Outpatient Surgery of Curvature Correction

PATIENT

Those, whose penises have a physical deviation or penile deformity, severe enough to interfere with coitus, might be suitable patients. There are two types of deviation: the congenital penile deviation [CPD] and the Peyronie's disease. The CPD is thought to be congenital although an inappropriate management of the penis during teenager development warrants scientific research, while the Peyronie's disease is definitely acquired. It is generally agreed that that the penile deformity in Peyronie’s disease should not be corrected until at least one year after the onset and only after the symptoms have been stable preferably for half year. Yet, the deformity should make intercourse difficult and the quality of erection should be adequate. With our outpatient based treatment experience of over 595 patients, we are now highly skilled and thoughtful in this procedure.

ANESTHESIA [Fig.3]

Topical block of proximal dorsal nerve block, peri-penile injection at penile base, ventral infiltration with 0.8%, 50 ml lidocaine solution, prepared in an aseptic steel bowel, and pre-rinsed with epinephrine, via a 10 ml syringe.

OPERATIONS

This operation begins with a circumferential incision [A] followed by a de-gloving procedure. The deep dorsal vein is removed [B, C & D] and saved for auto-logous grafting, if a grafting surgery is intended. After an application of the hydro-dissection technique, [3], the neuro-vascular bundle is freed and tagged [3]. The preceding operation is followed by either a modified Nesbit procedure, in which at least an elliptical tunica [the penis is a little shorter after the operation] is excised, or a tunical, with or without a venous patch [G&H; the penis will be a little longer after the operation] is in order. A 6-0 nylon suture has been consistently used since 1998 in this operation.

Figure 10.  Schematic illustration of curvature correction of the penis

1. retro-coronal circumferential incision is made and the pre-puce is de-gloved.
2. The major branch of the deep dorsal vein [DDV] is readily identified with a milking manipulation. Making openings that are appropriate at the exits of the emissary veins, rather than making a complete opening on the Buck's fascia, is made in order to perform the pull- through maneuver of the DDV.
3. It requires 4-5 openings to complete this maneuver.
4. The deep dorsal vein is stripped and doubly ligated with each emissary vein. This is preserved for patch material.
5. The hydro-dissection technique is used to facilitate the intact separation, the isolation, and the tag of the neuro-vascular bundle.
6. An artificial erection is performed, with normal saline, via a 21G scalp needle, in order to determine where the depression center is, which is feasible for an incision.
7. The adequate incision is made with a new, sharp surgical scalpel, when the neuro-vascular bundle is well protected, until the penis is straight.
8. The auto-logous venous grafting is fashioned to the tunical defect with a running suture of 6-0 nylon. It is enforced, afterwards, intermittently, each 1 cm

DISCUSSION:

1.This operation may be recommended with the technique in which the excessive tunica is sutured together with a stronger suture material which is entitled as placation procedure. It is much easier, it is time-saving, and it is, of course, much less expensive. For anatomic reasons, we definitely recommend this method. It is particularly so after we have successfully revised 25 patients who underwent previously placation surgery.
2.With local anesthesia, pain is negligible. It is a simple procedure because the penis is a protruding organ with layered tissue, with the paucity of fatty tissue, which, in turn, offers an ideal milieu to be palpated. A painful injection can generally be avoided via a quick puncture, as well as by a slow and precise injection. This is not an “impossible mission,” since the “free nerve ending”, which is responsible for pain reception, is not distributed in penile layers, except for the skin and the vessels. Every physician on our team can handle this technique expertly.
3.We recommend a circumferential incision for this operation. A circumcision will be performed simultaneously if a redundant foreskin is encountered.
4.A venous stripping will generally be performed because three patients who developed erectile dys-function were successfully treated via venous surgery during the period of 1995 to 1997. By then, we recommended the venous operation in order to prevent a possibly negative development, although this occurs rarely.
5.After the operation, a patient might sleep poorly as a result of the nocturnal penile tumescence which is a good indication for a normal erection. The following Chinese proverb expresses it well: “You will be the man above all others if you can tolerate the tough events which are intolerable to others.”
6.Some may hesitate to visit our clinic on an outpatient basis, believing that this is a lengthy and complicated operation. However, the procedure is so delicate and refined that, from our perspective, going back to work after the operation presents no problem. A penile dressing with gauze will be applied, encircling the entire shaft. This is mandatory for one week, following the operation. Patients can prevent the penile dressing from getting wet by tightly applying a short segment of a hose tube to the urethral meatus when urinating.
7.There are two major options for this operation: A modified Nesbit procedure or a grafting. The former is faster but will lead to a shorter post-operative penis. However the latter one requires an exact autologous venous or a tunical grafting that takes a longer time for surgery as well as for the period of recovery for the resumption of coitus.
8.To avoid the inconvenience resulting from urination during the operation, the patient is asked to be in the state of NPO [nothing per os] at least 8 hours before the surgery, although it is exclusively a local anesthesia operation on an out-patient basis.
9.This operation takes two [2] to five [5] hours. The patient should, therefore, inform the surgeon, at any time, if he needs to reposition his body in order to lie more comfortably and in a more relaxed position. Otherwise, any minute body movement on the part of the patient could cause inconvenience to the operation.
10.Suture material is an important consideration in this operation. We use a fine 6-0 nylon, which is sufficiently tenacious, rather than a coarser one, to repair the strong tunica, since it is suitable for anchoring the collagen bundle of the outer longitudinal layer of the tunica albuginea [fibro-skeleton]. The nylon material is most bio-compatible because of the paucity of tissue reaction.

