Cop+Ed+fisse 2006 Archivio Italiano di Urologia e Andrologia 2020; 92, 3182 ORIGINAL PAPER No conflict of interest declared. DOI: 10.4081/aiua.2020.3.182 Prepuce-sparing corporoplasty as a safe alternative for patients with acquired penile curvature Aldo Franco De Rose 1, Francesca Ambrosini 1, Guglielmo Mantica 1, Enrico Zero 2, Riccardo Banchero 1, Carlo Terrone 1 1 Department of Urology, Policlinico San Martino Hospital, University of Genoa, Genoa, Italy; 2 Department of Computer Science, Bioengineering, Robotics and Systems Engineering, University of Genoa, Genoa, Italy. Objectives: penile curvature is a rare condi- tion, classified as congenital or acquired (Peyronie’s disease) (PD). Surgical correction is the standard treatment. It’s common practice to associate circumcision with penile de-gloving to prevent complications. In this paper we evaluate the feasibility of penile surgery avoiding circumcision. Materials and methods: patients presenting with penile curva- ture were treated using a modified Nesbit procedure. Patients were divided into group A if they opted for a prepuce-sparing surgery and the others into group B. Patients were evaluated pre and postoperatively and postoperative complications were assessed. The 5-item International Index of Erectile Function (IIEF-5) was administered before and 6 months after surgery and we compared the difference of mean value using T-Test. Results: Group A and B were made of 53 and 16 patients respectively. Median age was 59 years [interquartile range (IQR) 12] in A and 62 (IQR 9) in B (p = 0.2). Median curva- ture was 40° (IQR 40°) in A and 40 ° (IQR 30°) in B (p = 0.62). Mean difference between pre- and post-operative IEFF was 1.9 ± 2 in A and 2.6 ± 2.1 in B (p = 0.36). Conclusions: According to our experience, surgical correction of penile curvature without performing circumcision could be a safe and feasible strategy. We recommend performing cir- cumcision only in patients who present with pre-operative phimosis. KEY WORDS: Erectile dysfunction; Foreskin; Male; Phimosis; Penile induration. Submitted 23 February 2020; Accepted 2 April 2020 INTRODUCTION Penile curvature can be considered a relatively uncom- mon condition, with an incidence of 0,4-0,6%. Estimated prevalence is about 0.5% but according to several Authors it may reach up to 10% due to misdiagnosis and low awareness of the disease (1, 2). While new promising therapies are developing and spreading (3-4), surgery is still indicated as primary management for many patients with penile curvatures, especially when the curvature does not allow a satisfactory intercourse (5-7). A common feature of the many different techniques of corporoplasty which were proposed over the last decades is to associate circumcision with penile degloving in order to prevent postoperative oedema, phimosis and necrosis of the pre- puce (8, 9). However, few recent studies have shown that a prepuce-sparing surgery is feasible with a low rate of local complications (10, 11). We aim to evaluate the fea- sibility and the safety of prepuce-sparing corporoplasty on a single-institution series. MATERIALS AND METHODS Data were collected from patients presenting with Peyronie’s disease (PD) who underwent to a modified Nesbit procedure from January 2014 to January 2019 at a single academic tertiary hospital. Our Institution’s prospectively updated database that have been retro- spectively evaluated. All the procedures were performed by the same experienced surgeon (A.F.D.R.). 1. Preoperative assessment and follow-up All patients had a stable disease for at least three months and suffered from pain during erection or during sexual intercourse. All patients underwent a standard clinical assessment, routine blood sample, urinalysis, physical examination during erection (after intracavernous injec- tion of vasoactive drugs or self-photography at orthogo- nal, frontal, and sagittal planes). Curvature degrees were measured using a goniometer. Both the prepuce and the degree of penile curvature were assessed before surgery. We considered curvature of more than 30 °. Medical and sexual history of patients was taken focusing on any pre- vious penile surgery. The 5-item International Index of Erectile Function (IIEF-5) was administered before and 6 months after the treatment. Degree of angulation was recorded at follow-up with self-photograph at orthogo- nal, frontal and sagittal planes. 2. Sample definition and analysis The patients were divided into two different groups: group A, made by patients who opted for a prepuce- sparing surgery, and group B made by those who decid- ed to be circumcised. Patients’ characteristics, intra-, post-operative and 6 months follow-up data were col- lected and analysed. Post-operative complications were assessed according to Clavien-Dindo (CD) classification (14). In the two groups, we assessed the difference of mean value of IIEF-5 score administered before and 6 months after the surgery by using T-Test. Data were entered into a Microsoft Excel (Version 14.0) database and then transferred to Sofastat TM 1.4.6 for Windows. Descriptive statistics were calculated for all patients’ variables and reported as median (IQR), mean ± stan- Summary 05De Rose-Ambrosini_Stesura Seveso 24/09/20 14:14 Pagina 182 183Archivio Italiano di Urologia e Andrologia 2020; 92, 3 Feasibility of prepuce sparing corporoplasty dard deviation (SD) or as proportion. The homogeneity and data of the two groups were compared using the Kolmogorov-Smirnov, Chi-Square, Fisher Exact and the paired T-test. We set the level of significance to 0.05. 