Penile Torsion Research Articles

Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias.

Transverse preputial onlay island flap urethroplasty (TPOIF) was described initially for distal hypospadias, but has seen extended application for proximal hypospadias. We describe a set of modifications in the technique and results in a large series of proximal hypospadias. All children who underwent TPOIF repair for proximal hypospadias (proximal penile, penoscrotal and scrotal) from June 2006 to June 2013 by a single surgeon were prospectively followed till June, 2014. A standard technique and postoperative protocol were followed. Salient points to be emphasized in the technique: (1) dissection of the dartos pedicle till penopubic junction to prevent penile torsion, (2) incorporation of the spongiosum in the urethroplasty, (3) midline urethral plate incision in glans (hinging the plate), (4) Dartos blanket cover on whole urethroplasty. Out of 136 children with proximal hypospadias, 92 children who underwent TPOIF formed the study group. Out of 92 children, 48 (52%) children required a tunica albuginea plication for chordee correction. In total, 16 (17%) patients developed 24 complications and 11 children (12%) required second surgeries: fistula closure in 7 (with meatoplasty in 5), glansplasty for glans dehiscence in 2 and excision of diverticulum in 2. Two children required a third surgery. Only 5 children had a noticeable penile torsion (less than 30 degree), and 7 had a patulous meatus. Transverse preputial onlay island flap urethroplasty can deliver reliable cosmetic and functional outcomes in proximal hypospadias.

Correlation of severity of penile torsion with type of hypospadias & ventral penile curvature and their management

ObjectiveThis study was carried out to evaluate the correlation between the severity of penile torsion on the one hand and the degree of ventral penile curvature and the type of hypospadias on the other. We also assessed the effectiveness of correction of chordee and torsion by penile degloving and mobilization of the urethral plate and the corpus spongiosum. Patients and methodsThis prospective study included 116 patients with hypospadias and penile torsion out of a total of 376 primary hypospadias cases seen between January 2006 and June 2013. The patients’ age ranged from 8 months to 26 years with a mean age of 8.37 and a median age of 6.4 years. Prior to surgery the type of hypospadias as per location of the meatus, the presence or absence of chordee, the size of the dorsal hood and deviation of the median raphe on the dorsal hood were noted. The torque of the penile shaft (torsion) toward either side of the midline and ventral curvature was measured using a sterile small protractor around the penile shaft. The techniques used for the correction of penile torsion and chordee were penile degloving and mobilization of the corpus spongiosum with the urethral plate and the urethra. ResultsThe abnormal penile rotation ranged from 15° to 110° (average 51.98°). In 70.69% of the patients the torque was on the left side, while it was on the right in 29.31%. 11.2% of the patients had a severe torque, while it was moderate in 37.94% and mild in 50.86% of the cases. The mean torque was 62.38°±23.03° in patients with distal penile (80 cases), 38.04°±18.50° in patients with mid penile (24 cases) and 18.25°±3.33° in patients with proximal penile hypospadias (12 cases) (P value=0.001). Ventral curvature was seen in 71 cases. Mean ventral curvature was 38°±18.55°, 44.28°±21.11° and 73.58°±32.96° in patients with distal penile, mid penile and proximal hypospadias, respectively (P value=0.001). The procedures of choice for the repair of penile torsion were penile degloving in 11% of the cases, mobilization of the urethral plate and the corpus spongiosum in 28% of the cases, mobilization of the proximal urethra in 40% of the cases and mobilization of the urethral plate into the glans in 21% of the cases. Chordee could be corrected using penile degloving and mobilization of the urethra/urethral plate in all cases. ConclusionsPenile torque is more common and severe in distal hypospadias, while ventral curvature is seen more often in proximal hypospadias. The degree of torsion is inversely proportional to the severity of ventral curvature. Techniques for the repair of penile torque and ventral curvature include penile degloving and mobilization of the urethral plate with the corpus spongiosum and the urethra.

Benign penile skin anomalies in children: a primer for pediatricians.