11.If the post-operative course uneventful, the patient can resume coitus in at least 6 weeks after the operation. As a rule, the operated tunica albuginea takes at least 6 weeks to heal. A hazardous penile fracture may ensue because the incompletely - healed tunica is unable to bear the pressure generated by coitus. In 1998, a young man at the age of 21 years had to have his tunica repaired a second time because of a severe rupture resulting from sexual intercourse two [2] weeks after the operation. We always advise our patients that it is un-wise to step on cement that is not sufficiently dry.
ANATOMY:

The human penis is a unique structure in which skeletal-muscle structures surround and contain smooth-muscle structures. However, these encased tissues, finally, pass through and are regulated by those surrounding structures. Thus the former include the ischio-cavernosus muscle, bulbouspongiosus muscle and its continuing tunica albuginea, while the latter is composed of smooth-muscle cells, intermingled with fibrous tissue, to form the wall of sinusoids. It looks like an independent organ because of these skeletal-muscle structures. However, in reality, it interlinks the body system with the vessel structure [rich in smooth muscle cells] and the nerve tissues. It mimics the structure of the human body where skeletal muscles and the skeleton encompass those visceral organs in which smooth muscles rest. It is a pendulous organ uniquely suspended from the front and strongly adheres to the pubic rami and ischium via tenacious periosteum. The organ leans upon the suspensory ligament which is an extension of the linea alba [median low abdomen]. Once the penis erects, it behaves like an athletic diver, both of whose upper extremities are amputated from the shoulder joint, standing on a spring-board immediately before he is ready to dive. Thus the glans penis corresponds to the head, the penile shaft corresponds to the body trunk, with the penile crui corresponding to the legs respectively.

The tunica albuginea of the corpora cavenosa is a bi-layered structure: The outer longitudinal layer and the inner circular layer. The outer layer bundle's paucity is at the region between 5 & 7 o'clock positions. This tuck fibro-skeleton is the determining tissue of the penile shape as well as the essential part of establishing a rigid penis.

Figure 11.  Schematic illustration of the human penis: The corpus spongiosum contains the urethra

It is capped with the glans penis. The corpora cavernosa are surrounded by the tunica albuginea which is a bi-layered structure of the inner circular and the oute longitudinal layer with multiple sub-layers. The intra-cavernosal pillar that may be considerably more numerous distally is a continuation tissue of the inner circular layer. Proximally, the corpus spongiosum is held by the bulbo-spongiosus muscle in which its fiber is most transversed and the corpus cavernosum is entrapped in the ischio-cavernosus muscle which the muscle fiber prefers to the longitudinal direction.

SUGGESTED READINGS

1. Hsu, G. L., Brock, G., Martinez-Pineiro, L. et al: The three-Dimensional structure of the human tunica albuginea: anatomical and ultrastructural levels. Int J Impot Res., 4: 117, 1992.
2. Hsu, G. L., Brock, G., Martinez-Pineiro, L. et al: The distribution of elastic fibrous elements within the human penis. Br J Urol, 73: 566, 1994.
3. Hsu, G. L., Chen, S. H. and Weng, S. S.: Out-patient surgery for the correction of penile curvature. Br J Urol, 79: 36, 1997.
4. Hsu, G. L.: Peyronie's disease. In: APSIR BOOK on Erectile Dysfunction, 1st ed. Edited by Kim, Y. C. and Tan, H. M. Malaysia: Pacific Cosmos Sdn Bhd., chapter 18, pp. 200-212, 1999.
5. Hsu, G. L., Wen, H. S. Hsieh, C. H. et al: Traumatic glans deformity: Reconstruction of distal ligamentous structure. J Urol, 166: 1390, 2001.
6. Hsu, G. L., Hsieh, C. H. and Wen, H. S.: Curvature correction in patients with tunical rupture: a necessary adjunct to repair. J Urol, 167: 1381, 2002.
7. Hsu GL. Hsieh CH. Wen HS. Hsieh JT and Chiang HS: Outpatient surgery for penile venous patch with the patient under local anesthesia. J Androl. 24:35-39,2003.
8. Hsu GL, Hsieh CH, Wen HS, Ling PY, Huang HM and Tseng GF. Formulas for determining the dimensions of venous graft required for penile curvature correction. International Journal of Andrology. 29:515-20, 2006.
9. Hsu GL, Lin CW, Hsieh CH, Hsieh JT, Chen SC, Kuo TF, Ling PY, Huang HM, Wang CJ, Tseng GF. Distal ligament in human glans: a comparative study of penile architecture. Journal of Andrology. 26(5):624-628, 2005.
10. Hsu GL: The hypothesis of human penile anatomy, erection hemodynamic and their clinical applications. Asian Journal of Andrology 8(2):225-234, 2006.
11. Hsu GL, Chen HS, Hsieh CH, Chen RM, Wen HS Liu LJ and Chua C. Long-term result of an autologous venous grafting for penile morphological reconstruction. Journal of Andrology. 28 (1):186-193, 2007.

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