3. Surgical procedure and perioperative management In all cases a modified Nesbit technique has been per- formed. The procedure starts with a sub-coronal circum- ferential incision 1 cm below the coronal sulcus. Then the degloving is carried out following the avascular plane between the dartos and the Buck’s fascia. We accurately spare the dartos in order not to damage the blood sup- ply to the prepuce. The neurovascular bundle is mobi- lized from the dorsum of the penis by incising Buck’s fas- cia laterally. Five micro-grams of prostaglandin E1 (PGE 1) are injected into the corpora cavernosa to obtain an artificial erection. The tunica albuginea can be grasped with an Allis clamp or with suspension stitches and then it is excised sharply with a cold scalpel (Figure 1). The albuginea continuous solution is closed with inter- rupted polyglycolic 3/0 suture. The result is assessed by inducing a final hydraulic erection. Buck’s fascia is reap- proximated with an absorbable monofilament suture. Finally, we perform an interrupted 4/0 suture to approx- imate the skin (Figure 2). For patients among group B the surgical procedure was similar to the technique performed for group A except for the final step of the circumcision. The redundant pre- puce is pulled upwards, the adhesions to the glans is released, and after skin excision, haemostasis is per- formed with an electrocautery. We approximate the skin and the mucosal borders with simple interrupted absorbable suture (polyglycolic 3/0). A transurethral catheter is placed during surgery and left for 1-2 days. All patients were premedicated with third generation cephalosporins as prophylactic antibiotic before induction of anaesthesia (12, 13). 4. Ethics statement Our institution doesn’t require an Institutional review board approval for retrospective observational studies. However, every patient at the admission had to give a written consent for the prospective collection and retro- spective analysis of data. RESULTS Group A and B were made of 53 and 16 patients, respec- tively. The median age was 59 years (IQR 12) in group A and 62 (IQR 9) in group B (p = 0.20). Median grade of penile curvature was 40° (IQR 40°) in group A and 40° (IQR 30°) in group B (p = 0.62). The two groups were similar in direction of curvature (Table 1). Median oper- ating time was 90 minutes (IQR 6) in group A and 100 minutes (IQR 30) in group B (p = 0.03). Patients of both two groups had their urethral catheters removed at a median of 1 day (IQR group A 1 and IQR group B 0) after surgery (p = 0.23). Median length of stay was 2 day (IQR 1) in group A and 2 day (IQR 0) in group B. Twenty-one patients of group A were used to take phos- phodiesterase type 5 inhibitor (PDE5 inhibitor) before sur- gery. After the treatment 19 (36%) of them continued to use PDE5 inhibitor while two of them started using intracavernous injections of vasoactive medication. Figure 1. The electric scalpel delimits the area of corporoplasty subsequently engraved with the cold knife. Figure 2. Sub-coronal suture with Vycril rapid 4/0 stitches without circumcision. Table 1. Summary table on the population of patients considered in the study. Variable Group A Group B P value Number of patients 53 16 0.91 Age (y), median (IQR) a 59 (12) 62 (9) 0.20 Curvature (°), median (IQR) Direction of curvature, n (%) 40° (40°) 40° (30°) 0.62 Dorsal 18 (34) 7 (44) 0.74 Ventral 16 (30) 5 (31) 0.98 Lateral 19 (36) 4 (25) 0.59 IEFF-5 score, mean ± SD 19 ± 2 17 ± 2 0.02 a IQR = interquartile range. Table 2. Summary table on the population of patients considered in the study. Variable Group A Group B P value Operating time (minutes), median (IQR) 90 (6) 100 (30) 0.03 Duration of catheterization (days), median (IQR) 1 (1) 1 (0) 0.23 Hospital stay (d), median (IQR) 1 (1) 1 (0) 0.24 Complications CD a Grade III 4 0 CD Grade IV 0 0 IIEF-5 score 6 months after, mean ± SD 21 ± 2 20 ± 2 0.11 IIEF-5 pre-/post-op. difference 1.9 ± 2 2.6 ± 2.1 0.36 Residual curvature at 6 months Straight 51 16 < 15° 2 0 a CD = Clavien Dindo. 05De Rose-Ambrosini_Stesura Seveso 24/09/20 14:14 Pagina 183 Archivio Italiano di Urologia e Andrologia 2020; 92, 3 A.F. De Rose, F. Ambrosini, G. Mantica, E. Zero, R. Banchero, C. Terrone 184 In group B, three patients used PDE5 inhibitor before surgery and they continued the same therapy also after the surgery. Mean difference between pre- and post- operative IIEF was 1.9 ± 2 in group A and 2.6 ± 2.1 in group B (p = 0.36). Four patients (7.5%) among Group A experienced CD grade III postoperative complications (secondary circumcision due to post-operative paraphi- mosis/edema). No CD grade IV complications were reported in both groups. Two patients among group A reported recurrent curvature of more than 15 degrees, but in both cases no secondary surgery was required (Table 2). DISCUSSION Penile curvature