A rational approach in Chordee without hypospadias

A guide to manage the variant of Hypospadias variant Chordee without Hypospadias

1. RATIONAL APPROACH IN RATIONAL APPROACH IN
MANAGEMENT OF CHORDEE MANAGEMENT OF CHORDEE
WITHOUT HYPOSPADIAS WITHOUT HYPOSPADIAS
* Dr. Amilal Bhat* Dr. Amilal Bhat
Department of UrologyDepartment of Urology
S.P. Medical college, S.P. Medical college,

BikanerBikaner
Rajasthan, INDIARajasthan, INDIA

2. CHORDEE WITHOUT CHORDEE WITHOUT
HYPOSPADIASHYPOSPADIAS
Synonyms - Hypospadism without hypospadiasSynonyms - Hypospadism without hypospadias
- Congenital penile curvature- Congenital penile curvature
- Corporeal disproportion - Corporeal disproportion
- Congenital short urethra- Congenital short urethra
Rare Rare - 4-10 % of Hypospadias - 4-10 % of Hypospadias
INTRODUCTIONINTRODUCTION
Bhat et al J . PAEDIATRIC UROLOGY Feb 2008

3. DEVELOPMENT OF URETHRA DEVELOPMENT OF URETHRA
•At 9 weeks the genital swellings (also called the labio-scrotal folds)
enlarge and rotate posteriorly. As they meet, they begin to fuse from
posterior to anterior.
• As the genital tubercle becomes longer, two sets of tissue folds develop
on its ventral surface on either side of a developing trough, the urethral
groove. The more medial endodermal folds will fuse in the ventral midline
to form the male urethra. The more lateral ectodermal folds will fuse over
the developing urethra to form the penile shaft skin and the prepuce. As
these two layers fuse from posterior to anterior, they leave behind a skin
line: the median raphe.
•By 13 weeks, the urethra is almost complete. A ring of ectoderm forms
just proximal to the developing glans penis. This skin advances over the
corona glandis and eventually covers the glans entirely as the prepuce or
foreskin.

4. EMBRYOLOGICAL EXPLAINATIONEMBRYOLOGICAL EXPLAINATION
Currently three main theories of penile
curvature are
1. Abnormal development of urethral plate
2. Abnormal fibrotic mesenchymal tissue
at the urethral meatus and penile shaft
3. Differential growth of dorsal and ventral
corporal tissue.

5. CLASSIFICATION CLASSIFICATION

Devine & HortonDevine & Horton
Type I - Hypoplastic urethraType I - Hypoplastic urethra
Type IIType II- Bucks fascia & Dartos- Bucks fascia & Dartos
Type IIIType III- Dartos fascia - Skin chordee - Dartos fascia - Skin chordee
KRAMERKRAMER
Type IVType IV- Short / in-elastic ventral tunica - Short / in-elastic ventral tunica
Type VType V- Congenital short urethra - Congenital short urethra
Hurwitz R A et al J urol 138: 372-75 1987

6. CHORDEE WITHOUT CHORDEE WITHOUT
HYPOSPADIASHYPOSPADIAS


Bhat et al J . PAEDIATRIC UROLOGY Feb 2008

7. CLASSIFICATION DEGREECLASSIFICATION DEGREE
•Mild up to 30 degree
•Moderate 30-60 degree
•Severe > 60 degree
•Significant Chordee ---Curvature more
than 20-30 degree
•Bologna R A et al Urology 53:608-10 1999

8. CHORDEE WITHOUT CHORDEE WITHOUT
HYPOSPADIASHYPOSPADIAS
Unfortunately there is no general
agreement on etiology or
surgical management of this
entity.

