|Year : 2000 | Volume
| Issue : 2 | Page : 134-139
Our experience with nesbit's procedure for chordee correction
Sulabha Punekar, Dhiren Buch, Atul Soni, G Swami, SR Rao, Sunil S Karhadkar, J Sathish Kinne
Department of Urology, King Edward VII Memorial Hospital, Mumbai, India
Dept. of Urology, K.E.M. Hospital, Parel, Mumbai - 400 012
Keywords: Nesbit′s Procedure; Chordee Correction
|How to cite this article:|
Punekar S, Buch D, Soni A, Swami G, Rao S R, Karhadkar SS, Kinne J S. Our experience with nesbit's procedure for chordee correction. Indian J Urol 2000;16:134-9
|How to cite this URL:|
Punekar S, Buch D, Soni A, Swami G, Rao S R, Karhadkar SS, Kinne J S. Our experience with nesbit's procedure for chordee correction. Indian J Urol [serial online] 2000 [cited 2013 Jun 18];16:134-9. Available from: http://www.indianjurol.com/text.asp?2000/16/2/134/22213
| Introduction|| |
In an adult male abnormal penile curvature usually presents with erectile deformity leading to difficulty in normal sexual activity. Penile chordee is due to congenital deformity with or without hypospadias and acquired due to Peyronie's disease. The surgical correction involves either lengthening the short side or shortening the long side. The method of shortening the long side was first described by Nesbit in 1965.  The technique involved excision of an ellipse from tunica albuginea. Using same technique 30 cases of penile chordee were subjected to Nesbit's procedure. No attempt was made to remove the plaque of fibrous tissue in cases of Peyronie's disease. Similar thing was described by Pryor and Fitzpatrick. 
| Material and Methods|| |
Nesbit's plication for chordee correction was performed in 30 patients, 16 having Peyronie's disease and 14 having congenital chordee curvature, i.e., chordee without hypospadias class IV.
Peyronie's disease: 16 patients presented with penile pain and difficulty during sexual intercourse, all cases had a palpable plaque in the tunica albuginea. Seven of these patients gave history of trauma during sexual activity and 2 patients had juvenile onset diabetes mellitus; a probable etiological factor for Peyronie's disease.
Congenital penile curvature: 14 patients presented with this condition and of these 9 were married who had extreme degree of difficulty in sexual intercourse. Five unmarried patients presented due to cosmetic disfigurement and apprehension.
All 30 patients presented with abnormal penile curvature. All cases with Peyronie's disease had pain and inability to perform sexual intercourse. None of the patients with Peyronie's disease had history of impotence or rapid detumescence. Among 14 patients with congenital penile curvature, 9 were married and had severe difficulty during intercourse. 5 unmarried males had never had sexual intercourse, but presented due to severe deformity.
Plaques were palpated in the tunica albuginea of stretched flaccid penis; location and approximate size was noted. Later 15 mg of papaverine hydrochloride was injected intracavernosally and the nature of chordee (dorsal/ventral/lateral), angle of deviation and length of erect penis were recorded and change of penile length on artificial erection was also noted. [Table 1],[Figure 1].
19 cases had ventral, 6 had dorsal, 3 cases had left lateral and 2 cases had right lateral chordee. All patient had more than 30° curvature and 5 unmarried patients with long penile curvature had deviation between 40° and 60°. All cases had adequate stretched penile length.
| Operative Procedure|| |
Preoperative counselling was done regarding the procedure and possible consequences thereof. Procedure was performed under regional anaesthesia.
