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

  • Marco BandiniEmail author
  • Sasha Sekulovic
  • Bogdan Spiridonescu
  • Pramod Krishnappa
  • Anuj Deep Dangi
  • Milan Slavkovic
  • Vladislav Pesic
  • Andrea Salonia
  • Alberto Briganti
  • Francesco Montorsi
  • Rados Djinovic
Original Article

Abstract

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.

Keywords

Hypospadias Penile curvature Pediatric urology Chordee Referral Center 

Abbreviations

PC

Penile curvature

DP

Dorsal plications

BMG

Buccal mucosa graft

IQR

Interquartile ranges

ULR

Univariable logistic regression

MLR

Multivariable logistic regression

DSD

Disorders of sex development

Notes

Acknowledgements

We thank all the employees of the BelMedicGeneral Hospital for their support. I also personally thank Dr. Mosca Beatrice for her help drawing the steps of dorsal plications that are visible on Supplementary Fig. 4.

Author contributions

MB protocol/project development, data collection or management, data analysis, manuscript writing/editing. SS data collection or management, manuscript writing/editing. RD manuscript writing/editing, protocol/project development. BS manuscript writing/editing. PK manuscript writing/editing. VP data collection or management. FM protocol/project development. ADD manuscript writing/editing. MS data collection or management. AB protocol/project development. AS protocol/project development.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. During my stay at the Sava Perovic Foundation I was granted by the European Urological Scholarship Programme (EUSP).

Compliance with ethical standards

Conflict of interest

The authors have stated that they have no conflict of interest.

Supplementary material

345_2019_2961_MOESM1_ESM.jpg (112 kb)
Supplementary Fig. 1. Geometrical system for assessing the severity of PC. First, we outlined the ideal axis of the penis in erection based on the anatomical conformation of the patient (this axis is drawn approximately ± 10 degree of angulation from the ideal axis perpendicular to the body of the patient). Second, we designed lines for every axes of curvature. Third, we calculated the angle from ideal axis and the axis of the maximal bending point. In this example, the baseline axis of the penis (green line) is oriented 10 degrees over the perpendicular axis (which is acceptable according to our definition). From that axis, the penis draws three additional axes of curvature (yellow lines), that have a maximum angulation of 32° starting from the baseline axis. Thus, the calculated curvature of that penis is 32°. In consequence, this system is based on geometrical but also physiognomic evaluation of the penile curvature. If we have taken an ideal perpendicular (to the body of the patient) axis as baseline axis (for example the first yellow line from the right), probably the resulting degrees of curvature would have been smaller than the one calculated in this example. However, using this second axis as reference for correction, the penis would have resulted with an unsolved curvature at the basis with worse aesthetic result
345_2019_2961_MOESM2_ESM.jpg (987 kb)
Supplementary Fig. 2. The current figure shows a curvature correction procedure in a failed hypospadias patient, who underwent one-stage repair using TIP-Mathieu technique. A) Aspect of the penis before the operation, with a noteworthy PC caused by fibrotic healing, short ventral skin and fibrosis of the corpora. B) After full degloving and excision of the fibrotic collar at the basis of the penis, we evaluated the PC, which appeared to be approximately 30°. C) We then opened the Buck fascia and we lifted the neurovascular bundle mono-laterally. D) We marked the point of the maximum bending, and the midline of the corpora to facilitate the orientation during the plications. E) We plicated the penis with 5-0 PDS stiches. F) After repeating the artificial erection, we found a residual PC of approximately 10°. G) We then added another line plication at more proximal level. H) The PC was subsequently re-evaluated showing a full straightening. I) Finally, we closed the Buck fascia
345_2019_2961_MOESM3_ESM.jpg (1.2 mb)
Supplementary Fig. 3. The current figure shows the steps for correction of a severe penile curvature (> 60°) in a patient underwent two-stage procedure. A) Aspect of the penis before surgery. B) Short urethra has been transected and a full degloving performed. C) PC has been checked revealing a severe bending (> 60°). D), E), F) Ventral-tunica attenuations have been performed on the ventral side of the tunica albuginea. G) Redundant well-vascularized Dartos was placed over the incisions. H) BMG was placed over the Dartos and then I) quilted with absorbable stiches (6-0 polyglactin 910)
345_2019_2961_MOESM4_ESM.pdf (1 mb)
Supplementary Fig. 4. The drawing illustrates our procedure for dorsal plication: The exposure of the dorsal surface of the corpora has reached after lifting the neurovascular bundle. The midline axis is marked, as well as the points of maximal bending (transverse line). We cut transversally the tunica albuginea (only the superficial layer) and then we suture it with 5-0 PDS. Four to five knots are usually necessary for each line of plication
345_2019_2961_MOESM5_ESM.docx (12 kb)
Supplementary material 5 (DOCX 12 kb)
345_2019_2961_MOESM6_ESM.docx (17 kb)
Supplementary material 6 (DOCX 17 kb)
345_2019_2961_MOESM7_ESM.docx (12 kb)
Supplementary material 7 (DOCX 11 kb)

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Marco Bandini
    • 1
    • 2
    Email author
  • Sasha Sekulovic
    • 1
  • Bogdan Spiridonescu
    • 1
  • Pramod Krishnappa
    • 3
  • Anuj Deep Dangi
    • 4
  • Milan Slavkovic
    • 1
  • Vladislav Pesic
    • 1
  • Andrea Salonia
    • 2
  • Alberto Briganti
    • 2
  • Francesco Montorsi
    • 2
  • Rados Djinovic
    • 1
  1. 1.Sava Perovic Foundation, Center for Genito-Urinary Reconstructive SurgeryBelgradeSerbia
  2. 2.Unit of Urology, Urological Research Institute (URI)IRCCS San Raffaele Hospital, Vita-Salute San Raffaele UniversityMilanItaly
  3. 3.Department of UrologyNU HospitalsBangaloreIndia
  4. 4.Department of UrologyChristian Medical College and HospitalVelloreIndia

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