Hurwitz R.S. et al J.Urol 138,372; 1987

9. CONTROVERSYCONTROVERSY

Young proposed that this entity was due
to congenital short urethra & he
suggested that it should be managed by
transection of hypo-plastic urethra &
reconstruction of urethra

Young HH Genital anomalies hermaphrodite and related adrenal
disease Wilkin & Wilkin 1937

10. CONTROVERSYCONTROVERSY
Devine & Horton in 1973 proposed that
chordee without hypospadias is due to
abnormal development of fascial layers of
penis & majority of these could be treated with
resection of fibrous tissue for chordee
correction, transection of urethra is rarely
required

Devine & Horton; Chordee without
Hypospadias J Urol 1973;110: 264

11. GOAL IN MANAGEMENT GOAL IN MANAGEMENT
STRAIGHT PENIS
WITHOUT MIGRATION
OF MEATUS

12. INDICATIONS OF SURGERY INDICATIONS OF SURGERY
•Most of the pediatrics urologists consider
chordee to be significant if it is more than
20-30 degree.
• A dorsal approach is preferred for mild
chordee up to 30 degree & conversely
chordee more than 50 degree in being
managed by ventral approach.
•Bologna R A et al Urology 53:608-10 1999

13. SURGERY AT WHAT AGE SURGERY AT WHAT AGE
•Cendron and Melin proposed that it should correct after
puberty. They believed that the curvature would improve
spontaneously with the age and secondly it might disturb
the growth of the penis by altering the tunica of corpora
cavernosa.
•But others advocate that if diagnosed in childhood
correction should be at that time. Type III chordee
without hypospadias with mild to moderate chordee it is
logical to wait but in type II and type I should operated in
same age group as of hypospadias or whenever the
child presents to the hospital.
Bhat et al J . PAEDIATRIC UROLOGY Feb 2008

14. METHODS OF CHORDEEMETHODS OF CHORDEE
CORRECTIONCORRECTION
Penile De-gloving
NESBIT’S
TAP ( Tunica Albuginea Plication)
Dorsal Midline Plication
MPP (Multiple Parallel Suture Plication)

15. METHODS OF CHORDEEMETHODS OF CHORDEE
CORRECTIONCORRECTION
Corporeal Rotation
Division of Hypoplastic Urethra
Penile Disassembly
Extended urethral mobilization
Tunica Vaginalis Free Graft
Dermal Graft Mingin and Baskin UCNA 2002,29;277
Bhat A. J Urol 2007

16. PENILE DEGLOVINGPENILE DEGLOVING
Advantages:
Simple technique, can be easily done
Dis-Advantages:
Effective only in type III
with mild curvature

17. PLICATION PROCEDURESPLICATION PROCEDURES
Most Commonly used technique
Various modifications
Variable results
Effective in mild to moderate
chordee

18. Modified technique of dorsal plication for penile
curvature with or without hypospadias.
Hayashi Y et al Urology 2002,59 ;584-87 Hayashi Y et al Urology 2002,59 ;584-87

19. 
Birt J Urol 2004;93:105-108.Birt J Urol 2004;93:105-108.

?

20. PLICATION PROCEDURESPLICATION PROCEDURES
DISADVANTAGESDISADVANTAGES
1. Against anatomical Principles1. Against anatomical Principles
2. Shortens the penis 2. Shortens the penis
3. Recurrent curvature3. Recurrent curvature
4. Chances of Nerve Injury4. Chances of Nerve Injury
5. Impotence5. Impotence
6. Numbness to glans and penile shaft6. Numbness to glans and penile shaft
7. Penile pain 7. Penile pain
8. Applicable in mild to moderate 8. Applicable in mild to moderate
curvature onlycurvature only

21. PLICATION PROCEDURES PLICATION PROCEDURES
DISADVANTAGESDISADVANTAGES
JOHN DUCKET’S STATEMENT
•To the eye of surgeon “The concept of
lengthening is better than shortening.”

22. PLICATION PROCEDURES PLICATION PROCEDURES
DISADVANTAGESDISADVANTAGES
•NESBIT REPORTED HIS LONG TERM
REULTS AS DISAPPOINTING WITH
SIGNIFICANT RECURRENCE
•J.UROL. HENDREN & CESSAR
1992,147;107.

23. PLICATION PROCEDURES PLICATION PROCEDURES
DISADVANTAGESDISADVANTAGES
The long term results the plication
procedures reported by various
authors had been poor and some
have raised the concern that dorsal
plication in childhood may result in
penile shortening and subsequent
erectile dysfunction
Bhat et al J . PAEDIATRIC UROLOGY Feb 2008
Yachia D J Urol 1990; 143 80-2
Hsieh JT Huang HEChen J Chang HC Liu SP BJU Int 2001; 88:236-40
Gholami SS, Lue TF J Urol 2002; 167: 2066-9.