The penis was degloved till the penoscrotal junction after circumcoronal incision. The skin along with the dartos fascia was reflected to expose the Buck's fascia which was then incised vertically to reach tunica albuginea. Artificial erection test of Gittes and McLaughlin was then performed. In the case of patients with ventral chordee, an ellipse of optimal dimension on the dorsum of tunica albuginea was marked out opposite the maximum concavity taking care not to damage the midline neurovascular bundle. The ellipse was excised taking care not to damage the underlying erectile tissue [Figure 2]. The defect was closed transversely with interrupted 5-0 proline stitches [Figure 3]. The artificial erection test was performed again. If the penis was not adequately straight ellipse/ellipses were excised (never more than 3) and the defect sutured as described above. Buck's fascia was closed with 4-0 vicryl and the skin sleeve was reapposed with 3-0 chromic catgut. In cases with dorsal chordee, the procedure was performed on the ventral surface, on the tunica albuginea and in patients with lateral chordee, on opposite lateral surface.
In cases of chordee without hypospadias, circumcoronal incision was made and dissection made in Dartos' layer and skin was de-loved till penile base. Artificial erection test was performed which demonstrated the location and character of curvature. Paraurethral wide dissection was done mobilizing the Buck's and Dartos' fascia surrounding the urethra. If the chordee still persisted after this manoeuvre, the chordee was obviously due to disproportionate corpus cavernosal bodies, i.e., fibrosis in the ventral aspect of corpus cavernosa - class IV chordee without hypospadias. Nesbit's procedure was performed as described above.
The patients were re-examined at the end of 3 months with intracavernosal papaverine injection. Morphological result in the form of straightening of penis as compared to the preoperative angle of deviation and any shortening in penile length were assessed. Functional results in the form of pain and resumption of sexual activity were recorded. Another examination was made at 1 year.
| Results|| |
After surgical correction, we based our results on the degree of residual chordee, resolution of penile pain and resumption of sexual activity and shortening of penile length.
No residual chordee or residual chordee less than 10° was excellent, between 10° & 20° was satisfactory, and chordee persisting beyond 20° was a poor surgical outcome.
Pain-free normal sexual activity without shortening, i.e., less than 1 cm was also categorized as an excellent functional result. Tolerable pain but resumption of sexual activity or shortening penile length between 1 & 2 cms was categorized as a satisfactory surgical outcome. Intolerable pain preventing sexual intercourse or penile shortening of more than 2 cm was a poor result. [Table 2].
26 patients had excellent morphological outcome and 3 had satisfactory result. I patient had poor outcome and was advised re-operation, but failed to follow up. Morphologically, 86% achieved excellent result [Table 3].
Of the 30 cases who underwent Nesbit's plication, 25 were married (16 with Peyronie's disease and 9 having congenital penile curvature). All married patients had normal sexual activity. 5 patients having congenital penile curvature were unmarried and in the age range of 14-16 years and till date are bachelors and have no sexual partners. All patients with Peyronie's disease had adequate resolution of pain after surgery. One unmarried male having congenital penile curvature had morphological result and failed to follow up. Hence, among the remaining 29 patients who had adequate morphological results, one patient had penile shortening of more than 2 cm and another patient had shortening of 1.6 cm. Both patients had no hindrance to their sexual lives [Table 4].
| Discussion|| |
Congenital or acquired chordee without hypospadias is due to inelasticity of one or more layers of the penis or disproportion between corpus cavernosa and corpus spongiosum. Peyronie's disease is a condition in which plaques of fibrous tissue are formed in the tunica albuginea. This is a benign, self-limited process of scar formation. Both these conditions usually lead to abnormal curvature of erect penis causing discomfort or inability to perform sexually.
Penile curvature can be corrected in one of the two ways. The short side could be lengthened, which in Peyronie's disease involves plaque excision and grafting the defect with dermis,  tunica vaginalis  temporalis fascia, or synthetic materials. The long side could be shortened either by tunical plication or excision of tunical ellipse as described by Nesbit. 
Nesbit  procedure was performed for correction of a congenital penile curvature in 1965. This was first used in Peyronie's disease in 1977 by Pryor and Fitzpatrick. 
Various modifications of this procedure have been described. A modified Nesbit procedure in which vertical incisions in the tunica albuginea are closed horizontally to correct the curvature was first described for Peyronie's disease by Lemberger et a1  , further modified by Yachia  and later reported by Sassine et al . 
