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Geometrical modified nesbit corporoplasty to correct different types of penile curvature: description of the surgical procedure based on geometrical principles and long-term results

Abstract

We present the use of a modified corporoplasty, based on geometrical principles, to determine the exact site for the incision in the tunica or plaque and the exact amount of albuginea for overlaying to correct with extreme precision the different types of congenital or acquired penile curvature due to Peyronie’s disease. To describe our experience with a new surgical procedure for the enhancement of penile curvature avoiding any overcorrection or undercorrection. Between March 2004 and April 2013, a total of 74 patients underwent the geometrical modified corporoplasty. All patients had congenital curvature until 90° or acquired stable penile curvature ‘less’ than 60°, that made sexual intercourse very difficult or impossible, normal erectile function, absence of hourglass or hinge effect. Preoperative testing included a physical examination, 3 photographs (frontal, dorsal and lateral) of penis during erection, a 10 mcg PGE1-induced erection and Doppler ultrasound, administration of the International Index of Erectile Function (IIEF-15) questionnaire. A follow-up with postoperative evaluation at 12 weeks, 12 and 24 months, included the same preoperative testing. Satisfaction rates were better assessed with the use of validated questionnaire such as the International Erectile Dysfunction Inventory of the Treatment Satisfaction (EDITS). Statistical analysis with Student’s t-test was performed using commercially available, personal computer software. A total of 25 patients had congenital penile curvature with a mean deviation of 46.8° (range 40–90), another 49 patients had Peyronie’s disease with a mean deviation of 58.4 (range 45–60). No major complications were reported. Postoperative correction of the curvature was achieved in all patients (100%). Neither undercorrection nor overcorrection were recorded. No significant relapse (curvature>15°) occurred in our patients. Shortening of the penis was reported by 74% but did not influence the high overall satisfaction of 92% (patients completely satisfied with their sexual life). The erectile function was analyzed in both groups, Student’s t-test showed a significant improvement in erectile function, preoperative average IIEF-15 scores were 17.43±4.67, whereas postoperatively it was 22.57±4.83 (P=0.001). This geometrical modified Nesbit corporoplasty is a valid therapy which allows penile straightening. The geometric principles make the technique reproducible in multicentre studies.

Introduction

Penile curvature is a common disease usually divided into congenital curvature and acquired curvature due to Peyronie’s disease.

Peyronie’s disease is a fibrotic wound-healing condition of the tunica albuginea that results in penile deformity, curvature, hinging, narrowing and shortening, penile pain, and in some cases, erectile dysfunction.1, 2, 3 Although a lot of non-surgical options have been proposed, none to date offer a trustworthy and effective correction of the penile curvature. As a result, surgery remains the gold standard treatment option, ensuring the faster and trustworthy treatment.4

Nesbit procedure or tunica albuginea plication are the recommended methods of straightening for patients with adequate rigidity and less severe deformity described as curvature <60° without narrowing/hinging.5, 6, 7 Patients who have more serious, complex Peyronie’s disease, with curves of >60° but maintaining good preoperative erectile function should be submitted to a straightening consisting in plaque incision or partial excision and grafting.5, 6, 7 In the end, for those patients who have erectile dysfunction and Peyronie’s disease, penile prosthesis placement with straightening procedure is the best method to cure both diseases.5, 6, 8, 9

The aim of this article is to present the use and advantages of a modified Nesbit corporoplasty, based on geometrical principles, to correct with precision different types of congenital penile curvature until 90° or acquired penile curvature due to Peyronie’s disease with a curvature <60°, not only to determine the exact site for the incision in the tunica or plaque avoiding traumatism of Allis clamps, but also to calculate the exact amount of tunica albuginea for overlaying, so that the longer side is as long as the shorter side and obtain a perfect penile straightening.

At the end of this geometrical corporoplasty, complete penile straightening is obtained, with the longer side (convex side) having been corrected to the same length as the shorter side (concave side).

AIMS

To describe our experience with a new surgical procedure for the correction of penile curvature that combines the advantages of corporoplasty based on geometrical principles and underlap technique, and avoiding overcorrection and undercorrection.

