Should We Routinely Test for Chordee in Patients

Original Article

Should We Routinely Test for Chordee in Patients with Distal Hypospadias? David Terence Thomas2

Aliye Kandirici2

1 Division of Pediatric Urology, Department of Pediatric Surgery,

Marmara University School of Medicine, Istanbul, Turkey 2 Department of Pediatric Surgery, Marmara University School of Medicine, Istanbul, Turkey

Sevim Yener2

Tolga Dagli1

Address for correspondence Halil Tugtepe, MD, Division of Pediatric Urology, Department of Pediatric Surgery, Marmara University School of Medicine, Mimar Sinan Cad No. 41, Fevzi Cakmak Mah Pendik, Istanbul 34034, Turkey (e-mail: [email protected]).

Eur J Pediatr Surg

Abstract

Keywords

► chordee ► distal hypospadias ► TIPU

Objectives The aim of this study was to determine the incidence of chordee in distal hypospadias and compare our intraoperative findings with those reported by the families of patients and to determine if routine testing for chordee should be performed in patients with distal hypospadias. Material and Methods Surgical reports and medical files of distal hypospadias patients operated from January 2008 to January 2013 were prospectively reviewed. The type of hypospadias, family’s report of chordee, intraoperative finding of chordee and its degree were noted. All patients were tested for chordee intraoperatively after degloving. Results A total of 156 patients of which 27 had glandular, 61 coronal, and 68 subcoronal hypospadias were included in the study. Chordee was found in 52 patients (33.3%) intraoperatively, whereas only 15 families (9.6%) reported chordee preoperatively. Conclusion There is risk of chordee in patients with distal hypospadias that needs to be accurately identified and corrected. Families are not always aware of the presence of chordee.

Introduction Hypospadias, the most common congenital defect of the male genitalia occurring in approximately 1 in 125 to 200 live births, is caused by incomplete development of the urethra and can be accompanied by genital malformations.1–3 The urethra is proximally ectopically positioned and on the ventral aspect of the penis, the foreskin on the ventral surface is deficient and anomalies such as cryptorchidism, inguinal hernia, and chordee may be present.1,4 Chordee, referring to ventral curvature of the penis,4 can be caused by atrophy of the corpus spongiosum, fibrosis of the tunica albuginea and fascia over the tunica, tightness of the ventral skin and Buck fascia, tethering of the penile shaft skin onto the underlying structures or tethering of the urethral plate onto the corpora covernosa.4,5

received August 29, 2013 accepted after revision December 4, 2013

Chordee may only be noticeable with, and becomes more prominent with, penile erection. Chordee is mostly associated with severe hypospadias, and evidence is weak on its general incidence with scarce published articles, especially in patients with distal hypospadias.1 The determination and correction of chordee is shown to have a positive impact on confidence, self-esteem, and future sexual function.6 The aim of our study was to determine the incidence of chordee in patients with distal hypospadias to determine if chordee testing should be routinely performed in all hypospadias repairs.

Material and Methods At our institute, all patients operated for hypospadias are routinely checked for chordee using the Gittes test,7 after

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DOI http://dx.doi.org/ 10.1055/s-0034-1368797. ISSN 0939-7248.

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Halil Tugtepe1

Tugtepe et al.

queried regarding the presence of penile curvature, especially when penile erection was observed. A descriptive analysis of all data was later performed. For all patients in this study, an artificial erection (Gittes test7) was used for intraoperative diagnosis of chordee. The measurements of the degree of chordee were performed by the same surgeon and always after degloving. Chordee was measured using a goniometer and defined as mild if between 15 and 30 degrees, moderate if between 30 and 40 degrees, and severe if over 40 degrees (►Fig. 1). Chordee was corrected by plication corporoplasty, the Baskin technique was used for chordee between 15 and 30 degrees and the Nesbit technique for chordee above 30 degrees. A second Gittes test was performed to confirm correction of chordee before moving on to hypospadias correction. At discharge, all parents were instructed to observe erections, looking for the presence of chordee. During follow-up, the same operating surgeon evaluated each patient on the postoperative 1st, 6th, and 12th months and yearly thereafter. Physical examination and chordee questioning was performed.

Results

Fig. 1 Subcoronal hypospadias before (a) and after (b) performing an erection test showing 40 degrees of chordee as measured using a digital goniometer (c). The patient’s family had reported no chordee in a preoperative interview.

degloving. From January 2008 until January 2013, distal hypospadias patients’ surgical data was prospectively collected. When the patients presented to our out-patient clinic, parents and if old enough the patients themselves were