Abnormalities involving the skin coverage of the penis are difficult to define, but they can significantly alter penile appearance, and be a cause of parental concern. The present review was based on a nonsystematic search of the English language medical literature using a combination of key words including "penile skin anomalies" and the specific names of the different conditions. Conditions were addressed in the following order, those mainly affecting the prepuce (phimosis, balanitis xerotica obliterans, balanitis, paraphimosis), those which alter penile configuration (inconspicuous penis and penile torsion), and lastly focal lesions (cysts, nevi and vascular lesions). Most of these anomalies are congenital, have no or minimal influence on urinary function, and can be detected on clinical examination. Spontaneous improvement is possible. In the majority of cases undergoing surgery, the potential psychological implications of genital malformation on patient development are the main reason for treatment, and the age generally recommended for surgery is after 12 months of age. This review provides the pediatrician with a handy tool to identify the most common penile skin anomalies, counsel parents adequately, make sensible and evidence based choices for management, and recognize complications or untoward outcomes in patients undergoing surgery.

A penile torsion with a fistula due to previous hypospadias surgery: A case report

We presented a case of penile torsion due to previous hypospadias surgery. A patient applied to our clinic for treatment of hypospadias fistula and accompanying penile torsion. Patient's urethral fistula was repaired first and penile torsion was corrected in the second stage due to multiple fistula tracts. Proximal based flip flap technique was used for closure of the fistula and simple degloving with release of fibrous tissue and pedicle of the previous preputial island flap was used for correction of the penile torsion. Post hypospadias surgery torsion deformity as in our case may corrected with simple degloving and dissection at the level of the buck fascia.

Jarcho-Levin syndrome with association of unilateral pulmonary hypoplasia and diastometamyelia: A case illustration.

Sir, Jarcho–Levin syndrome (JLS) is a rare distinctive form of short-trunk dwarfism with rib and vertebral anomalies. This is the first case of a newborn exhibiting an unusual combination of spondylothoracic and spndylocostal JLS with lung anomaly and diastematomyelia to be reported. A new born (1-day-old) male baby, born by Lower segment Caesarean section (indication was nonprogression of labor), birth weight 2.35 kg, first child of nonconsanguinous marriage, was referred to our tertiary care hospital with multiple anomalies and recurrent episodes of cough, cold, vomiting after feeds, and rapid breathing. On examination, the baby was afebrile, with tachycardia, and tachypnea (32 per min). Head circumference was 35 cm, short stature (length is 37 cm), short neck, anteverted nares and dysmorphic features (low-set ears, hypertelorism, high-arched palate, short upper segment). Distal penile hypospadias with chordee and penile torsion, bifid scrotum, hypertrophy of left hemiscrotum were also present. On further examination, abdomen was distended with visible bowel loops. Imperforate anus and anal pit was noted. Spinal examination showed scoliosis in thoracolumbar region with curvature to right along with sacral agenesis, left calcaneovalgus, and over-riding of feet. Chest radiography showed fusion and fanning of ribs [Figure 1a and b]. Milks scan [Figure 1c] was performed due to vomiting after feeds and images revealed no evidence of gastroesophageal reflux. Computed tomography of thorax showed hypoplastic left lung. MRI spine [Figure 2] showed severe kyphoscolotic deformity of dorsolumbar spine, agenesis of sacral segments, multiple vertebral segmentation and fusion anomalies in the dorsolumbar region. Bifid ribs were noted. Cervical cord was normal. There was a low-lying cord, split at D5 level by fibrous bar, which is known as diastometamyelia. 99m Tc DTPA (diethylene triamine penta acetic acid) renogram was performed to look for any associated renal anomalies and revealed bilateral normally functioning kidneys [Figure 1d]. Based on the constellation of symptoms and imaging findings, JLS was suspected and was advised DNA isolation.Figure 1: (a) Chest radiography showing short neck, fusion, and fanning of bilateral ribs. (b) radiography of spine showed scoliosis in thoracolumbar region with curvature to right along with sacral agenesis. (c) 99m Tc sulphur colloid gastroesophageal (GE) scintigraphy (otherwise known as milk scan) was performed to look for any GE reflux disease and was confirmed to be negative. (d) 99m Tc DTPA (diethylene triamine penta acetic acid) renogram showed normally functioning, PUJ (pelviureteric junction) nonobstructed bilateral kidneysFigure 2: Magnetic resonance imaging and computed tomography spine: Images revealed severe dorsolumbar kyphoscoliosis, sacral agenesis, multiple vertebral segmentation and fusion anomalies, and bifid ribs. Patient also showed diastometamyelia at D5 level (arrow)JLS is a rare distinctive form of short-trunk dwarfism with rib and vertebral anomalies. This is the first case of JLS revealing a rare combination of both subtypes of JLS with lung anomaly and diastematomyelia the other case published from India showed diastematomyelia and spondylocostal dysostosis.[1] Hernias, neural tube defects and anomalies of the anal opening, urinary tract, external genitalia, uterus and lower limbs may be associated.[2] Recently, airway abnormalities have been described in two patients with the JLS similar to our case.[3] Malformations of the spinal cord with a separation into two hemicords have been termed “diastematomyelia,” which has been rarely reported in the literature, which is present in our patient. JLS has been divided into two major subtypes, that is, spondylothoracic dysostosis (“fan-like” or crab-like” rib) and spondylocostal dysostosis (vertebral anomalies with marked rib anomalies such as absent ribs, abnormal orientation, irregularity of shape and size, bifurcation, broadening, fusion). They are more often short statured than patients with spondylothoracic dysostosis and have twice their survival rate and have no associated neural tube defects. Both these subtypes of JLS are inherited as autosomal recessive traits, and exhibit a high mortality rate.

