Does the dorsal plication matter with the results of primary hypospadias repair?

Abstract

Background

In this study, we aimed to evaluate the efficacy of dorsal plication (DP) in correcting mild-to-moderate ventral penile curvature (VPC) during primary hypospadias repair with urethral plate preservation.

Materials and methods

We retrospectively reviewed medical records of patients who underwent DP during primary hypospadias repair with urethral plate preservation between January 2018 and December 2021. Patients were categorized into 2 groups based on the degree of curvature following degloving: <30° (group 1) and 30° to 40° (group 2). Recurrent VPC, urethral complications, and pediatric penile perception scores were analyzed.

Results

Seventy-six patients met the inclusion criteria: 59 in group 1 and 17 in group 2. The incidences of recurrent VPC (1.7% vs. 5.9%; p = 0.928) and urethral complications (32.2% vs. 29.4%; p = 0.827) were comparable between groups. A total of 29 completed pediatric penile perception scores questionnaires were collected. No significant difference was observed in dissatisfaction with penile length (13.6% vs. 14.3%; p = 0.692).

Conclusions

Dorsal plication did not increase the rates of VPC recurrence, urethral complications, or dissatisfaction with penile length in cases with 30° to 40° VPC after degloving. Long-term follow-up with larger sample sizes is warranted to further assess the efficacy of DP.

1. Introduction

Hypospadias is a congenital malformation of the male external genitalia, characterized by an abnormally positioned external urethral meatus. This condition is typically accompanied by a ventral penile curvature (VPC). Adequate correction of VPC is crucial for the successful primary repair of hypospadias. Various surgical techniques have been developed to address VPC, following degloving of the penis and release of the fibrous band. These include dorsal tunica albuginea plication,^[1,2] extensive proximal urethral dissection,^[3] multiple ventral incisions in the tunica albuginea of the corpora (fairy cuts or three corporotomies),^[4] and ventral penile lengthening with corporeal patching,^[5] tailored to the etiology and degree of curvature.

Dorsal plication (DP) is a commonly employed method for correcting VPC,^[6] particularly in cases of urethroplasty that preserve the urethral plate. Compared with ventral corporoplasty, which is typically reserved for moderate-to-severe VPC and often involves urethral plate transection, DP is simpler to perform, results in less damage to the corpora cavernosum, and rarely leads to erectile dysfunction or tissue herniation. Given the importance of preserving the urethral plate, DP is a valuable technique for correcting mild-to-moderate VPC. However, the extent to which DP can effectively address VPC remains a topic of debate. Dorsal plication has been associated with a high recurrence rate of VPC, particularly in patients with moderate-to-severe curvature. Some urologists believe that DP may lead to penile shortening, which can significantly impact patient satisfaction with the postoperative appearance of the penis. Therefore, this study aims to evaluate the efficacy of DP in correcting mild-to-moderate VPC with urethral plate preservation, as well as its effects on complications and cosmetic outcomes.

2. Materials and methods

We conducted a retrospective review of consecutive patients who underwent primary hypospadias repairs performed by a single experienced surgeon at our institution between January 2018 and December 2021. The urethroplasty techniques used included tubularized incised plate and onlay preputial graft methods. The follow-up period for all patients exceeded 6 months.

The operation commenced with a circumcision, followed by penile skin degloving. After complete dissection of the fibrotic band and tunica dartos, the surgeon performed an artificial erection and measured the degree of curvature using a goniometer. Dorsal plication was performed to correct the VPC by placing 1 to 3 5-0 Prolene nonabsorbable sutures in the tunica albuginea at the site of maximum penile curvature, following mobilization of the dorsal neurovascular bundle over the tunica albuginea.^[7–9] All patients were reported to have a straight penis following the induction of repetitive artificial erection.

The urethral catheter was removed 3 to 4 weeks postoperatively. Patients were examined monthly for the first 3 months, and, when necessary, at 6 months, 1 year, and yearly thereafter. The follow-up period was defined as the duration from the first surgery to the last outpatient follow-up, during which recurrent VPC and common urethral complications were recorded. Pediatric penile perception score (PPPS) questionnaires were distributed to parents 12 months postoperatively.

The patients were divided into 2 groups based on the intraoperative evaluation of the VPC after degloving: <30° (group 1) and 30° to 40° (group 2). Statistical analyses were performed using SPSS version 25.0 software (IBM SPSS, Armonk, NY, USA), with p < 0.05 considered statistically significant. Quantitative data were expressed as medians and interquartile ranges (IQRs). The χ² test, Fisher's exact test, or the Wilcoxon rank-sum test was used to analyze the results between the 2 groups.

