Long-Term Followup of Dermal Grafts

for Repair of Severe Penile Curvature

Hesham Badawy* and Hani Morsi
From the Department of Urology, Cairo University, Cairo, Egypt

Purpose: There is some reluctance to use dermal grafts for augmenting the tunica albuginea to correct severe forms of
chordee. The main concern is that by violating the integrity of the tunica albuginea venous leakage could presumably ensue
and result in erectile dysfunction. We present our long-term followup of dermal grafts used to correct severe penile curvature
associated with hypospadias or as an isolated malformation.
Materials and Methods: A total of 16 patients received a single dermal graft harvested from the nonhair bearing inguinal
skin fold. Patient age was 1 to 19 years (average 7). Of the patients 14 had hypospadias, which was scrotal in 12 and perineal
in 2, while 2 had congenital penile curvature. In the hypospadias group 13 patients underwent primary repair and 1 had
undergone 2 previously failed repairs with persistent severe curvature. Additionally, 5 patients in the hypospadias group had
associated penoscrotal transposition. Eight patients in the hypospadias group received testosterone injections preoperatively.
Results: Average followup was 10 years (range 6 to 15). At the time of the study all patients were postpubertal and 3 had
married. Evaluation of the results was based on patient interview reporting of penile straightness, erectile quality and
satisfaction with sexual relations, if present. Two of the 3 patients who married reported satisfactory sexual activity and 1
had fathered children. The other 13 patients reported rigid erections. Two patients had mild residual curvature that would
not necessitate any further intervention.
Conclusions: Some boys with severe penile curvature, particularly those with hypospadias and a borderline size phallus,
need a dermal graft rather than a plication procedure to correct curvature. Our study suggests that using dermal grafts is
safe for erectile function.
Key Words: hypospadias, penis, transplants, dermis, penile erection

here is always some reluctance to use a ventral graft

for augmenting the tunica albuginea in cases of severe
curvature associated with hypospadias. 1) The procedure may have to be staged. 2) There is justifiable concern
about violating the integrity of the tunica albuginea, which
could endanger its veno-occlusive mechanism. This concern
probably stems from published literature on the use of grafts
to treat Peyronies disease.13
Different materials have been used for corporeal grafting,
including dermis, tunica vaginalis, porcine small intestine submucosa, dura and pericardium with good results.4 10 Because
of concern with the long-term outcome of these grafts, we
looked at our patients who had received a dermal patch graft to
correct extensive penile curvature after they attained puberty
or became sexually active about 10 years after the procedure.

MATERIALS AND METHODS

Between 1992 and 2000, 16 patients underwent surgical
correction of severe penile curvature using a dermal patch
graft (table 1). Patient age at surgery was 1 to 19 years
(average 7). Of the patients 14 had hypospadias, which was
scrotal in 12 and perineal in 2. In addition, 5 patients had
penoscrotal transposition. In 13 patients repair was pri-

* Correspondence: 16 Abou Bakr Seddik St., Giza, Egypt, 12411

(telephone: 20122147341; FAX: 20237617316; e-mail: heshbadawy@
gmail.com).

0022-5347/08/1804-1842/0
THE JOURNAL OF UROLOGY
Copyright 2008 by AMERICAN UROLOGICAL ASSOCIATION

mary, while 1 had undergone 2 previously failed repairs

with persistently severe chordee. Eight patients received
preoperative testosterone injections at the discretion of the
attending surgeon. In all 14 patients the procedure was
staged with urethroplasty performed at stage 2 at least 6
months later. The urethra was constructed as a Duplay tube
from the ventrally transferred preputial skin in 13 primary
repairs and from the surrounding penile skin in 1 patient
who had undergone 2 previously failed repairs.
Two patients who were 18 and 19 years old, respectively.
had congenital penile curvature, which was ventral (80 degrees) in 1 and left lateral (60 degrees) with rotation in the
other. The latter patient had undergone prior repair with
plication only and severe curvature persisted. In the former
patient an island of tunica albuginea was excised from the
dorsum, while the latter received a single dermal graft at the
site of maximum concavity and excision of an island of
tunica albuginea at the site of maximum convexity to
achieve complete straightening.