The contemporary role of 1 vs. 2-stage repair for proximal hypospadias.

This review discusses the most commonly employed techniques in the repair of proximal hypospadias, highlighting the advantages and disadvantages of single versus staged surgical techniques. Hypospadias can have a spectrum of severity with a urethral meatus ranging from the perineum to the glans. Associated abnormalities are commonly found with proximal hypospadias and encompass a large spectrum, including ventral curvature (VC) up to 50 degrees or more, ventral skin deficiency, a flattened glans, penile torsion and penoscrotal transposition. Our contemporary understanding of hypospadiology is comprised of a foundation built by experts who have described a number of techniques and their outcomes, combined with survey data detailing practice patterns. The two largest components of hypospadias repair include repair of VC and urethroplasty. VC greater than 20 degrees is considered clinically relevant to warrant surgical correction. To repair VC, the penis is first degloved—a procedure that may reduce or remove curvature by itself in some cases. Residual curvature is then repaired with dorsal plication techniques, transection of the urethral plate, and/or ventral lengthening techniques. Urethroplasty takes the form of 1- or 2-stage repairs. One-stage options include the tubularized incised urethroplasty (TIP) or various graft or flap-based techniques. Two-stage options also include grafts or flaps, including oral mucosal and preputial skin grafting. One stage repairs are an attractive option in that they may reduce cost, hospital stay, anesthetic risks, and time to the final result. The downside is that these repairs require mastery of multiple techniques may be more complex, and—depending on technique—have higher complication rates. Two-stage repairs are preferred by the majority of surveyed hypospadiologists. The 2-stage repair is versatile and has satisfactory outcomes, but necessitates a second procedure. Given the lack of clear high-quality evidence supporting the superiority of one approach over the others, hypospadiologists should develop their own algorithm, which gives them the best outcomes.

Penile rotation and penoscrotal transposition associated with hypospadias and bifid scrotum: A case report

Penoscrotal transposition is a rare anomaly of the external genitalia that can be complete or incomplete while incomplete type is more common. Penile torsion is a rotational defect of the penile shaft. Various surgical methods are described for correction of incomplete penoscrotal transposition and penile torsion. Here we are presenting our experience of case of incomplete penoscrotal transposition and penile torsion correction.

English

AIM: To study the comparative result of hypospadias repair by dividing the patients in two groups (a) hypospadias repair with waterproofing layer by one of the technique of hypospadias repair.(b) hypospadias repair without waterproofing, and evaluate the complication rates between these two groups especially in reference to incidence of urethrocutaneous fistula. MATERIAL AND METHODS: A prospective study done in the regional institute of surgery and pediatrics, M.L.B. Medical College, Jhansi during 2010 to 2013 with complain of location of urethral meatus on undersurface of penis i.e. hypospadias on 18 cases. RESULT: In the present study, most of our cases (83.33) were of less than 8 years of age. Most common type was middle hypospadias (50%), followed by proximal (27.77%) and distal (22.22%). Chordee was present in 66.66% of our cases.11.11% cases had penile torsion in pre-operative period. Asopa technique was used in cases with significant chordee and Snodgrass technique used in cases without significant chordee. Urethral plate was well formed and grooved in 66.66% cases, shallow in 27.77% cases and distorted in 5.55% cases. Waterproofing of neourethra was done in 55.55% cases, 44.44% cases were without Water proofing layer. Without Water proofing group had better cosmetic results(87.5%) than with Water proofing (70%) but more chances of metal stenosis and skin flap necrosis that leads to urethrocutaneous fistula formation. So Waterproofing decrease the chances of metal stenosis and skin flap necrosis