Various treatment modalities have been tried for Peyronie's disease. Convervative measures like vitamin E,  DMSO, ultrasound therapy, iontrophoresis of steroids,  collagenase injection, , p-aminobenzoate  and corticosteroids have been tried over the years with uniformly unsatisfactory results.
The goal of therapy in penile curvature, congenital or secondary to Peyronie's disease, would be straight erection that is sufficiently rigid for satisfactory intercourse. Nesbit's procedure has yielded favourable results in correction of both congenital chordee and in Peyronie's disease as reported by many authors. ,,,,, In Peyronie's disease, Nesbit's procedure was undertaken after stabilization of the plaque in the tunica albuginea.
Nesbit's procedure involves excision of ellipse/ellipses of tunica albuginea and plication on the side opposite to that of deviation, resulting in a straightening of curvature. Penile shortening is inevitable but the magnitude of shortening is not significant in cases with adequate penile length preoperatively. It may affect the results in patients with short penile length. In this series, only two patients had shortening of penis more than 1 cm without any coital difficulty. Pryor et al  reported 5% incidence of shortening of penile length in their series of 359 patients. However only 6 (<2%) had coital difficulties because of shortening.
The diseased plaque is not removed in Nesbit's procedure and this does cause some concern. But with correction of curvature, the pain completely resolved in 80% and significantly decreased in the rest 20%. No patient had intolerable pain postoperatively. The plaque remained stable in the follow-up period. Pryor and Fitzpatrick  reported 100% pain relief after Nesbit's procedure in Peyronie's disease.
All patients were potent preoperatively and remained so. It is known that patients with Peyronie's disease may also have veno-occlusive dysfunction and/or arterial disease which should be evaluated preoperatively whenever suspected.
Morphologically excellent results were achieved in 86% and satisfactory in 96%. 1 patient had significant residual curvature (>30%) but was lost to follow-up. 25 patients were married and reported satisfactory resumption of coital activity with resolution of pain. 5 patients were unmarried and functional assessment was not possible though they had good morphologic outcome and pain resolution.
Pryor and Fitzpatrick  used Nesbit's procedure for the first time in Peyronie's disease and reported 85% success rate in 23 cases. Ralph & Pryor  published their 16 years' experience in Nesbit's procedure for Peyronie's disease stating 82% success rate in 359 cases. Gross  reported 100% success rate with Nesbit's procedure. Lemberger et a1  reported 95% success rate in Peyronie's disease. Yachia had good to excellent results in all his 19 patients.  Sassine et all described satisfactory cosmetic and functional correction of penile curvature in 95% patients. Benson and Patterson  had 100% success in 8 patients of Peyronie's disease with severe deformity and stated that Nesbit's plication is the best treatment for potent patients of Peyronie's disease [Table 5].
| Conclusion|| |
30 patients with abnormal penile curvature, 16 cases of Peyronie's disease and 14 cases of chordee without hypospadias class IV were selected for this study. The common clinical presentation was pain in 16 (52%) patients and difficulty at coitus in 25 (80%) patients. After documenting chordee by means of artificial erection test of Gittes & McLaughlin, the patients were subjected to Nesbit's procedure.
Postoperatively, morphological and functional results were assessed. Excellent morphological results were obtained in 26 patients (86%), residual curvature persisted in 3 patients (10%) but was not a hindrance to coital activity. Painless and satisfactory coital activity was possible in all 25 (100%) married males. One patient (3%) had a failed repair. Thus, Nesbit's procedure for the correction of abnormal penile curvature gives excellent morphological and functional results in cases having moderate to normal penile length.
| Acknowledgements|| |
We wish to thank Dr. P.M. Pai, the Dean of Seth G.S. Medical College and King Edward Memorial Hospital, Mumbai for permission and Mrs. Namrata P. Parab for the secretarial help.
| References|| |
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]