25-year-old adult presented to the Hypospadias Foundation OPD with complaints of severe ventral curvature of the penis. There were no urinary complaints. He also that the curvature has worsened over time. There were no urinary complaints.. On examination, there was severe ventral curvature (downward bending) of the penis- the curvature was almost 90 degrees. Meatus was located on the glans and was normal in location. No plaques were felt on palpation. Ultrasound doppler of the penis was done which was normal. He was counselled for chordee repair surgery.
The plan was to deglove the penis, examine everything once again in detail including degree of curvature, urethral calibre and then decide for a single stage or a staged chordee correction repair.
Picture 1: Pre-operative assessment showed normal location of the meatus. Second image shows marking for degloving
Surgery was started by taking a stay stitch on the glans with 4-0 prolene. Marking of the degloving incision was done and local anaesthesia (lignocaine with adrenaline) was injected at the marked site. Complete degloving was done. Chordee was assessed by artificial erection test and more than 60-degree chordee was noted. Since the penile length was good and urethra was not appearing short or taut, we decided to proceed with dorsal plicationprocedure to correct the chordee.
Buck’s fascia along with neurovascular bundle was raised on the dorsal side starting laterally and upto the midline. Chordee was reassessed and exact site of curvature was marked. 24 dots (12 dots on either side) were marked. 4 dots proximal and 8 dots distal to the site of maximum curvature. Longitudinal plication sutures were placed at these sites with 4-0 prolene involving full thickness tunica albuginea. The sutures were first held tight without tying them up and chordee was reassessed and there was no chordee. Once we were sure that the chordee is fully corrected, we tied off the sutures and checked chordee again- Chordee was completely corrected by these plication sutures. Buck’s fascia was closed on either side with 6-0 PDS. Circumcision was completed and skin rearranged and closed in 2 layers with 6-0 PDS and 5-0 vicryl rapide. 12Fr silicone catheter was placed per urethra anddressing was done. Catheter was removed after 7 days. At follow up at 6 months after surgery, there was no chordee and the erection was straight.
Picture 2: Complete degloving done and artificial erection test done which showed more than 60-degree chordee.
Picture 3: Neurovascular bundle raised on both sides upto the midline. Marking done, applications sutures placed, held and artificial erection test done. No chordee noted
Picture 4: 24 dot plications completed and circumcision done
Picture 5: Good result- Straign penis at erection 6 months after surgery
Picture 6: Good Cosmetic result 6 months after surgery
Severe ventral chordee in adults: Diagnosis and management
Chordee is characterised by the curvature of the penis, which is noticeable only during penile erection. While chordee can occur in adulthood due to Peyronie’s disease, most of the cases of chordee are present from birth (congenital). Chordee can be missed in childhood, especially if there is no hypospadias. In such cases, men present with challenges in adulthood,d such as pain during erection, difficulty in sexual intercourse and some men can also have psychological implications impacting self-esteem.
In chordee, there is a noticeable bend in the penis during an erection, which can be downward, upward or sideways. The most common chordee type is ventral chordee, where the penis bends downwards, as in the present case. Surgical correction is the only effective method of chordee correction in adults. The goal of the chordee correction surgery is to straighten the penis and restore normal function. Chordee correction can be done by dorsal plication or a ventral lengthening procedure. The ventral lengthening procedure is done if there is a short urethra, which contributes to the penile curvature. If the urethra is normal with good penile length, then dorsal plications are preferred.
In the above-mentioned case, the penile length was good, and the urethra was normal, hence we proceeded with dorsal plication. In this procedur,e multiple (16 or 24) non-absorbable fine sutures are strategically placed on the convex side of the penis. These sutures are placed in pairs and in a parallel fashion to create plications in the tunica albuginea. Neurovascular bundles are carefully raised and saved from any injury before placing the plication sutures.
Important note for adult chordee
It is essential for adults considering chordee correction to have a thorough evaluation by a hypospadias specialist who specializes in penile reconstructive surgery. The surgeon will
Assess the type and degree of curvature, discuss the case and recommend the most appropriate surgical technique whether plication or a staged procedure. At hypospadias foundation, we get adults and children from all over the world in search of treatment for hypospadias and chordee. We provide support and information for children, adults and their families affected by hypospadias. Dr A K Singal is a highly experienced surgeon and regarded as the best hypospadias surgeon in India and in the world. He has dedicated his life towards treating children and adults with hypospadias. His expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias.
Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. Dr Singal and Dr Shenoy are deeply devoted to creating awareness and helping patients get the right treatment for hypospadias be it primary, redo or adult hypospadias. Children and adults from more than 25 countries visit our hypospadias foundation in search for cure and are cured of hypospadias. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.