Correction of penile torsion and chordee by mobilization of urethra with spongiosum in chordee without hypospadias

ObjectiveTo investigate the feasibility of correcting coexistent penile torsion and chordee without hypospadias by mobilization of the urethra and spongiosum. Materials and MethodsA retrospective study of nine patients with simultaneous penile torsion and chordee without hypospadias was undertaken between January 2006 and December 2012. During this period, a total of 364 cases of hypospadias and 38 of chordee without hypospadias were operated on, making a total of 402 patients with hypospadias-related complexes. The same steps were used for correction of both torque and chordee. After a circumcoronal incision, the penis was fully degloved and the spongiosum with urethra was lifted up off the cavernosa. Next, mobilization of the hypoplastic urethra with spongiosum was extended into the glans. If chordee or torque persisted, urethral mobilization was performed proximally up to the bulbar urethra, as required. Spongioplasty and glansplasty were done and a per-urethral stent was kept in for three to five days. ResultsThe age of the patients ranged from 5 to 16 years (median 6 years). Penile torsion ranged from 30° to 120°, with a median of 75°. Ventral chordee ranged from 45° to 100°, with a median of 50°. A ratio of 1:9.6 was found for chordee without hypospadias compared to the total hypospadias cases, with an incidence of 9.5%. The ratio of chordee without hypospadias with torsion compared to the total hypospadias cases was 1:29. There was an incidence of chordee without hypospadias with penile torsion of 3.5% in all patients with hypospadias. The ratio of chordee without hypospadias with torsion to only chordee without hypospadias was 1:1.71, with an incidence of 37.0%. Every step contributed to the correction of curvature and torsion. Chordee was corrected in two patients by penile degloving and lifting of the spongiosa off the urethral plate; three patients required additional mobilization of the urethra into the glans. Another two patients needed proximal urethral mobilization and one required a dorsal plication. In five patients, torque was corrected by penile degloving, lifting of the spongiosa and mobilization of the urethra into the glans; four patients required further proximal urethral mobilization. All patients had excellent functional and cosmetic results. No residual chordee or torque was observed in any patient on follow-up at 12–24 months. ConclusionThe technique of distally mobilizing a hypoplastic urethra with spongiosum from the corpora into the glans, and proximally up to the bulbar region corrects moderate to severe chordee and torsion with excellent cosmetic results. The incidence of torsion with chordee without hypospadias was 3.5% of all cases of hypospadias.

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

ObjectiveTo evaluate the correction of different degrees of penile torsion following a ladder step so that simpler steps are used whenever possible. This can avoid the morbidity and complications of complex procedures. Patients and methodsCases of congenital and acquired penile torsion were repaired on a ladder step basis irrespective of the degree of torsion, starting with degloving and skin realignment, then a dorsal dartos flap and finally corporopexy. The torsion is checked with artificial erection after each step, and if corrected completely then the next step(s) is omitted. ResultsTwenty-five cases of penile torsion (30–180°) were repaired over a 4-year period. Three cases were corrected by degloving only, 12 by degloving and skin realignment, five by a dartos flap and four required a corporopexy. Postoperative complications included five cases of penile edema, one case of hematoma and one case of dorsal skin gangrene. Residual torsion of <15° occurred in three cases. No cases required redo surgery. ConclusionA ladder step approach is a good option for penile torsion repair, starting with simpler techniques until complete correction is achieved. There is no need to plan a complex procedure in advance.