is a congenital or acquired deformity which results in sexually debilitating condition and sig- nificant psychological stress for patients and their part- ners (15). Once medical treatment is excluded or unuse- ful, surgery becomes the standard of choice (16). Both shortening and lengthening procedures are good options for patients. The first technique to correct penile curvature was described by Nesbit (17). In the following years various modifications to Nesbit’s technique were suggested such as the Yachia corporoplasty technique with or without penile degloving. According to the liter- ature the outcomes of the “degloving” and “without deglov- ing” techniques are similar (18). Regardless of the procedure performed, penile degloving is generally combined with circumcision to reduce risk of postoperative oedema of the prepuce, with subse- quent phimosis and necrosis (19, 20). However, recent studies demonstrate that circumcision is not always nec- essary, particularly when patients present with no phi- mosis pre-operatively (10, 11). Alei et al. (21) described a new corporoplasty technique named as the ‘double- breasted’ corporoplasty, with penoscrotal and infrapubic access not requiring circumcision. They reported no major complications nor neurovascular lesions or change in erectile function, low morbidity, low recurrence rate and excellent aesthetic results. Garaffa et al. (10) reviewed a series of 251 patients who underwent a Lue (86 patients) or a Nesbit procedure (162 patients) or a combination of both. They reported very few complica- tions in the group of patients without pre-operatively phimosis that chose not to be circumcised. They could state that circumcision should not be considered as a routine part of penile surgery unless a significant phimo- sis is present. Similarly, Pavone et al. (11) reported a series of 147 patients treated with Nesbit's corporoplas- ty without circumcision and no major complication were described. The authors affirmed that circumcision must not be considered a mandatory time in Nesbit procedure if the anatomical structures are carefully respected, the number of artificial erections is reduced. In this paper we analysed surgical outcomes of a group of patients treated with modified Nesbit procedure without circumcision comparing them with a similar group treat- ed with the same technique but completed with circumci- sion. Pre and post-operative data were similar in both two groups and no major complications were reported. Not performing circumcision in penile surgery could be a safe strategy if some precautions are followed. We rec- ommend minimizing trauma of tissues carefully isolating the plane between the dartos and the Buck’s fascia to avoid bleeding and ischaemia. In addition, the initial subcoronal circumferential incision 1 cm below the coronal sulcus allows to spare a sufficient prepuce vas- cularization. In this way the risk of tissue retraction and consequent- ly to phimosis and foreskin necrosis could be reduced. Overall, regardless of prepuce sparing surgery, reported success rate with tunica albuginea plication procedures is about 85%, with a good erectile function (IIEF-5 > 21 in more than 85% of patients) (22). In our analysis surgical correction of penile curvature has a good impact on erectile function (IIEF score improve in both two groups) and the comparison of the IIEF dif- ference between the 2 groups didn’t show any statistical- ly significant difference. Thus, it seems that if circumcision is not performed sex- ual outcomes could not be negatively affected. Many limitations exist in the current research beginning with the study design because of the retrospective nature of the study and the limited sample. However, the Institution’s database has been prospectively updated and the size of the sample, even if small, is comparable to that of other previous studies. Furthermore, the enrol- ment period is quite long. Anyway, to the best of our knowledge, the literature on this topic is weak and we couldn’t find any study on this subject with a prospective design. CONCLUSIONS In conclusion, according to our experience, surgical cor- rection of penile curvature without performing circumci- sion could be a feasible and safety strategy with low rate of foreskin complications. Additional prospective studies with larger patient cohorts are required to draw stronger conclusion. 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Straightening corporo- plasty for Peyronie’s disease: a review of 218 patients with median follow-up of 89 months. Eur Urol. 2004; 46: 610-4. Correspondence Aldo Franco De Rose, MD aldofdr@libero.it Francesca Ambrosini, MD (Corresponding Author) f.ambrosini1@gmail.com ORCID 0000-0003-2160-763X Guglielmo Mantica, MD guglielmo.mantica@gmail.com Riccardo Banchero, MD riccardo.banchero@hsanmartino.it Carlo Terrone, MD carlo.terrone@med.uniupo.it Department of Urology, Policlinico San Martino Hospital, University of Genoa Largo Rosanna Benzi, 10, 16132, Genoa, Italy Enrico Zero, MD zero.enrico@gmail.com Department of Computer Science, Bioengineering, Robotics and Systems Engineering, University of Genoa, Genoa, Italy 05De Rose-Ambrosini_Stesura Seveso 24/09/20 14:14 Pagina 185