International Urology and Nephrology (2019) 51:1313–1319 https://doi.org/10.1007/s11255-019-02163-9 UROLOGY - ORIGINAL PAPER Procedures used for correction of isolated penile torsion: are they competitive or complementary? Hamed M. El Darawany1 · Mahmoud E. Al Damhogy2 · Mohamed S. Kandil2 · Mohamed E. ELkordi2 · Salah A. Nagla3 · Mohamed R. Taha3 Received: 9 March 2019 / Accepted: 29 April 2019 / Published online: 10 May 2019 © Springer Nature B.V. 2019 Abstract Objectives To report our experience in starting the correction of penile torsion, whatever its degree (moderate or severe) with one or more simple procedures either separately or complementary in the same session. Patients and methods Between 2013 and 2018, 62 patients who have signifcant isolated penile torsion (> 45°) were involved in this study. Those patients were subjected to either simple degloving with skin reposition, degloving with skin overcor‑ rection and/or dartos fap procedures. Those procedures were performed either separately or complementarily. All patients were examined postoperatively after 7 days and followed up at 3, 6, and 9 months postoperatively. Results 37 out of 62 patients had a moderate degree (45–90) of penile torsion; 21 of them were corrected using skin deglov‑ ing–reattachment technique, 11 patients were corrected by degloving with skin overcorrection, and in the remaining 4 patients dartos fap technique was used for correction. In 25/62 patients who had severe degree (> 90°) of torsion; 9 patients were managed by degloving with skin overcorrection, while in 13 patients the procedure was shifted to dartos fap technique, and the remaining 3 patients, 2 of whom had 180° torsion, were managed by dartos fap with added skin overcorrection. Conclusion Performing degloving and skin reattachment with or without skin overcorrection procedure and dartos fap procedure either separately or complementarily in the same patient whatever the degree of torsion (moderate or severe) is associated with good results and can protect some patients from exposure to more difcult and extensive procedures as corporopexy and corporeal plication. Keywords Penile torsion · Degloving · Dartos fap · Corporopexy Introduction * Hamed M. El Darawany [email protected] Congenital penile torsion is rotation or twist of the penile Mahmoud E. Al Damhogy shaft along its longitudinal axis. It is usually counterclock‑ [email protected] wise and may occur independently or in association with Mohamed S. Kandil other penile anomalies such as hypospadias. Torsion of the [email protected] penis can vary in severity ranging from 30° in mild cases Mohamed E. ELkordi to 180°. The true incidence of this anomaly is unknown; [email protected] however, the incidence of isolated penile torsion is 1.7–27%, Salah A. Nagla and torsion of more than 90° is reported in 0.7% of the cases [email protected] [1, 2]. Mohamed R. Taha Most of the children who present with penile torsion are dr‑[email protected] asymptomatic; however, the parents usually wish to correct the penile torsion for the cosmetic defect and their concern 1 Urology Department, Faculty of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal about future functional defect. Actually, it is hard to know University, P.O. Box 40076, 31952 Alkhobar, Saudi Arabia how much of a functional problem this malformation causes 2 Tanta Insurance Hospital, Tanta, Egypt in adults. It has been reported that no patient has complained of sexual dysfunction related to penile torsion [3]. 3 Urology Department, Tanta University, Tanta, Egypt Vol.:(0123456789)1 3 1314 International Urology and Nephrology (2019) 51:1313–1319 The etiology and pathogenesis of congenital penile tor‑ straight at the end of the repair. If this technique is not enough sion are not exactly known [4–6]. It might be due to abnor‑ and signifcant penile torsion persists, the procedure is shifted mal skin attachment, or abnormal development of the dartos to dartos fap technique. fascia that causes disorientation of the penile shaft and cor‑ Under general anesthesia, penile degloving was performed poreal torsion around its longitudinal axis [4]. by circumferential incision 5 mm proximal to the coronal sul‑ Several techniques have been described to correct penile cus, followed by degloving of the penile skin up to the penile torsion, but none of them has gained consensus as an opti‑ base and skin reattachment and assessment of post‑correction mal, ideal and versatile technique. Those techniques vary penile torsion by artifcial erection. from simple degloving of the penis with repositioning of To perform the dartos fap technique, after a subcoronal the penile skin to more complex techniques involving the circumferential incision, the dartos fap is created by dissec‑ corporeal tissue. If the penile torsion is less than 45°, surgi‑ tion between