3. Results

A total of 76 patients were enrolled in the study, with a median age of 33.0 months (IQR, 24.1–43.8 months). The median follow-up duration was 21.0 months (IQR, 13.0–33.0 months). Of the patients, 59 (77.6%) had a VPC <30°, whereas 17 (22.4%) had a curvature of 30° to 40°. Detailed information on age at initial surgery, preoperative meatus location, urethroplasty procedure, use of DP sutures in the initial surgery, and follow-up periods for both groups is provided in Table 1.

Table 1.

Univariate analysis of characteristics in 2 groups according to the degree of VPC after degloving (n = 76).

Variable	Group 1 (<30°) n = 59	Group 2 (30°–40°) n = 17	p
Age at initial surgery, median (IQR), mo	32.5 (22.0–44.3)	38.5 (26.1–40.3)	0.503
Meatus location, n (%)			1.000
Distal	35 (59.3)	10 (58.8)
Middle	13 (22.0)	4 (23.5)
Proximal	11 (18.7)	3 (17.7)
DP sutures, n (%)			0.002
1 Suture	23 (39.0)	0 (0.0)
3 Sutures	36 (61.0)	17 (100.0)
Urethroplasty procedure, n (%)			0.416
Tubularized incised plate	52 (88.1)	13 (76.5)
Onlay preputial graft	7 (11.9)	4 (23.5)
Follow-up period, median (IQR), mo	21.0 (13.0–29.4)	21.0 (12.0–33.8)	0.627

DP = dorsal plication; IQR = interquartile range; VPC = ventral penile curvature.

During the follow-up period, 2 patients experienced recurrent VPC: 1 patient (1.7%) from group 1 and 1 patient (5.9%) from group 2 (p = 0.928) (Table 2). In group 1, 1 of 23 patients (4.3%) with a single DP suture experienced recurrent VPC, whereas none of the 36 patients with 3 DP sutures had recurrence. In group 2, all patients were treated with 3 plication sutures, and 1 patient (5.9%) experienced recurrent VPC. No statistically significant difference was observed in the recurrent curvature rates between the 2 groups in patients with 3 DP sutures (p = 0.321).

Table 2.

Univariate analysis of postoperative complications in 2 groups according to the degree of VPC after degloving (n = 76).

Complication, n (%)	Group 1 (<30°)	Group 2 (30°–40°)	p
Recurrent VPC	1 (1.7)	1 (5.9)	0.928
Urethrocutaneous fistula	9 (15.3)	3 (17.6)	1.000
Urethral diverticulum	2 (3.4)	0 (0.0)	1.000
Urethral stricture	2 (3.4)	2 (11.8)	0.456
Glans dehiscence	6 (10.2)	0 (0.0)	0.390

VPC = ventral penile curvature.

The incidence of urethral complications, including urethrocutaneous fistula (15.3% vs. 17.6%, p = 1.000), urethral diverticulum (3.4% vs. 0.0%, p = 1.000), urethral stricture (3.4% vs. 11.8%, p = 0.456), and glans dehiscence (10.2% vs. 0.0%, p = 0.390), did not differ significantly between the 2 groups.

A total of 29 PPPS questionnaires were completed by parents, including 22 from group 1 and 7 from group 2. In group 1, 3 parents (13.6%) and, in group 2, 1 parent (14.3%) expressed dissatisfaction with penile length. There was no significant difference in the dissatisfaction rate between the 2 groups (p = 0.692).