TECHNIQUE
The decision to use a dermal graft is always made intraoperatively. After exhausting all attempts at straightening,
including division of the urethral plate and proximal mobilization of the urethra with division of any residual tissue,
artificial erection is done. If curvature is still 40 degrees or
more, the decision is made to augment the deficient aspect of

1842

Vol. 180, 1842-1845, October 2008

Printed in U.S.A.
DOI:10.1016/j.juro.2008.04.082

LONG-TERM FOLLOWUP OF DERMAL GRAFTS FOR SEVERE PENILE CURVATURE

1843

TABLE 1. Patient characteristics

No. pts
No. pathological finding:
Scrotal
Perineal
Ventral curvature
Lt lat rotation
Age (yrs)
No. penoscrotal transposition
No. preop testosterone
No. primary repair
Procedure
Urethroplasty

Hypospadias

Congenital
Penile
Curvature

14

12
2
117
5
8
13
Dermal grafts
Stage 2 Thiersch-Duplay
tube from transferred
dorsal skin prepuce

1
1
18 19
Not applicable
0
1
Dermal graft
albugineal
island excision
None

the penis with a graft (fig. 1). We used a single dermal patch
harvested from the nonhairy inguinal skin fold in all patients. An area of 3 2 cm is delineated and the graft is
harvested. The graft is subsequently trimmed according to
the size of the created defect.
Artificial erection is repeated and at the point of maximum curvature the tunica albuginea is incised a full half
circle from the 3 to 9 oclock positions and not less (fig. 2). The
septum is included in the incision. These 2 maneuvers are
important to allow full straightening. Care is taken to elevate
Bucks fascia on the lateral aspect of the penis to enable proper
extension of the incision without injuring the nerves that
course lateral in this position. Care also is taken to incise only
the tunica and avoid the cavernous tissue as much as possible.
The harvested graft is trimmed to an elliptical shape to fit
loosely in the created defect. The graft is secured in position
in 4 quadrants using 6-zero polyglycolic acid suture. Two
stitches are used to fix the graft to the septum. The graft is
attached to the edge of the tunica albuginea using a running

FIG. 2. Tunical incision is full half circle. Graft should balloon

slightly because it is 20% to 30% larger than defect.

stitch in each of the 4 quadrants. Artificial erection is repeated to ensure complete orthoplasty and absent leakage.
Any leakage is addressed with more stitches. Early on we
made the fatty side (subcutaneous side) of the graft face
outward. However, it does not seem to make a difference if it
faces the cavernous side.
RESULTS
Average followup was 10 years (range 6 to 15). All patients
are currently postpubertal and 3 have married.
Our aim was to determine whether violating the integrity
of the tunica albuginea by applying a dermal graft would
adversely affect erectile function during extended followup,
particularly after the changes of puberty have occurred.
Evaluation was based on patient interview reporting on 3
specific questions, including 1) erectile quality (hard and
satisfactory or not), 2) penile straightness, and 3) sexual
activity and whether it was satisfactory.

TABLE 2. Results

FIG. 1. Phallus with extensive curvature (about 80 degrees)

Overall
Penile straightness:
Straight
Mild dorsal curve (overcorrection)
Mild residual curvature
Erectile quality:
Hard
Less than preop
Sexual activity:
Not quantified
Married, satisfied (father)
Married, satisfied
Married, weak erections

No.
Hypospadias

No. Congenital
Penile Curvature

14

13
1
2
14

1
1

13
1
1
1

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LONG-TERM FOLLOWUP OF DERMAL GRAFTS FOR SEVERE PENILE CURVATURE

FIG. 3. Dorsal curvature (overcorrection) in patient in hypospadias

group.