the undersurface of the dorsal penile skin and the cal correction is not considered. Correction of penile shaft Buck’s fascia downward up to the penopubic junction (Fig. 2). skin torsion by skin degloving and realignment [7] can be The fap was rotated around the penis against the direction of sufcient for correction of mild torsion of less than 90°. penile torsion (Figs. 3, 4) and then sutured to the ventral aspect However, when it comes to cases of 90° or more, another of the shaft of the corpus cavernosum with absorbable sutures procedure should often be done such as suturing the tunica PDS 5/0 with an amount of tension. The dartos fap can be albuginea to the periosteum of the pubis (corporopexy) [5], sutured to the lateral side of the corpus cavernosum or even dorsal dartos fap rotation [8], or diagonal corporeal plica‑ to the dorsum of the corpus if needed for proper correction of tion sutures parallel to and away from the neurovascular the penile torsion. The amount of fap rotation was adjusted bundle [9]. during the operation until satisfed correction was reached. The From our point of view, a simple technique (skin deglov‑ catheter was fxed in the frst two cases who needed dartos fap ing) should be started in any patient with isolated penile tor‑ technique aiming not to injure the urethra during fxation of sion. If penile torsion persists after artifcial erection, more the dartos fap on the ventral surface of the penis and it was techniques should be considered in the same session till removed at the end of the procedure. Later on during the study, complete correction of penile torsion is gained. The aim of we did not use Foley catheter. this study is to report our experience in starting the correc‑ Residual penile torsion more than 30° after dartos fap tion of penile torsion, whatever its degree, with one or more positioning could be managed by skin overcorrection proce‑ simple procedures either separately or complementarily in dure in which the skin realigned with some degree of over‑ the same session. rotation against the direction of residual penile rotation by suturing of the penile skin using Vicryl 5/0 at 6–7 o’clock (point 1) to the glanular skin at 1–2 o’clock (point 2) ven‑ Patients and methods trally as shown in Fig. 5a and/or suturing the penile skin at 12–1 o’clock (point 1) to the glanular skin at 10–11 o’clock All patients who came asking for circumcision between 2013 (point 2) dorsally as shown in Fig. 5b to bring the penis in a and 2018 were examined for any penile abnormalities. In straight non‑rotated position. those who had penile torsion, the degree of penile torsion The residual penile torsion less than 30° was consid‑ was calculated after putting the penis in a straight upright ered as a satisfactory result. At the end of the procedure, position with a simple protractor. Only patients who had the penile skin was refashioned and the excess skin was isolated penile torsion were categorized according to the excised. The penile skin was realigned using Vicryl 5/0 angle of torsion to mild (< 45°) torsion, moderate (45°–90°) sutures (Fig. 6), and then fucidin ointment was applied to and severe (> 90°). The direction of penile torsion was also the suture line followed by application of a simple gauze evaluated if it was clockwise or counterclockwise. Those around the penis. This simple dressing was removed on the who had mild degree of torsion were circumcised without frst postoperative day. correction, while those who had moderate or severe degree All patients were seen after 7 days and followed up at 3, of isolated penile torsion were included in the study and 6, and 9 months postoperatively. scheduled for correction. Usually, we correct penile torsion at the age of 6 months and thereafter. According to the algorithm shown in Fig. 1, Results our policy is to start correction of any case of penile torsion, whatever the degree of torsion (moderate or severe), with the From the 1650 children who came for circumcision, 514 skin degloving–reattachment technique. If the penile torsion (31.2%) had isolated penile torsion. 452 of them (27.3%) had is not resolved with degloving of the shaft skin, the skin is penile torsion less than 45°, while 62 patients (3.7%) were reattached in an over‑rotated fashion to allow the penis to be found to have signifcant isolated penile torsion (more 45°). 1 3 International Urology and Nephrology (2019) 51:1313–1319 1315 Fig. 1 Algorithm used for penile torsion corrections In 37 patients (2.2%), the torsion was moderate (from 45° to 90°) and in the other 25 patients (1.5%) the torsion was severe (more than 90°). 2 of them had 180° penile torsion. Of the 62 patients, 3 had clockwise torsion and the remaining 59 had torsions in the counterclockwise direction. Patients with penile torsion less than 45° were circumcised without correction.