24. CORPOREAL ROTATION : a split & roll CORPOREAL ROTATION : a split & roll
technique .technique .

Decter RM J. Urol. 1999,162 ;1152-55 Decter RM J. Urol. 1999,162 ;1152-55

25. CORPOREAL ROTATION : a split & CORPOREAL ROTATION : a split &
roll technique .roll technique .
Analysis Analysis

•Extensive Dissection
•Excessive bleeding
•Chances of dorsal vein & corporal injuries
•Chances of Nerve injury
•Significantly long operative time
•Shortens the penis
•Against anatomical principles
•Correction only in mild to moderate
curvature

26. A new approach to treatment of A new approach to treatment of
penile curvature penile curvature

Perovic et al Perovic et al
J Urol 1998 160 ;1123-27 J Urol 1998 160 ;1123-27

27. J Urol 1998 160 ;1123-27 J Urol 1998 160 ;1123-27

PENILE DISASSEMBLYPENILE DISASSEMBLY

28. PENILE DISASSEMBLYPENILE DISASSEMBLY
advantage advantage


• All type of cases can be done
•Corporoplasty is feasible

29. PENILE DISASSEMBLYPENILE DISASSEMBLY
Dis-advantageDis-advantage


•Extensive Dissection
•Excessive bleeding
•Chances of dorsal vein & corporal injury
•Chances of Nerve injury
•Takes long time
•Potential weak area at the site of graft
•Significant long learning curve

30. GRAFT PROCEDUREGRAFT PROCEDURE
DERMAL GRAFTSDERMAL GRAFTS
TUNICA VAGINALIS TUNICA VAGINALIS
GRAFTGRAFT
SMALL INTESTINEL SMALL INTESTINEL
SUBMUCOSASUBMUCOSA
J urol 1998 160 ;1128-30J urol 1998 160 ;1128-30

31. GRAFT PROCEDUREGRAFT PROCEDURE
AdvantageAdvantage
Corporoplasty is feasible in Type IV CWC Corporoplasty is feasible in Type IV CWC
Hypoplastic urethra can be preservedHypoplastic urethra can be preserved

32. GRAFT PROCEDUREGRAFT PROCEDURE
• DISADVANTAGESDISADVANTAGES
Requires incision in corporaRequires incision in corpora
Extensive dissectionExtensive dissection
Chances of bleedingChances of bleeding
Potential weak area at graft site Potential weak area at graft site
Chances of Aneurysm Chances of Aneurysm

33. RESECTION / DIVISION RESECTION / DIVISION
HYPOLASTIC URETHRAHYPOLASTIC URETHRA

34. RESECTION OF HYPOPLASTIC RESECTION OF HYPOPLASTIC
URETHRA URETHRA
Extensive procedure Extensive procedure
Bleeding due to resection of corpus spongiosumBleeding due to resection of corpus spongiosum
Flap tube urethroplasty - Poor resultsFlap tube urethroplasty - Poor results
Complications like fistula, torsion, strictureComplications like fistula, torsion, stricture

35. OPTIONSOPTIONS
•INTERPOSITION OF SKIN TUBE
•DISTAL SKIN TUBE
•FLAP WITH TUBE
•DORSAL PLICATION PROCEDURES
•TWO STAGE REPAIR

36. COMLICATIONSCOMLICATIONS
•FISTULA
•DIVERTICULA
•STRICTURE
•TORSION
•MEATAL STENOSIS
•RETRUSIVE MEATUS

37. AIMAIM
PRESERVE & UTILISE
HYPOPLASTIC
URETHRA & CORPUS
SPONGIOSUM

38. How to correct How to correct
CHORDEECHORDEE
?

39. OUR TECHNIQUE OF CHORDEE OUR TECHNIQUE OF CHORDEE
CORRECTIONCORRECTION
•Mobilization of Hypoplastic urethra &
corpus spongiosum into glans and
proximal extended urethral mobilization
•Spongioplasty and Glanuloplasty.
Bhat et al J . PAEDIATRIC UROLOGY Feb 2008

40. TECHNIQUE TECHNIQUE
STEPS FOR CHORDEE CORRECTIONSTEPS FOR CHORDEE CORRECTION
Gitte’s Test at complete correction Gitte’s Test at complete correction
Step1- Penile skin de-gloving
Step2- Mobilization of divergent corpus
spongiosum
Step3- Mobilization of hypoplastic urethra
Step4- Mobilization of proximal urethra up

to bulbar urethra
Step4- Mobilization of hypoplastic urethra

into glans
Step5- Dorsal plication
Step6- Division/ resection of hypoplastic
urethra
Step7- Penile Dis-assembly.