Materials and methods

Patient Population

Between March 2004 and April 2013, a total of 74 patients underwent the geometrical modified corporoplasty.

A meticulous sexual and medical history was obtained, including the duration and progression of disease, erectile function, use of medical drugs and previous penile trauma.

All patients had congenital curvature or acquired stable penile curvature >60° that makes sexual intercourse very difficult or impossible, normal erectile function, absence of hourglass or hinge effect.

A preoperative evaluation included:

- a physical examination

- 3 photographs (frontal, dorsal and lateral) of penis during erection to evaluate penile curvature 10

- a 10 mcg PGE1-induced erection and Doppler ultrasound to evaluate penile curvature and erectile function

- administration of the International Index of Erectile Function (IIEF-15) questionnaire, a 15-item,11 self-administered questionnaire for the assessment of erectile function. Five factors or response domains were identified: erectile function; orgasmic function; sexual desire; intercourse satisfaction; and overall satisfaction.

All patients provided an informed consent including the functional and aesthetic improvement, the presence of recurrent or residual curvature, penile shortening, palpable sutures and erectile dysfunction.

Surgical technique

The penis was degloved after a circumcision incision. A tourniquet was placed at the root of penis.

A full erection has been induced by saline injection through the glans using a 21 G needle, to determine the point of maximum penile curvature.

In cases of ‘ventral’ curvature, Buck’s fascia and its neurovascular bundles were dissected from the tunica albuginea to expose the tunica albuginea at the point of maximal curvature, incisions were made in Buck’s fascia laterally on each side of the penile shaft and the neurovascular bundles were minimally mobilized longitudinally and minimally elevated towards the midline using a Babcock clamp (Figure 1).

Figure 1
figure1

The transverse incisions of albuginea are made in the dorsal region near the intercavernosal septum, one in the right corpora cavernosa and the other on the left.

Then the surgical procedure then was performed as follows:

  1. 1

    Two tangential lines to the penile axis were established and drawn with a dermographic pen, while erection was being induced and maintained (X–X′and Y–Y′; Figure 2);

    Figure 2
    figure2

    Geometrical principles applicated to ‘ventral’ curvature. (a) Two tangential lines to the penile axis are established and drawn. From the point of maximum curvature (Z) a circumferential line at the bisectrix of the angle formed by the two tangential lines (X–X′ and Y–Y′) is established and drawn. (b) Two perpendicular lines to the penile axis are established and drawn with a dermographic pen (A–A′ and B–B′) on the straight penile segments (outside the area of curvature), to measure the difference in length between the long (convex) and the short (concave) side of the penis. (c) The amount of the albuginea tissue for overlaying obtained from the difference between the length of the convex and the concave sides (difference (W) between A–B and A′–B′) is established and drawn with a dermographic pen having the middle the circumferenzial line at the bisectrix (Z).

  2. 2

    From the point of maximum curvature (Z) a circumferential line at the bisectrix of the angle formed by the two tangential lines (X–X′and Y–Y′) was established and drawn with a dermographic pen (Figure 2);

  3. 3

    Two perpendicular lines to the penile axis were established and drawn with a dermographic pen (A–A′ and B–B′) on the straight penile segments (outside the area of curvature), to manually calculate and measure the exact amount of tunica albuginea plication to obtain a penile straightening, this amount corresponded to the difference in length between the long (convex) and the short (concave) side of the penis (Figure 2b);

The amount of the albuginea tissue for overlaying obtained from the difference between the length of the convex and the concave sides (difference (W) between A–B and A′–B′) were established and drawn with a dermographic pen having the middle the circumferential line at the bisectrix (Z; Figure 2c).

Once the position of the circumferential line, (Z), and the exact amount of albuginea necessary for the overlay was determined, two transverse incisions of albuginea were made in the dorsal region near the intercavernosal septum or towards the 12 o’clock position. These incisions were symmetrical on either side of the midline, one in the right corpus cavernosum and the other on the left (Figure 3).

