Hypospadias with dorsal chordee: Case report of a novel approach for correction.

We report a novel surgical technique for correction of dorsal chordee with coronal hypospadias. The bulbar elongation and anastomotic meatoplasty procedure gave an excellent cosmetic and functional outcome.

INTRODUCTION

Dorsal penile curvature is extremely rare; it may or may not be associated with hypospadias. We propose the limited bulbar elongation and anastomotic meatoplasty (BEAM) procedure to simultaneously correct both dorsal chordee and distal hypospadias.

CASE REPORT

A 10-year-old boy presented with a coronal hypospadias and significant dorsal chordee. The glans was conical and the glans groove was deep. There was no fan-shaped marker dorsally over the skin. The dorsal preputial hood was adequate in size and was seen as in usual cases of hypospadias.

The surgical procedure was carried out under regional anesthesia with sedation. After catheterization of the meatus, circum–coronal incision was taken and the penis was degloved up to the base of the penis. A tourniquet was applied and the artificial erection test was performed [Figure 1]. A transverse incision was taken distal to the meatus so as to mobilize the urethra with the spongiosum in a plane close to the corpora cavernosa [Figure 2]. The urethra was mobilized proximally till a point just proximal to maximum curvature. The excess length was excised just proximal to the neo-meatus at the level of the normal corpora spongiosa. Then, meatoplasty and glansplasty was performed. This was adequate enough to correct both dorsal chordee and hypospadias. Complete correction of the chordee was confirmed by repeating the artificial erection test [Figure 3]. An indwelling catheter was left in place and a nonocclusive dressing was applied. The dressing and the catheter were removed on the 10th day.

Figure 1

Dorsal chordee after degloving, Gittes test

Figure 2

Urethra was mobilized along with spongiosum in a plane close to the corpora cavernosa

Figure 3

Straight penis after correction

At follow-up of 4 years, there was complete disappearance of dorsal chordee and the child was passing urine in a single stream from the tip of the penis.

DISCUSSION

The first case of dorsal penile curvature was reported by Udall in 1980 in a 14-year-old boy.[1] The first reported case of dorsal chordee with hypospadias was published by Redman in 1983.[2] He discussed six cases of dorsal chordee, of which three had distal hypospadias. Scott in 1992 reviewed his experience of surgical correction of 1300 cases between 1976 and1989 and compiled a series of seven cases of distal hypospadias with dorsal chordee.[3]

Udall corrected the deformity by closing three transverse ellipses longitudinally of the tunica albugenia on the dorsal aspect of the penis.[1] Redman corrected the dorsal chordee by removing a pair of ellipses of the tunica albugenia from the ventrum of the penis at the site of maximum curvature, after reflecting the corpora spongiosa and urethra from the corpora cavernosa.[2] Scott corrected the dorsal chordee in all seven cases by using a “reversed Nesbit” procedure. The hypospadias was corrected by the Meatal Advancement and Glansplasty technique in six cases and flip–flap procedure was performed in one case.[3] Both Redman and Scott corrected the hypospadiac urethra as a separate procedure.

The dorsal dissection of the Buck's fascia on corporal bodies invariably damages the neurovascular bundles and makes the penis insensate and, hence, dorsal procedures to correct the chordee are not advocated.[4] The reverse Nesbit's procedure may shorten the penis significantly, particularly when the penis is small. An additional procedure for correction of the hypospadic urethra is required.

Congenital ventral curvature is a normal stage development in the formation of the penis. The extreme rarity of the dorsal chordee has prevented accurate elucidation of its etiology and it is still not well documented.[5-8]

We propose modified “Beck's procedure” as an ideal procedure for the treatment of this rare entity, dorsal chordee associated with distal hypospadias.[69] This procedure avoids dorsal dissection and the corporal bodies are neither plicated nor are their ellipses excised; thus, alteration to their anatomy is avoided, as seen in the “Reverse Nesbit” procedure. The transposition of the meatus to the tip simultaneously corrects the dorsal chordee and the hypospadias.