad results using a dura graft but great results using a tunica vaginalis vascularized flap. The animal models seem to suggest that the graft or flap material eventually gets reabsorbed and replaced with tunica albuginea-like tissues. From this, I conclude that the main purpose of the graft or flap is to prevent bleeding and not to replace the tunica albuginea.
Most of the evidence does not show issues with erections long-term. However, a recent paper by Dr. Husmann from the Mayo Clinic in Rochester looked at 100 consecutive adults (18-40 years of age) who were evaluated for penile problems after hypospadias repair in childhood. He found a 37% incidence of moderate to severe erectile dysfunction. Among the 10 patients who have had a corporotomy with grafting, there was a 90% incidence of erectile dysfunction. (I have a great appreciation for Dr. Husmann’s work since he has been steadily collecting prospective data for much longer than anyone else in our field. His studies and observations have provided pediatric urologists with perspectives that cannot be ascertained when only looking at short-term data).
If one decides to shorten the penis, it appears that the Yachia procedure – pairs of longitudinal incisions in between the dorsal vein and paired arteries closed in a Heineke-Mikulics fashion with absorbable suture—provides the highest success rate, with fewer suture related problems, compared to Nesbits or 16-24 dots plications. The procedure has a low chance of affecting the NVB and of causing erectile dysfunction but does shorten the penis anywhere from 1-3 cm, being bothersome in about 10% of patients.
Lengthening procedures have been less studied and done. When the urethra is divided, these procedures can potentially be associated with greater morbidity, given the potential 2-3 procedures, use of catheters postoperatively, etc. Lengthening procedures do appear to be more successful than shortening procedures and do not seem to be associated with erectile dysfunction in the short term –but new evidence suggests there could be problems in the long term. The price thus for avoiding shortening and having a more reliable surgery is having 3 surgeries, all of them with catheters for 5-7 days, and possibly higher risk of erectile dysfunction.