Figure 3
figure3

Geometrical principles applicated to ‘lateral’ curvature

After the albuginea of the right and left corpora have been incised (Figures 1 and 4), tunical dissection from the spongy tissue of the cavernosal body was performed on the proximal tunica, the underlying cavernosal tissue was meticulously mobilized, first sharply and then bluntly, (the upper albugineal flap is free from the cavernosus tissue and is about to overlap the lower flap which is not free from the cavernosus tissue; Figures 5 and 6).

Figure 4
figure4

The transverse incisions of albuginea are made in the dorsal region near the intercavernosal septum, one in the right corpora cavernosa and the other on the left.

Figure 5
figure5

Underlying cavernosus tissue is separated first with scissors then with a small sponge to get proximal and distal-free albuginea flaps.

Figure 6
figure6

Underlying cavernosus tissue is separated first with scissors then with a small sponge to get proximal and distal-free albuginea flaps.

Then modified Nesbit corporoplasty was performed, four interrupted 2-0 polygycolic acid sutures were placed asymmetrically in a U shape with the maximum overlaying towards the midline or 12 o’clock (Figures 7 and 8). After the four sutures have been placed, corporoplasty was completed using a 2-0 running polygycolic acid suture on the free edges of the albuginea to allow the reduction of bleeding from corpora cavernosa. The same operative steps were performed for the left corpora cavernosa.

Figure 7
figure7

Modified Nesbit corporoplasty is performed, four or five interrupted 2-0 polygycolic acid suture sutures are placed in a U shape.

Figure 8
figure8

Modified Nesbit corporoplasty is performed, four or five interrupted 2-0 polygycolic acid suture sutures are placed in a U shape.

At this point of procedure, a full erection was induced by injection of saline solution to check that the curvature has been completely corrected.

At the end of corporoplasty, Buck’s fascia was closed with 3-0 rapid polyglycolic acid suture, then an aspirative drainage was placed. The penis was re-gloved, the foreskin was removed and the incision was closed.

In cases of ‘dorsal’ curvature the technique is similar (Figures 9a and b, Figure 10) with the following differences: the two transverse incisions of albuginea are made in the para-urethral region, on both side of the urethra without mobilizing the urethra itself, one in the right corpora cavernosa and the other on the left with the maximum overlaying at midline or towards 6 o’clock (Figure 9c).

Figure 9
figure9

Geometrical principles applicated to ‘dorsal’ curvature.

Figure 10
figure10

Geometrical principles applicated to ‘dorsal’ curvature.

At the end, ‘lateral’ curvatures are corrected using the same technique (Figures 11a and b, Figure 3), in this case only one transverse incision of albuginea is necessary and performed on the controlateral, convex side of penis (Figure 11c).

Figure 11
figure11

(ac). Geometrical principles applicated to ‘lateral’ curvature.

Follow-up: main outcome measures

A follow-up with postoperative evaluation, at 12 weeks, 12 and 24 months, include the same criteria as preoperative testing.

The parameters considered for the outcome analysis were divided into early and long-term postoperative outcome.

The early outcome include: correction of deviation, undercorrection or overcorrection, minor complications (wound infection, hematoma and neurological impairment) and major complications requiring surgical revision (hematoma and paraphimosis).

The long-term outcome include: significant recurrence (curvature >15 degrees), shortening of the penis, palpable subcutaneous indurations, erectile function and patient overall satisfaction, the satisfaction rates were better assessed with the use of validated questionnaire such as the International Erectile Dysfunction Inventory of the Treatment Satisfaction (EDITS).

This aspect was also evaluated with the question, ‘Would you undergo the same surgical procedure again if you could come back after having known the outcome?’.12

Statistical analysis with Student’s t-test was performed using commercially available, personal computer software.

Results

The characteristics of our patients are shown (Table 1), a total of 25 patients had congenital penile curvature with a mean deviation of 46.8° (range 40–90), another 49 patients had Peyronie’s disease with a mean deviation of 58.4 (range 45–60). Mean age was 22.4 (range 17–26) for patient with congenital penile deviation, and 57.6 (range 53–68) for patients with Peryonie’s disease.

