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Congenital true diphallia, complete duplicate bladder, bladder exstrophy, and anorectal malformation in a child are uncommon. Here, we present the case of a 3-year-old boy with multiple genitourinary malformation, including true diphallia, complete duplicate bladder, bladder exstrophy, epispadias, and anorectal malformation. Multi-departmental collaborative treatment for complex conditions ultimately achieved an ideal appearance for this patient. All vital signs were stable after the surgery and they remained consistent during follow-up. In such cases, surgical correction is individualized to achieve adequate urinary continence and erection with adequate esthetics., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To report the technique and outcomes of tissue expansion (TE) for generating additional penile skin for urethroplasty and/or skin coverage during primary or redo hypospadias repair in penoscrotal transposition (PST) patients with a proximal hypospadias., Methods: Proximal hypospadias and PST patients with a lack of penile skin, congenitally or after failed repair, who underwent TE assisted reconstruction were reviewed. TE were placed under the penile shaft and expanded skin was used for tubularized incised plate repair. Success was defined as urethral advancement to the corona or more distal with tension free skin coverage., Results: A total of 24 patients underwent reconstruction including 16 as part of primary repair and for redo repairs in 8. Nine patients experienced expander extrusion and posturethroplasty complications occurred in 43.8% of primary repairs and 75.0% of redo repairs; a urethrocutaneous fistula was most common (n = 8). Overall, success was achieved in 87.5% of patients with postoperative meatal locations almost all coronal (45.8%) or glanular (50.0%)., Conclusion: Proximal hypospadias reconstruction is challenging, and complications are not infrequent. TE is a useful alternative for complex patients with a skin paucity such that cutaneous coverage would be difficult following urethroplasty. Although the complication rate was 43.8% for primary repair, TE generated sufficient residual skin for success after additional reconstruction. For redo repair early use is most beneficial as there is more expandable skin. The pseudocapsules provide vascularized coverage to reinforce the urethra while there is sufficient skin to minimize the need for a skin graft for penile coverage., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To define the incidence and associations of patient-reported penile curvature and shortening after urethroplasty. Alterations in penile curvature or length post-urethroplasty are associated with patient dissatisfaction but are poorly described., Methods: From 2011 to 2019, 387 patients completed enrollment in a prospective single-centre study assessing patient-reported outcomes pre-operatively and 6-months post-urethroplasty. Primary outcomes of perceived penile shortening and curvature were assessed at 6-months follow-up. Descriptive statistics were used to summarize findings while univariate and multivariate binary logistic regression was used to identify associations between loss of penile length or chordee with other clinical factors., Results: Of the 387 patients, mean age was 49.5 years with mean stricture length of 4.5 cm. Postoperatively, 12.7% of patients perceived penile curvature (8.0% "somewhat", 4.7% "severe") and 22.8% of patients perceived penile shortening (14.5% "somewhat", 8.3% "a lot"). Multivariate binary logistic regression identified stricture location (P = .02) to be associated with perceived curvature while prior urethroplasty (P = .17), type of urethroplasty (P = .08) and other factors were not. Specifically, penile (O.R. 4.27, 95%CI 1.56-11.68, P = .005) and panurethral (O.R. 10.15, 95%CI 3.46-29.77, P <.001) locations were independently associated with this outcome. In a multivariate model, panurethral strictures (O.R. 4.23, 95%CI 1.10-16.20, P = .04) and hypospadias (O.R. 5.46, 95%CI 1.32-22.70, P = .02) were associated with patient perceived shortening while other factors such as age (P = .19), type of urethroplasty (P = .14) and other etiologies or locations were not., Conclusion: Clinically significant changes in penile appearance are more common post-urethroplasty than generally thought. Stricture location and etiology are important predictors of these patient-perceived changes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aphallia is an exceedingly rare condition often associated with an array of genitourinary anomalies. Classically, aphallia was thought to have to co-exist with a urethral fistula for adequate urine outflow to avoid the sequelae of oligohydramnios, while the absence of a fistula has historically been incompatible with life. We report the first case of a prenatally unrecognized aphallia with complete urethral atresia in a full-term baby, without an associated fistula or ectopic urethra. We postulate a urachal cyst noted on prenatal ultrasound resolved into a patent urachus providing sufficient outflow to avoid sequelae of oligohydramnios and allowed for term birth., (Published by Elsevier Inc.)