41. CHORDEE WITHOUT HYPOSPADIASCHORDEE WITHOUT HYPOSPADIAS
TYPE II TYPE II

42. MOBILIZAION OF HYPOPLASTIC URETHRA
& Gittes test& Gittes test

43. SEPARATION OF HYPOPASTIC
URETHRA FROM SKIN

44. MOBILIZAION OF HYPOPLASTIC
URETHRA

45. GLANLOPLASTYGLANLOPLASTY

46. ADVANTAGE OF ADVANTAGE OF
SPONGIOPLASTYSPONGIOPLASTY
•Y TO I spongioplasty adds length to
urethra
•Reconstructs near normal urethra
•Helps in correction of Curvature
•Healthy tissue cover prevents fistula

47. ADVANTAGE OF ADVANTAGE OF
GLANULOPLASTY GLANULOPLASTY
•Corrects glanular curvature
•By rotation of flap adds length
•Glans Conical and at tip

48. A
B C D
E
F G H
Steps of chordee correction in type III chordee without hypospadias

49. A B C D
F
G
H
I
E
Steps of chordee correction in type II chordee without hypospadias

50. A
B C D E
F G H
I J
Steps of chordee correction in type I chordee without hypospadias with torsion

51. B C D
J K
L
M
N
F
G
E
Steps of chordee correction in type II chordee without hypospadias with plication
N
O P
A F
J K
I
H

52. PATIENTS & METHODSPATIENTS & METHODS
Our experience Retrospective Study
From Jan. 1991 to July 2006
- 25 cases of chordee without
Hypospadias

53. COMPLICATIONCOMPLICATION

54. PRESERVATION OF HYPOPLASTIC PRESERVATION OF HYPOPLASTIC
URETHRA & CORPUS SPONGIOSUMURETHRA & CORPUS SPONGIOSUM
ADVANTAGESADVANTAGES


Repair as per anatomical principlesRepair as per anatomical principles
No tissue as good as urethraNo tissue as good as urethra
Hypoplastic Urethra can be utilized Hypoplastic Urethra can be utilized
Spongioplasty reconstruct – Normal urethra Spongioplasty reconstruct – Normal urethra
Bleeding is minimum Bleeding is minimum
Short learning curve Short learning curve

56. TAKE HOME MESSAGE TAKE HOME MESSAGE
Mobilization of proximal urethra & Hypo-plastic Mobilization of proximal urethra & Hypo-plastic
urethra to correct chordee – simple and effective urethra to correct chordee – simple and effective
techniquetechnique
Care should be taken while mobilizing the Hypo-Care should be taken while mobilizing the Hypo-
plastic urethra plastic urethra
Saline injection will help in separating the skin from Saline injection will help in separating the skin from
hypoplastic urethrahypoplastic urethra

57. TAKE HOME MESSAGE TAKE HOME MESSAGE
Preservation & utilization of Hypo-plastic urethra Preservation & utilization of Hypo-plastic urethra
with spongioplasty reconstructs near normal urethra with spongioplasty reconstructs near normal urethra
Corporoplasty is feasible in Type IV CWC after Corporoplasty is feasible in Type IV CWC after
mobilization of hypoplastic urethramobilization of hypoplastic urethra
Trauma to hypoplastic urethra may lead to fistula Trauma to hypoplastic urethra may lead to fistula

58. CHORDEE WITHOUT HYPOSPADIASCHORDEE WITHOUT HYPOSPADIAS
Skin De-gloving+ Gitte’s testSkin De-gloving+ Gitte’s test
Chordee Resolved Chordee Resolved IIIIII