Table 1 Patient characteristics

A follow-up with postoperative evaluation, at 12 week, 12 and 24 months, was assessed.

No major complications like hematomas or neurovascular bundle lesions were reported.

Only a postoperative transient sensory change including sexual sensation were reported in 1% of patients.

All the patients were discharged home the day after surgery.

The patients had no postoperative infection, with normal resumption of sexual activity after 6–8 weeks (Table 2).

Table 2 Early postoperative outcome and satisfaction

Postoperative correction of the curvature was achieved in all patients (100%; Table 2).

Neither undercorrection nor overcorrection were recorded.

During the follow-up carried out 24 months after the surgery in all patients, the following long-term outcome has been shown (Table 3).

Table 3 Long-term outcome and satisfaction (follow-up 24 months)

No significant relapse (curvature>15°) occurred in our patients (Table 3).

Shortening of the penis was reported by 74% but did not influence the high overall satisfaction of 92% (patients completely satisfied with their sexual life; Table 3).

Palpable subcutaneous indurations were reported by 4 patients (5%; Table 3).

The erectile function was analyzed in both groups, none of the patients complained about the worsening of erectile dysfunction (Table 3), Student’s t-test to compare the mean difference between the preoperative and postoperative IIEF-15 scores revealed that the mean IIEF-15 erectile domain score increased from 17.43±4.67, whereas postoperatively it was 22.57±4.83, showing a significant improvement in erectile function (P=0.001; Table 4).

Table 4 Comparison of preoperative and postoperative IIEF-15

Discussion

Several procedures for the correction of congenital and acquired penile curvature have been proposed. Reconstructive surgery for penile curvature is composed of: either shortening the convex side of the penis (Nesbit corporoplasty or plication procedures) indicated to correct curvature <60°, or lengthening the concave side (incision and grafting) indicated to correct curvature >60°.13, 14, 15, 16

Shortening procedures – Nesbit vs plicational corporoplasty – incision vs excision of albuginea

There are no prospective randomized studies comparing the different techniques.

Plicational corporoplasty, respect to Nesbit corporoplasty, avoiding the excision of tunica albuginea might ensure a less invasive procedure to correct penile curvature,12 with a less postoperative bleeding with hematoma, erectile dysfunction and percentage of overcorrection or undercorrection.17

Nesbit procedure compared with a plication technique offers a better correction of the deviation.18 Plication procedures had a higher percentage of relapses and recurrence after plication respect to the Nesbit corporoplasty, most likely as a consequence of an insufficient tensile strength of the plications.18, 19, 20, 21

The procedures of tunical plication with horizontal incisions, avoiding excision of albuginea, reported a lowered recurrence rate compared with simple plication procedures, similar results are reported with the underlap technique by means of U-shaped incisions that allows an increase tensile strength.21

Lenghtening procedures

Surgical grafting techniques include partial plaque excision or plaque incision.

Modified H or double-Y incisions usually are made in the area of maximum curvature.22

As described in literature, it is possible to perform a single penile incision based on geometrical principles, indicated to correct any penile curvature especially ‘more’ than 60°.

At present, this surgical technique uses geometrical principles to define the exact point of incision on the penile tunica albuginea, to create a rectangular-shaped defect that will be more effectively substituted by a heterologous graft; geometrical calculations allow the exact ‘length’ as well as the exact ‘width’ of the defect to be determined.

At the end of the procedure, complete penile lengthening and straightening are obtained, with the shorter side (concave side) having been corrected to the same length as the longer side (convex side).23

Penile straightening was achieved in 63–100%, the reported patient satisfaction rate ranges from 41 to 96%, erectile dysfunction is reported in 0–35%, depending on the graft material recurrence of curvature can be seen from 0 to 16%.24, 25

Characteristics of the geometrical modified nesbit corporoplasty

We presented our experience with a new geometrical modified corporoplasty based on geometrical principles.