A total of 156 patients underwent distal hypospadias repair during the aforementioned time period. Data were available for all patients. Of these patients, 27 had glandular, 61 had coronal, and 68 had subcoronal hypospadias. Average age at surgery was 42.5 months (range 5 mo–15 y). No patient had previous hypospadias surgery and no comorbidities were noted. Penile curvature was seen and corrected in 33.3% (n ¼ 52) of patients. Of these patients, 78.8% (n ¼ 41) had mild and 9.6% (n ¼ 5) had moderate and 11.5% (n ¼ 6) severe curvature. The incidence of penile curvature was 3.7% for glandular (n ¼ 1), 23.0% for coronal (n ¼ 14), and 54.4% for subcoronal (n ¼ 37) hypospadias (►Table 1). Only 9.6% of parents (n ¼ 15) reported penile curvature preoperatively. Report of penile curvature by parents grouped by the type of hypospadias is shown in ►Table 1. Of 15 parents who reported penile curvature, 60% (n ¼ 9) did indeed have chordee requiring surgical correction, while in

Table 1 Parents’ report and intraoperative finding of penile curvature, grouped by hypospadias type, and severity of chordee

Glandular

Coronal

Subcoronal

Parents’ report (n)

Chordee test (n)

Mild chordee

Moderate chorde

Severe chordee

Positive

0

1

1

0

0

Negative

27

26

Total

27

27

Positive

2

14

10

2

2

Negative

59

47

Total

61

61

Positive

13

37

30

3

4

Negative

55

31

Total

68

68

European Journal of Pediatric Surgery


Routine Test for Chordee in Patients with Distal Hypospadias

141 parents who reported no curvature, 30.5% (n ¼ 43) had chordee over 15 degrees. Patients’ average follow-up was 13.5 3.2 (range 7–53) months. No patient or family reported chordee postoperatively.

Discussion Hypospadias is the most common male genital anomaly and literature reports an unexplained increasing trend.3,8 Hypospadias is associated with a spectrum of anomalies, one of which is ventral curvature of the penis. Children with hypospadias have a normal onset of puberty and most have normal testicular and androgen end-organ functions.9,10 Fertility is not effected unless the patient has an associated anomaly such as cryptorchidism and chromosomal abnormality, and sexual function should be normal after successful hypospadias repair.4,11,12 As the presence of chordee causes sexual dysfunction, painful erection, fertility problems, low selfesteem, and low confidence,6 its identification and repair is essential. There are many techniques described for the repair of penile curvature with or without hypospadias.13–19 The incidence of penile curvature associated with hypospadias is not clear. Baskin et al20,21 found significant penile curvature in 25% of patients after releasing the skin and dartos in patients with hypospadias who underwent island flap reconstruction. Samuel et al22 reported that in their series of 381 boys with distal hypospadias, none required chordee correction. Snodgrass et al23 reported that curvature is not a problem in distal hypospadias and that it should be part of the standard evaluation during surgery for proximal hypospadias. Our data demonstrates that 33.3% of patients with distal hypospadias had penile curvature, suggesting that chordee is in fact a problem in patients with distal hypospadias too. Although literature reports surgical correction for chordee above 20 degrees,1,23,24 it is our institutional policy to surgically correct any penile curvature greater than 15 degrees, due to feedback received from parents before the commencement of this study. Even if we remove patients with chordee between 15 and 20 degrees (n ¼ 13, 1 coronal and 12 subcoronal), the incidence is 25.0%. Stojanovic et al1 performed a study to determine the incidence of penile curvature in patients with hypospadias. They separated patients into two groups: patients in group 1 were intraoperatively tested for curvature as a standard procedure and patients in group 2 curvature was only formally assessed in severe, proximal hypospadias or it was incidentally observed in other milder forms of hypospadias. The incidence of penile curvature in distal hypospadias patients in group 1 was found to be 31.25% whereas for distal hypospadias patients in group 2 the incidence was 14.0% (p < 0.01). Similarly, in a series of 454 patients, Djordjević et al24 similarly compared two groups of patients composed of all types of hypospadias. Group 1 was routinely checked for the presence of chordee intraoperatively whereas patients in group 2 were not. While the incidence of penile curvature in group 1 was 31.6%, the rate was only 11.6% in group 2 (p < 0.01).

Tugtepe et al.

In our patient group, only 9.6% of parents were aware of their child’s penile curvature, whereas the actual incidence was 33.3%, demonstrating that parent observation is not in itself enough to determine the presence or absence of chordee. Although it may be argued that 66.7% of patients underwent the Gittes test unnecessarily, it is also true that a vast majority if not all of 33.3% of patients in which chordee was detected would need additional surgery at a later date for chordee correction, had this test not been performed. We suggest that testing for chordee during hypospadias surgery should not be based on patient history or the personal preference of the surgeon, but be routinely used. Similarly, it could be suggested that a drawback of this study is the lack of chordee test at follow-up as we have shown that parents’ observations are inadequate. However, it is not justifiable to perform a chordee test under general anesthesia to these patients during follow-up. Ekmark et al suggested that patients who underwent surgery with hypospadias should be followed until after they reach puberty with standardized follow-up protocols as incurvation may occur during puberty.25

Conclusion Our data shows that even in cases of distal hypospadias there is unavoidable risk of chordee that should be accurately identified and corrected. Families are not always aware of its presence.

Conflict of Interest None.

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