GlanuloplastyGlanuloplasty
Chordee Persisted Chordee Persisted I,II,IV,V.I,II,IV,V.
Mobilization of Mobilization of
Hypoplastic UrethraHypoplastic Urethra
& corpus Spongiosum& corpus Spongiosum
Chordee Resolved Chordee Resolved IIII
SpongioplastySpongioplasty

GlanuloplastyGlanuloplasty
Chordee Persisted Chordee Persisted I,II,IV,V.I,II,IV,V.
Mobilization of UrethraMobilization of Urethra
Chordee Persisted Chordee Persisted I,IV,VI,IV,V..
Tube UrethroplastyTube Urethroplasty
Chordee Resolved Chordee Resolved I, IV,V.I, IV,V.

Division/resection of Division/resection of
Hypoplastic UrethraHypoplastic Urethra

Penile Dis-assembly /GraftPenile Dis-assembly /Graft
Persisted Persisted IVIV
Dorsal plication
Chordee Persisted Chordee Persisted I,IV,V.I,IV,V.
Chordee Resolved Chordee Resolved I,IVI,IV

60. Chordee correction in type I chordee without hypospadias with torsion

61. TYPE IIITYPE III

62. CHORDEE WITHOUT CHORDEE WITHOUT
HYPOSPADIASHYPOSPADIAS

63. TYPE IIITYPE III

64. TYPE IIITYPE III

65. AGEAGE
Age (Yrs.)Age (Yrs.)No. of patients PercentageNo. of patients Percentage

01-O501-O5 0303 12.0012.00
O5-10O5-10 0303 12.0012.00
10- 1510- 15 1212 48.0048.00
> 15> 15 0707 28.00 28.00
TotalTotal 25 25 100.00 100.00

66. ASSOCIATED ANOMALIESASSOCIATED ANOMALIES
Anomaly No. of PT. Anomaly No. of PT. Percentage Percentage

TORSIONTORSION 0202 0808
UDTUDT 0101 0404
HERNIAHERNIA 0101 0404

67. DISTRIBUTION OF CASESDISTRIBUTION OF CASES
Type Type No. of Pt. No. of Pt. Procedure Procedure No. of Pt.No. of Pt.
Penile-dissembly Penile-dissembly 1 1
Type I Type I 11 11 Resection of UrethraResection of Urethra 3 3
Mobilization & preservation 6Mobilization & preservation 6
Nesbit’s PlicationNesbit’s Plication 2 2
Type II Type II 06 06 Resection of UrethraResection of Urethra 1 1
Mobilization & spongioplasty 3Mobilization & spongioplasty 3

Penile Degloving 5Penile Degloving 5
Penile Degloving +Penile Degloving +
Type III Type III 08 08 Nesbit’s Plication Nesbit’s Plication 2 2
Mobilization + spongioplasty 1Mobilization + spongioplasty 1

68. RESULTSRESULTS
Procedure No. Op. Time Results Complications Pt’s No.
Penile de-gloving 5 45-50 Good NilPenile de-gloving 5 45-50 Good Nil
NESBIT’S 2 60-75 mts. Fair residual Chordee 1
Penile de-gloving+Penile de-gloving+
NESBIT’S 2 60-75 Good Good residual Chordee 1
Tube 4 80-100 mts. Fair Fistula 1
Urethroplasty stricture 1
Penile Dis- Penile Dis-
assembly 1 assembly 1 120 mts Good NilGood Nil
Urethral Mobilization Urethral Mobilization
& spongioplasty 10 60-80 & spongioplasty 10 60-80 mts Good NilGood Nil

69. TAKE HOME MESSAGE TAKE HOME MESSAGE
Mobilization of proximal urethra & Hypo-plastic Mobilization of proximal urethra & Hypo-plastic
urethra to correct chordee – very good techniqueurethra to correct chordee – very good technique
Preservation & utilization of Hypo-plastic urethra Preservation & utilization of Hypo-plastic urethra
with spongioplasty and glanuloplasty corrects with spongioplasty and glanuloplasty corrects
chordee in most of the cases chordee in most of the cases