4. Discussion

The correction of VPC during hypospadias repair is crucial for achieving satisfactory cosmetic and functional outcomes, including a straight penis. Dorsal tunica albuginea plication is commonly used to correct mild-to-moderate corporeal disproportion, particularly in surgeries involving the urethral plate.^[10] Baskin et al.^[11] reported that 177 of 183 patients who underwent DP to correct VPC achieved straight penises. Wang et al.^[12] observed a lower rate of recurrent VPC in patients who underwent urethral plate transection combined with DP, compared with those who underwent urethral plate transection with simple skin degloving (28.6% vs. 50%, p = 0.093). A multicenter evaluation indicated that 99% of respondents performed DP to correct a VPC of 30° to 40°, whereas 54% preferred ventral correction for a VPC >50°.^[6] However, there remains no consensus on a clear cutoff for the degree of curvature that warrants DP. Some surgeons suggest ventral lengthening when the VPC is between 30° and 45°, as recurrence rates may be higher if DP is performed beyond this threshold.^[13–15] Braga et al.^[15] found that VPC recurrence was higher in patients who underwent DP compared with those who underwent ventral penile lengthening (27.9% vs. 9.4%, p = 0.03). Additionally, a curvature of over 45° preoperatively was less common in the DP group (64.7% vs. 96.8%). However, the potential influence of urethral plate transection on outcomes could not be excluded due to the limited sample size, which may have affected statistical significance.^[15] A meta-analysis found that recurrent curvature occurred in 31 of 122 patients (25.4%) who underwent DP alone but in only 24 of 460 (5.3%) patients who received ventral lengthening. Despite this, the degree of curvature before correction was not included in the analysis, making direct comparison challenging.^[16] Golomb et al.^[17] also reported an increased rate of recurrent curvature after puberty in patients who underwent DP, compared with those who underwent simple skin degloving (77% vs. 43%, p = 0.087). In the present study, 1.7% of cases with a curvature of <30° and 5.9% of cases with a curvature of 30° to 40° developed recurrent VPC; however, no statistically significant difference was found in recurrence rates between the groups. Therefore, DP appears to be effective for correcting VPC in the 30° to 40° range without significantly increasing the risk of recurrence. The degree of curvature in this study was objectively measured using a goniometer. Although surgeons can easily identify a straight penis or one with a curvature of 90°, it remains challenging to precisely measure curvature between these extremes.^[14] Accurate assessment using a goniometer, as opposed to visual inspection, is essential, as underestimation of the curvature could influence the therapeutic evaluation of DP.

In this study, DP was performed by placing 1 or 3 nonabsorbable sutures in the tunica albuginea at the point opposite the maximum curvature. Some experts suggest that correction with multiple sutures is more effective than with a single suture, as residual curvature is more common when only 1 suture is used.^[9] The recurrent curvature rate in patients with 3 sutures was not significantly different between the VPC <30° and 30° to 40° groups, suggesting that 3 sutures are sufficient for achieving satisfactory results. Repeated artificial erection was performed after DP to confirm complete correction of VPC during surgery.

Penile length loss after DP is a critical concern, particularly in proximal hypospadias repair or for severe curvature correction.^[18–20] Shortening of 1 to 1.5 cm has been reported in approximately 85% of patients who underwent DP for penile curvature correction in Peyronie's disease, although penile shortening rarely leads to sexual dysfunction.^[21] Parents, particularly in cases of severe hypospadias, may be concerned about potential changes in penile size postsurgery. Although length loss has been emphasized, it may not always be of critical importance. However, specific measurement data on penile length after degloving and plication procedures were lacking in most cases of this study. As a result, the PPPS, a subjective cosmetic assessment instrument, was used to evaluate the influence of DP on penile length. Cosmetic evaluations of penile length did not differ significantly between patients who underwent DP for VPC <30° or 30° to 40°. Nonetheless, only 29 parents completed the PPPS questionnaire, with others declining to participate due to concerns about their child's privacy, leading to a potential selection bias in the results.

Several postoperative complications associated with DP have been reported. Nyirády et al.^[2] published long-term follow-up data on 54 patients with congenital curvature, with no erectile dysfunction postoperatively. However, decreased sensation in the penis was noted in 3 cases, and palpable nodules were present in 12 patients.^[2] In a more recent study by Akdemir et al.,^[22] DP was performed on 72 patients with an average curvature of 43.66° (range, 35°–60°). At a 7-year follow-up, no patients experienced painful erections or loss of erectile function or sensation, although 2 patients did report palpable sutures during the postoperative period. In our study, no patients exhibited palpable sutures or pain during erection at follow-up. Given the relatively young age of most patients in this study, long-term observation is necessary to fully evaluate the potential for erectile dysfunction and other complications related to sexual function.

5. Conclusions

Dorsal plication for correcting VPC of 30° to 40° during hypospadias repair with urethral plate preservation did not increase the rates of recurrent VPC, urethral complications, or dissatisfaction with postoperative penile length. Performing an artificial erection test and objectively measuring the curvature using a goniometer are critical steps to ensure adequate correction. Long-term follow-up is necessary to assess the sustained efficacy and safety of DP in this patient population.

Acknowledgments

None.

Statement of ethics

This study was conducted in accordance with the World Medical Association's Declaration of Helsinki. All participants' parents signed a written informed consent form. Approval was granted by the Ethics Committee of Shandong Provincial Hospital (SWYX no. 2022–454).

Conflict of interest statement

The authors declare no competing financial or nonfinancial interests related to this work.

Funding source

None.

Author contributions

WL, RW, XW: Study conception and design;

XW, GD, HW, ZL, YH, YX: Material preparation, data collection and analysis;

YX, GD: Drafting of the manuscript;

WL, RW, YW: Critical revision.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.