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Purpose: There is some reluctance to use dermal grafts for augmenting the tunica albuginea to correct severe forms of
chordee. The main concern is that by violating the integrity of the tunica albuginea venous leakage could presumably ensue
and result in erectile dysfunction. We present our long-term followup of dermal grafts used to correct severe penile curvature
associated with hypospadias or as an isolated malformation.
Materials and Methods: A total of 16 patients received a single dermal graft harvested from the nonhair bearing inguinal
skin fold. Patient age was 1 to 19 years (average 7). Of the patients 14 had hypospadias, which was scrotal in 12 and perineal
in 2, while 2 had congenital penile curvature. In the hypospadias group 13 patients underwent primary repair and 1 had
undergone 2 previously failed repairs with persistent severe curvature. Additionally, 5 patients in the hypospadias group had
associated penoscrotal transposition. Eight patients in the hypospadias group received testosterone injections preoperatively.
Results: Average followup was 10 years (range 6 to 15). At the time of the study all patients were postpubertal and 3 had
married. Evaluation of the results was based on patient interview reporting of penile straightness, erectile quality and
satisfaction with sexual relations, if present. Two of the 3 patients who married reported satisfactory sexual activity and 1
had fathered children. The other 13 patients reported rigid erections. Two patients had mild residual curvature that would
not necessitate any further intervention.
Conclusions: Some boys with severe penile curvature, particularly those with hypospadias and a borderline size phallus,
need a dermal graft rather than a plication procedure to correct curvature. Our study suggests that using dermal grafts is
safe for erectile function.
Key Words: hypospadias, penis, transplants, dermis, penile erection
0022-5347/08/1804-1842/0
THE JOURNAL OF UROLOGY
Copyright 2008 by AMERICAN UROLOGICAL ASSOCIATION
TECHNIQUE
The decision to use a dermal graft is always made intraoperatively. After exhausting all attempts at straightening,
including division of the urethral plate and proximal mobilization of the urethra with division of any residual tissue,
artificial erection is done. If curvature is still 40 degrees or
more, the decision is made to augment the deficient aspect of
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No. pts
No. pathological finding:
Scrotal
Perineal
Ventral curvature
Lt lat rotation
Age (yrs)
No. penoscrotal transposition
No. preop testosterone
No. primary repair
Procedure
Urethroplasty
Hypospadias
Congenital
Penile
Curvature
14
12
2
117
5
8
13
Dermal grafts
Stage 2 Thiersch-Duplay
tube from transferred
dorsal skin prepuce
1
1
18 19
Not applicable
0
1
Dermal graft
albugineal
island excision
None
the penis with a graft (fig. 1). We used a single dermal patch
harvested from the nonhairy inguinal skin fold in all patients. An area of 3 2 cm is delineated and the graft is
harvested. The graft is subsequently trimmed according to
the size of the created defect.
Artificial erection is repeated and at the point of maximum curvature the tunica albuginea is incised a full half
circle from the 3 to 9 oclock positions and not less (fig. 2). The
septum is included in the incision. These 2 maneuvers are
important to allow full straightening. Care is taken to elevate
Bucks fascia on the lateral aspect of the penis to enable proper
extension of the incision without injuring the nerves that
course lateral in this position. Care also is taken to incise only
the tunica and avoid the cavernous tissue as much as possible.
The harvested graft is trimmed to an elliptical shape to fit
loosely in the created defect. The graft is secured in position
in 4 quadrants using 6-zero polyglycolic acid suture. Two
stitches are used to fix the graft to the septum. The graft is
attached to the edge of the tunica albuginea using a running
stitch in each of the 4 quadrants. Artificial erection is repeated to ensure complete orthoplasty and absent leakage.
Any leakage is addressed with more stitches. Early on we
made the fatty side (subcutaneous side) of the graft face
outward. However, it does not seem to make a difference if it
faces the cavernous side.
RESULTS
Average followup was 10 years (range 6 to 15). All patients
are currently postpubertal and 3 have married.
Our aim was to determine whether violating the integrity
of the tunica albuginea by applying a dermal graft would
adversely affect erectile function during extended followup,
particularly after the changes of puberty have occurred.
Evaluation was based on patient interview reporting on 3
specific questions, including 1) erectile quality (hard and
satisfactory or not), 2) penile straightness, and 3) sexual
activity and whether it was satisfactory.
TABLE 2. Results
Overall
Penile straightness:
Straight
Mild dorsal curve (overcorrection)
Mild residual curvature
Erectile quality:
Hard
Less than preop
Sexual activity:
Not quantified
Married, satisfied (father)
Married, satisfied
Married, weak erections
No.
Hypospadias
No. Congenital
Penile Curvature
14
13
1
2
14
1
1
13
1
1
1
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DISCUSSION
Children with hypospadias and extraordinary chordee usually have significant disproportion between the dorsal and
ventral aspects of the corpora cavernosa.6,7 It is imperative
to ensure complete penile straightening at primary repair.
Incomplete correction of curvature may necessitate repeat
surgery despite successful urethroplasty. Dorsal plication is
not sufficient to correct curvature of this magnitude. Fur-
8.
9.
10.
11.
12.
13.
14.
15.
16.
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