In the hypospadias group 13 of 14 patients had straight

erections (table 2). Paradoxically 1 patient had mild dorsal
curvature or overcorrection (fig. 3). All 14 patients had hard
erections. Only 1 patient had married. He was satisfied with
his sexual performance and has fathered children.
In the congenital penile curvature group the 2 patients
had mild residual curvature that did not necessitate further
correction. They were satisfied about the appearance. In
regard to erectile function 1 patient who had ventral curvature currently had hard erections. He was married and
satisfied with his sexual performance. However, the other
patient complained that the quality of erections was less than
preoperatively. He had married 3 months previously, and complained of weak erections and the fact that he used sildenafil to
improve sexual performance. Clinical examination revealed a
weakened, depressed area on the left lateral aspect of the
tunica albuginea that corresponded to the graft. When we
reviewed his operative pictures, we found that the applied
dermal graft was unduly blown out (fig. 4). Could this have
resulted in a weakened graft that was responsible for erectile
dysfunction? He was referred to an andrologist for evaluation.
Intracavernous administration of 0.25 ml trimix solution (10
g prostaglandin E1, 6 mg papaverine and 1 mg per ml phentolamine) produced a rigid erection that lasted for 35 minutes.
The patient thereafter attended 2 followups with the andrologist and was satisfied with his sexual performance.

thermore, we believe that it is better to lengthen the shorter

ventral aspect of an already modest organ than shorten its
longer dorsal aspect. In our study 8 of 14 patients (57%) in
the hypospadias group received preoperative testosterone,
attesting to the modest size of the phallus.
Vandersteen and Husmann reported the late onset of
recurrent penile chordee 10 years after successful hypospadias repair in 22 patients.11 Overall 68% of patients had
corporeal disproportion.
In the study by Gershbaum et al of 34 patients with
perineoscrotal hypospadias and severe chordee the results of
a staged approach were superior to those of 1-stage repair.12
In 11 patients who underwent 2-stage repair chordee was
corrected by dermal or tunica vaginalis grafting of the ventral tunica albuginea. None of these cases showed residual
curvature at a minimum of 5 years of followup. In contrast,
5 of the 23 patients (24%) who underwent 1-stage repair
with chordee corrected by Nesbit or tunica albuginea plication had residual chordee.
Normally stretching and elongation of the tunica albuginea during erection crimps the emissary veins, resulting in
veno-occlusion. The main concern of using a graft to augment the tunica albuginea is the fear of jeopardizing these
veno-occlusive properties, which are responsible for rigid
erection. Indeed, this is not a theoretical concern. Early
reports of venogenic impotence associated with grafts to
treat Peyronies disease have aggravated these concerns.1
However, the 2 populations are different, not only in age, but
also in the pathogenesis of the condition.
There are few long-term outcome studies in older postpubescent individuals who had undergone proximal hypospadias repair in early childhood. Most investigators tend to
evaluate overall sexual behavior and function as well as
adult satisfaction after hypospadias surgery. The relationship between the technique used and the outcome is not
clear.1316 We specifically wanted to see whether there are
any ill effects of applying a graft to the tunica albuginea on
long-term erectile function.
All 14 patients in the hypospadias group were beyond
puberty and all had straight hard erections. One of the 2
patients with congenital penile curvature had hard erections
with mild residual curvature not necessitating intervention,
while the other complained of weak erections and was on
oral phosphodiesterase inhibitors (sildenafil) to improve
erectile quality. However, intracavernous injection of trimix
solution administered by a third party produced a rigid
sustained erection, which probably negates veno-occlusive
dysfunction. Probably more study is needed to ascertain the
safety of grafts in this population.

DISCUSSION
Children with hypospadias and extraordinary chordee usually have significant disproportion between the dorsal and
ventral aspects of the corpora cavernosa.6,7 It is imperative
to ensure complete penile straightening at primary repair.
Incomplete correction of curvature may necessitate repeat
surgery despite successful urethroplasty. Dorsal plication is
not sufficient to correct curvature of this magnitude. Fur-

FIG. 4. Graft blowout applied to penile left lateral aspect

LONG-TERM FOLLOWUP OF DERMAL GRAFTS FOR SEVERE PENILE CURVATURE

CONCLUSIONS
Dermal grafts are a safe and indispensable tool for severe
penile curvature associated with hypospadias. This longterm followup beyond puberty suggests that they do not
affect erectile function. It is better to undergo a planned
rather than a forced 2-stage procedure. In patients with
congenital penile curvature probably more study is needed
to ensure the safety of grafts.
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