Distal extension of the midline urethral-plate incision in the Snodgrass hypospadias repair: An objective assessment of the functional and cosmetic outcomes

ObjectivesTo objectively assess the functional and cosmetic outcomes of a modified tubularised incised-plate (TIP) urethroplasty (Snodgrass) technique, with particular attention to the uroflowmetry study and Hypospadias Objective Scoring Evaluation (HOSE) score. Patients and methodsIn a prospective case-series study, 43 consecutive patients with primary distal hypospadias were evaluated. The modified Snodgrass technique included an extension of the midline relaxing incision of the urethral plate from within the hypospadiac meatus to the very tip of the glans. The neourethra was tubularised starting at the neomeatus and proceeding proximally. The neourethra was covered with either a single or double dartos flap. In toilet-trained boys, at least 3months after surgery, the flow pattern, maximum (Qmax), and mean urinary flow rate (Qave) were recorded, and the results plotted against a recently published flow-rate nomogram from normal children. The postvoid residual urine volume was measured using ultrasonography. The cosmetic outcome was assessed using the HOSE system. ResultsThe native meatus was coronal in 11 (26%), subcoronal in 23 (53%) and distal penile in nine (21%) of the patients. The median (range) age was 4.2 (0.5–14) years. The neourethra was covered by a single dorsal dartos flap in 25 and a double dartos flap in 18 patients. At a median (range) follow-up of 6 (3–24) months, the uroflowmetry findings in 26 uncomplicated toilet-trained boys with a median (range) age of 5.2 (3.3–14) years showed an abnormal Qmax below the fifth percentile in four (15%), with the Qave above the fifth percentile in all. The flow pattern was bell-shaped in nine boys (35%), interrupted/intermittent in five (19%), slightly flattened in 10 (39%) and a plateau in two (8%). A vertical slit-like meatus located at the distal glans was created in 39 (91%) boys, and at the proximal glans in four (9%). The urinary stream was single and straight in 39 and angled in four patients. A straight erection was observed in 42 (98%) boys. Four patients had preoperative mild penile torsion of <45°, that was corrected by surgery. The mean (SD, range) HOSE score was 15.8 (0.6, 13–16). Two patients had a small, single subcoronal fistula. ConclusionExtending the midline urethral plate-incision in the modified Snodgrass repair to the apical part of the glans can be done safely with a high rate of locating the neomeatus at the glans tip, with no resultant meatal stenosis. The functional and cosmetic results of the procedure are good, but long-term data and comparative studies are required to confirm these results.

Dorsal onlay urethroplasty using buccal mucosa graft versus penile skin flap for management of long anterior urethral strictures: a prospective randomized study

Objective. The aim of this study was to compare the outcomes of dorsal onlay urethroplasty using buccal mucosa graft (BMG) versus penile skin flap (PSF) in the repair of long anterior urethral strictures. Material and methods. Patients with long anterior urethral strictures were randomized to receive either dorsal onlay BMG urethroplasty or PSF urethroplasty. All patients were evaluated preoperatively and during follow-up with the International Prostate Symptom Score (IPSS) and uroflowmetry. Success was reported when there were no obstructive symptoms on IPSS, with a peak urinary flow rate (Qmax) of at least 15 ml/s. Failure was reported in patients with obstructive symptoms, Qmax less than 15 ml/s and evidence of recurring stricture on urethrography. Results. The study included 19 and 18 patients in the BMG and PSF groups, respectively. The mean operative time was significantly shorter in the BMG than in the PSF group. The success rate was higher in the BMG than in the PSF group (89.5% vs 83.3%), but not statistically significant different. The PSF group included one case of extensive skin loss, three cases with superficial skin necrosis and two with minor penile torsion. In the BMG group, there were three cases of perioral numbness and another three had increased salivation. The incidence of troublesome postvoid urinary dribbling was significantly higher in the PSF than in the BMG group. After 6 months of urethroplasty, patient satisfaction was statistically significantly higher in the BMG than in the PSF group. Conclusions. BMG and PSF dorsal onlay urethroplasty had similar success rates. However, BMG is technically easier, takes less operative time and has a potential advantage in reducing postoperative morbidity, therefore leading to satisfaction for most patients.