The present technique is based on a transverse incision in the tunica albuginea and/or plaque, it may be used to correct all types of congenital or acquired curvature due to Peyronie’s disease <60°. Inducing a full erection is crucial for accurately applying these geometrical principles and consequent identification of the exact site for the tunical incision and following overlaying. The difference between the long and short sides, that will define the amount of albuginea to overlay, can be measured between any two points on the straight portions of the penis, because it will always be the same.

When geometrical principles and induced erection are correctly applied, the amount of tunica albuginea to overlay can be calculated before the incision is made, avoiding undercorrection or overcorrection, simplifying the surgical correction of any curvature and providing enhance precision to the correction of the curvature.

The procedure is performed without applying Allis clamps on the tunica albuginea so that we avoid the possible traumatism on the tunica albuginea due to re-adjustment of Allis clamps to find the correct placement and appropriate site until the penis is completely straightened, this is very important especially in young patients with congenital penile curvature.26

As described by other authors21 avoiding excision of the tunica albuginea might reduce invasiveness, this is one of the advantages of our technique.

Moreover, as no tunical tissue was excised but only overlayed, any undercorrection or overcorrection, could easily be corrected intraoperatively.

Undercorrection can be righted by getting more tissue to overlaying with the running suture or cutting previous U-shaped sutures and placing new sutures, since the albuginea has not been excised, as is done instead in Nesbit’s procedure. The same adjustment applies for overcorrection.

No major complications like hematomas or neurovascular bundle lesions were reported.

Only a postoperative transient sensory change including sexual sensation were reported in 1% of patients (2 patients with ventral curvature of 60° due to Peyronie disease).

In our patients, postoperative correction of the curvature was 100%.

Neither undercorrection nor overcorrection were recorded.

No significant recurrence (curvature >15°) occurred only in our patients, this finding is lower than after plication or Nesbit’s procedures,19, 20, 21 probably because a high tensile strength can be achieved by forming double layers of tunica albuginea by means of the overlaying technique similarly to results of other authors.21

Shortening of the penis was reported by 74% but did not influence the high satisfaction rate of 92%.

We want to stress that, as shortening is a consequence of all kinds of Nesbit variants, detailed informed consent is crucial.27

Of all patients, anyone reported erectile dysfunction, mean IIEF-5 erectile domain score increased from 17.43±4.67, whereas postoperatively it was 22.57±4.83, showing a significant improvement in erectile function (P=0.001).

This is a surprising result in contrast with results reported by Schwarzer et al. probably due to the fact that in our procedure only the superior flap is meticulously freed from the corpus cavernosum, without mobilizing and compromising spongy tissue in the inferior flap, the damage of the spongy tissue underneath the tunica could induce the erectile dysfunction, techniques such as the stage or TAP technique avoid this potential problem since they excise only the outer layer of the tunica without compromising spongy tissue, on the other hand we added that it is not always so easy and possible to distinguish outer layer from the inner one and excise only the outer layer of the tunica albuginea, especially in patient affected by Peryonie’s disease in which the tunica is compromised.26 Moreover the disadvantage of stage technique is that it could only be performed in patients with congenital penile curvature, whereas our geometric corporoplasty does not have such limit.

Finally, the high rates of complete penile straightening achieved, as well as the preservation of erectile function and overall patient satisfaction, show that using the Geometrical Modified Nesbit Corporoplasty is no inferior to any other procedure that has been published so far.26

Conclusions

This geometrical modified Nesbit corporoplasty could be a recommended procedure which allows the correction of congenital penile curvature until 90° or the acquired curvature <60° caused by Peyronie’s disease. It allows solid and tight closure of albuginea defects, low morbidity, obtaining a perfect straightening of the penis.

The most important part of the procedure is determining the exact location for placement of the sutures within the tunica so as to create the appropriate under laying and correction of the curvature.

The present technique allows for the standardization of a transverse tunical incision procedure that may be reproducible in multicentre studies.

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Vicini, P., Di Nicola, S., Antonini, G. et al. Geometrical modified nesbit corporoplasty to correct different types of penile curvature: description of the surgical procedure based on geometrical principles and long-term results. Int J Impot Res 28, 209–215 (2016). https://doi.org/10.1038/ijir.2016.28

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