TORSION CORRECTION BY DIAGONAL CORPORAL PLICATION SUTURES
BRENT W. SNOW
Division of Urology, University of Utah, Salt Lake City, Utah, USA
Penile torsion is commonly encountered. It can be caused by skin and dartos adherence or Buck’s fascia attachments. The authors suggest a new surgical approach to solve both problems. If Buck’s fascia involvement is demonstrated by artificial erection then a new diagonal corporal plication suture is described to effectively solve this problem.
words: penis; sutures; male urologic surgical procedure
Penile torsion in childhood is usually in the counterclockwise direction, if the physician is facing the patient. If the penile torsion is less than 20-30 degrees, surgical correction is not considered. The etiology of torsion of the penis has been thought to be due to skin and dartos attachments and yet others suggest involvement of Buck’s fascia. When penile torsion correction is appropriate, various repairs have been considered: 1) penile shaft skin rotation (1); 2) suturing the tunica albuginea to the periosteum of the pubis (2) or 3) dorsal dartos flap rotation (3); 4) Nesbit plication (4) or u-shaped plicating sutures (5). A new technique is presented to correct penile torsion that is persistent after the skin had been completely degloved and an artificial erection has demonstrated persistence of the torsion.
skin of the penis is degloved to the base of the penis and an artificial
erection is performed. If the penile torsion is resolved with degloving
of the shaft skin, the skin is over-rotated to allow the penis to be straight
in the flaccid state to complete the repair.
With this recommended technique of degloving first and performing an artificial erection if only skin and dartos are involved with the torsion, the common over-rotation of the skin can be used to complete the penile detorsion procedure. If the erections demonstrate persistent penile torsion, this diagonal corporal plication suture is much easier to perform than suturing the corpora to the periosteum of the pubis, which requires much more dissection, and has been very effective.
CONFLICT OF INTEREST
penile torsion is not frequent in childhood, it is not so rare. Each individual
urologist will face a few cases of torsion during the life of their practice.
Despite the most common technique used to repair this defect is the modified
Nesbit plication. I believe in everyday practice we all perform this procedure
as mentioned by the authors. On the other hand, because young men can
present very strong erections I in fact prefer to use an inverted permanent
braided 2-0 suture.
This is another reliable technique for correction of penile torsion. I am concerned that the sutures are tied over the neurovascular bundle with the consequent strangulation. A procedure around this is the mobilization of the bundle at the desired site of plication and placing the suture beneath the bundle. In addition, diagonal sutures at different vertical levels across the midline may result in shortening especially in cases of severe torsion requiring multiple sutures. In this context, it is my opinion that the “diagonal corporal placation sutures” should be the last resort if other shortening-free techniques prove short of full correction, not merely skin over-rotation (a step within the author’s procedure) but also dorsal dartos flaps.
The true incidence of penile torsion, which is not a very common deformity, is not known. Penile torsion can be encountered independently or in association with other penile and urethral malformations, such as chordee and hypospadias (1). Several relatively old techniques have been described in the literature for correcting penile torsion, including degloving the penis and reattaching the skin (2) incising the base of the penis (3) and removing angular ellipses of corporeal tissue with subsequent plication, in addition to the techniques described in the literature of the current paper. However, these procedures have not been very effective in severe penile torsion cases or associated with significant operative morbidity. In the current report author described a novel technique to correct penile torsion that is persistent after the skin had been completely degloved and an artificial erection has demonstrated persistence of the torsion. The author has demonstrated that diagonal corporal plication suture is much easier to be performed than suturing the corpora to the periosteum of the pubis, which requires much more dissection, and has been very effective. Although the current technique is promising and has some potential, however long term data on a larger number of patients is required to popularize this technique.
Dr. Ahmed I. El-Sakka