Snodgrass urethroplasty for hypospadias repair: A retrospective comparison of two variations of the technique

The Snodgrass technique is a widely accepted method for hypospadias repair. In this paper, we compare two methods of performing this technique with respect to postoperative complications and outcome, with emphasis on meatal stenosis, fistula formation, residual chordee and penile torsion. We reviewed the results of 320 cases treated by Snodgrass urethroplasty between March 2007 and February 2012 at the maternity and children’s hospital of Almadinah Almunawwarah, Kingdom of Saudi Arabia. The two methods differed in the extent of urethral plate incision, the type of flap used and the degree of degloving of the penile skin. In group A (115 boys), the urethral incisions and the sagittal deep longitudinal incision were extended from the posterior edge of the hypospadiac meatus to the tip of glans, and the neourethra was covered by a dorsal preputual flap. In group B (205 boys), the urethral incisions and the deep longitudinal incision extended to the mid-glans, and the neourethra was covered by a lateral dartos flap. After tubularization of the urethral plate and a circumferential incision proximal to the coronal sulcus from each edge of the urethral plate, the penile skin was degloved from 1 cm proximal to the hypospadiac meatus in group A and to the penoscrotal junction in group B. The mean age of the children was 1.5 years. Complications occurred in 45 patients (14.1%). A urethrocutaneous fistula occurred in 8 patients (2.5%), with 6 in group A (5.2%) and 2 in group B (0.98%). Ten patients (3.1%) developed meatal stenosis, with 7 in group A and 3 in group B. Penile torsion was recorded postoperatively in 13 patients (total rate, 4.1%), with 9 cases in group A (7.8%) and 4 in group B (2.0%). The differences between the two groups were statistically significant. A shorter urethral plate incision, use of a lateral dartos flap to cover the neourethra and more extensive skin degloving in Snodgrass urethroplasty reduce the rate of complications.

Degloving and skin realignments or dorsal dartous flap technique in management of isolated penile torsion in pediatrics

Objective: To evaluate the proper technique used for management of penile torsion in pediatrics in relation to degree of torsion. Patients and methods: From February 2008 to December 2010, 54 patients were assessed for the degree of penile torsion at pediatric surgery center at Al-Khansaa Teaching Hospital in Mosul. The angle of torsion was assessed using a digital photograph of the penis and classified into three grades, Mild with 15 - 30 degree angle of torsion, moderate with 45-90 degree angle of torsion and sever with 100-170 degree angle of torsion. Two techniques were used for repairing the torsion, the degloving and skin realignment technique for the mild condition and dorsal dartous flap technique for the moderate and severe types. All operations were done as a day case procedure. No catheter used. Results: Forty five patients (83%) were discovered accidentally while assessing for circumcision or other problems, 30 patients (55%) were in the first year of life, 50 patients (93%) have a counter clock wise direction of torsion (to the left) while only 4 patients (7%) have a clockwise direction (to the right). Thirty five patients (65%) classified as mild torsion, while 16 patients (29.5%) have moderate degree of torsion and only 3 patients (5.5%) severe degree. Degloving and realignment of skin were used for the mild condition in 35 patients (65%) while dorsal dartous flap technique was confined for moderate (29.5%) and both procedures used for severe type patients (5.5%). Conclusion: Simple realignment technique during circumcision was enough to manage the mild degree, while in severe degree, dorsal dartous flap rotation seems to be more effective. There were no complications, and good cosmetic results were obtained. Keywords: Penile torsion, degloving, dorsal dartous flap.

424 Correlation of severity of congenital penile torsion with type of hypospadias and management by urethral plate with spongiosum/urethral mobilization

424 Correlation of severity of congenital penile torsion with type of hypospadias and management by urethral plate with spongiosum/urethral mobilization

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

ObjectivesTo evaluate the effectiveness of urethral mobilisation for correcting moderate and severe penile torsion associated with distal hypospadias. Patients and methodsNineteen patients with distal hypospadias and congenital moderate and severe penile torsion were treated surgically. The hypospadias was at the distal shaft, coronal and glanular in seven, eight and four patients, respectively, and six had mild chordee. The mean (SD, range) angle of torsion was 94.7 (19.9, 75–160)°. The urethra was mobilised down to the perineum. If the urethral mobilisation was insufficient the right border of the tunica albuginea was anchored to the pubic periosteum. The hypospadias was repaired using the urethral mobilisation and advancement technique, with a triangular plate flap for meatoplasty. The patients were followed up for 12–18months. ResultsAll patients had a successful functional and cosmetic outcome, with no residual torsion. Two patients had a small subcutaneous haematoma that resolved after conservative treatment. Massive oedema occurred in three patients and was treated conservatively. Urethral mobilisation did not correct the penile torsion completely. Although the mean (SD, range) angle of torsion was reduced to 86.1 (14.3, 65–130)°, statistically significantly different (P=0.001), it was not clinically important. The presence of chordee had no significant correlation with the reduction of penile torsion. ConclusionUrethral mobilisation cannot completely correct moderate and severe penile torsion but it might only partly decrease the angle of torsion. Periosteal anchoring of the tunica albuginea might be the most reliable manoeuvre for the complete correction of penile torsion.