70. CONVENTIONAL METHODS CONVENTIONAL METHODS
DISADVANTAGESDISADVANTAGES
Extensive procedure Extensive procedure
Bleeding due to resection of corpus spongiosumBleeding due to resection of corpus spongiosum
Flap tube urethroplasty - Poor resultsFlap tube urethroplasty - Poor results
Plication procedure - Against anatomical Plication procedure - Against anatomical
PrinciplesPrinciples
Shorten the penisShorten the penis
Chances of Nerve InjuryChances of Nerve Injury
ImpotenceImpotence
Numbness Numbness
Pain Pain

71. TAKE HOME MESSAGE TAKE HOME MESSAGE
Gitte’s Test after every stepGitte’s Test after every step
Step1- penile skin de-gloving
Step2- mobilization of divergent corpus
spongiosum
Step3- mobilization of hypoplastic urethra
Step4- mobilization of proximal urethra up
to bulbar urethra
Step5- Division/ resection of hypoplstic
urethra
Step6- Penile Dis-assembly.

72. Skin ClosureSkin Closure

77. SPONGIOPLASTY & SPONGIOPLASTY &
SEPARATION OF CORPORASEPARATION OF CORPORA

H. DODAT ET ALH. DODAT ET AL
BJU International 91, 528-531, April 2003BJU International 91, 528-531, April 2003
Corpora dissected & separated
Urethra pulled dorsal side

78. METHODS OF CHORDEEMETHODS OF CHORDEE
CORRECTIONCORRECTION
–Penile De-gloving
–TAP ( Tunica Albuginea Plication)
–Dorsal Midline Plication
–MPP (Multiple Parallel Suture
Plication)
–NESBIT’S

79. (CONTD.)(CONTD.)
•Division of Hypoplastic Urethra & Fibrous
Tissue Resection
•Penile Disassembly
•Corporeal Rotation
•Tunica Vaginalis Free Graft
•Dermal Graft

80. CONVENTIONAL METHODS CONVENTIONAL METHODS
DISADVANTAGESDISADVANTAGES
•Extensive procedure
•Bleeding due to resection of corpus spongiosum
•Flap tube urethroplasty - Poor results
•Plication procedure - Against anatomical
Principals
•Shorten the penis
•Chances of Nerve Injury
•Impotence

81. PRESERVATION OF HYPOPLASTIC PRESERVATION OF HYPOPLASTIC
URETHRA & CORPUS SPONGIOSUM URETHRA & CORPUS SPONGIOSUM
ADVANTAGESADVANTAGES
•No tissue as good as urethra
•Hypoplastic Urethra can be utilized
•Corpus spongiosum utilization –
Normal urethra
•Bleeding is minimum
•Repair as per anatomical principals
•Vascular pedicle coverage results are
the best

82. CORRECTION OF CHORDEE CORRECTION OF CHORDEE
BY MOBILIZAION OF BY MOBILIZAION OF
URETHRA IN CHORDEE URETHRA IN CHORDEE
WITHOUT HYPOSPADIASWITHOUT HYPOSPADIAS
* Dr. Ami Lal Bhat* Dr. Ami Lal Bhat
Chief of UrologyChief of Urology
Department of UrologyDepartment of Urology
S.P. Medical college, S.P. Medical college,

BikanerBikaner
Rajasthan, INDIARajasthan, INDIA

83. GRAFT PROCEDUREGRAFT PROCEDURE
 J urol 1998 160 ;1128-J urol 1998 160 ;1128-
3030

84. HYDRODISSECTION HYDRODISSECTION
TECHNIQUETECHNIQUE
•
Hydro-dissection for separating adherent skin Hydro-dissection for separating adherent skin
• Preserved thin distal urethraPreserved thin distal urethra
• Y to I spongioplasty Y to I spongioplasty
• Thin urethra covered by prepucial tissueThin urethra covered by prepucial tissue
• Avoiding urethroplasty & TAP Avoiding urethroplasty & TAP
Yang SSD , Chen SC, Liu SP & Hsieh J T Department of Yang SSD , Chen SC, Liu SP & Hsieh J T Department of
Urology, National Taiwan University Hospital, Taiwan,ChinaUrology, National Taiwan University Hospital, Taiwan,China
J Urol Vol.168,2189-91. Nov.2002J Urol Vol.168,2189-91. Nov.2002