Congenital prepubic sinus: A variant of epispadiac dorsal urethral duplication

Congenital prepubic sinus is a tract originating in the skin overlying the base of the penis. Its embryologic basis is still debated. We present a 9-month-old boy with a recurrent muco-purulent discharge from a tiny opening in the midline prepubic area on the base of the penis. Examination revealed a ventrally hooded prepuce, dorsal chordee, penile torsion to the left, and a 3-mm-diameter prepubic sinus 1 cm from the base of the penis. Histology of the excised tract showed a transitional epithelium. We believe our case is an epispadiac variant of dorsal urethral duplication.

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

PurposeTo compare the results of dorsal dartos flap rotation versus suturing tunica albuginea to the pubic periosteum for correction of congenital penile torsion. Patients and methodsSeventeen patients with congenital penile torsion were evaluated and managed from 2006 to 2010. On a random basis, 9 patients underwent surgical repair using a dorsal dartos flap rotation technique (group 1), and 8 patients by suturing tunica albuginea to the pubic periosteum (group 2). All were followed up every 6 months. ResultsThe mean age in group 1 was 52.3 ± 24.8 months, while in group 2 it was 53.4 ± 33.6 months. Mean follow up was 22.3 ± 10.2 and 21.5 ± 7.2 months in group 1 and group 2 respectively. Torsion was corrected in 6 (66.7%) patients of group 1; 3 (33.3%) had residual torsion < 10°. In group 2, correction was achieved in 6 (75.0%) patients and 2 (25.0%) had residual torsion < 10°. The mean operative time was significantly less for group 1 than for group 2: 45.3 ± 7.1 and 74.5 ± 5.3 min, respectively (P < 0.0001). ConclusionsIn short-term prepubertal follow up, both dorsal dartos flap rotation and suturing tunica albuginea to the pubic periosteum are effective for correction of congenital penile torsion. The former technique is easier to perform as it requires much less dissection.

Kutlay technique for hypospadias repair

Although many techniques have been described, new techniques with a wide range of therapeutic options are needed. The Kutlay technique is a novel technique that is based on the reconstruction of the neourethra with two horizontal meatal-based skin flaps. In the present study, the data of 31 patients who underwent surgery with the Kutlay technique are presented. Thirty-one patients with hypospadias with an average age of 5.6 years who did not have previous hypospadias repair were operated on with the Kutlay technique. Ten patients had chordee. Among those patients, three patients were circumcised. The patients were followed up for 4-13 months (average, 9.3 months). During the follow-up period, a fistula was observed in only one patient. None of the patients developed neourethral dehiscence, meatal stenosis, urethral stricture, wound infection, penile torsion, hematoma, or persistent or recurrent chordee. On uroflowmetry studies, the maximum flow rate of the patients was approximately 10.5 ml/s (range, 6-17 ml/s). The patients were observed to void with a single straight urinary stream in a forward direction. The Kutlay technique is a technique that is easily applied in patients with chordee and that provides a low risk of fistulas and acceptable functional and esthetic results. The factors that reduce the risk of fistula are the lack of the superposition of the suture lines of the skin and the urethra, the reconstruction of the urethra with well-vascularized flaps, and the replacement of the neourethra in its appropriate location through the tunnel created in the glans.

Isolated Penile Torsion in Brothers: A Case Report

Penile torsion can be congenital and associated with hypospadias and chordee, or can be acquired after circumcision. The incidence of isolated neonatal penile torsion was 1.7 to 27% in the literature. The majority were between 10° and 20°. Generally, torsion was to the left in cases. The techniques for correction of penile torsion described in the literature are penile de-gloving and reattaching of skin, resection of Buck’s fascia incising the base of the penis and removing angular ellipses of corporeal tissue with subsequent plication of tunica, and dorsal dartos flap rotation in severe cases. In conclusion, penile torsion may be familial. Therefore, brothers should be examined carefully. The degloving and realignment technique is successful in isolated penile torsion.