Bladder agenesis is a rare congenital anomaly infrequently reported in the literature, with an incidence of 1/600,000 patients. 1 Commonly associated with other fatal malformations, the condition is often incompatible with life. 2 Prior reports estimate that over 90% of living children born with this malformation are female, owing to renal preservation resulting from low pressure drainage of urine into the vagina, uterus, and vestibule. 3 , 4 Herein we report a rare case of an infant male born with penoscrotal transposition and end stage renal disease secondary to bilateral cystic renal dysplasia found to have concurrent bladder agenesis and bilateral ureteral ectopia., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Diphallia is an exceedingly rare anomaly characterized by partial or complete duplication of the phallus. Approximately 100 cases have been reported worldwide since its initial documentation, and incidence is estimated at 1 in 5 to 6 million live births. Therapeutic management is dependent on the extent of the anomaly, ranging from phallic excision to complex reconstructive procedures in cases of broader systemic involvement. We present the case of congenital true diphallia with associated penoscrotal transposition, bifid scrotum, partial urethral duplication, ventral chordee, large scrotal lipoma and sacral dimple. We further present a review of available literature pertaining to diphallia., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Total phallic reconstruction (TPR) is a reconstructive challenge., Objective: To report both surgical outcomes and patient-reported outcomes (PROs) of genetic male patients undergoing TPR utilising a radial artery forearm free flap (RAFFF)., Design, Setting, and Participants: A retrospective tertiary referral centre analysis of a series of genetic male patients with penile insufficiency (PI) either due to congenital micropenis, or from traumatic or surgical amputation was conducted., Surgical Procedure: RAFFF phalloplasty was conducted as a multistaged procedure: (1) TPR, (2) glans sculpting with second-stage urethroplasty when indicated, and (3) penile prosthesis implantation., Measurements: A descriptive analysis of the patient's baseline features, surgical outcomes, and PROs was conducted., Results and Limitations: A total of 108 patients were enrolled. The median age was 32.5 yr (interquartile range [IQR] 24-46) and median follow-up was 78.5 mo (IQR 30-129). A primary anastomotic urethroplasty was performed in 90 patients (83.4%) and a staged procedure in the remainder. Four patients experienced an acute arterial thrombosis, leading to complete loss of the phallus in two. Immediate surgical exploration saved the flap in two cases of venous thrombosis. Urethral complication occurred in 49.1% of patients. The multivariate logistic regression analysis showed an association (p=0.04) between the staged urethral reconstruction and the incidence of urethral complications. The limitations of our study are its retrospective nature and the lack of control., Conclusions: Despite the high incidence of postoperative complications and the possible need for revisions, TPR in the genetic male with PI using a RAFFF yields satisfactory aesthetic and functional results. PATIENT SUMMARY: in this report, we looked at the outcomes from TPR in a large population of male patients with penile inadequacy either due to congenital micropenis, or from traumatic or surgical amputation. Our results support the idea that penile reconstruction with a forearm free flap leads to satisfactory outcomes., (Crown Copyright © 2020. Published by Elsevier B.V. All rights reserved.)

The exstrophy-epispadias complex is a rare congenital anomaly presenting as a wide spectrum of disorders. The complex nature of this malformation leads to continuous investigations of the basic science concepts behind it. Elucidating these concepts allows one to fully understand the mechanisms behind the disease in order to improve diagnosis, management, and treatment ultimately leading to improvement in patient quality of life. Multiple technological advancements within the last 10 years have been made allowing for new studies to be conducted. Herein, the authors conduct a literature review of studies from 2009 to 2019, considering novel theories regarding the genetics, embryology, bladder, bony pelvis, prostate, and genitalia of patients with bladder exstrophy-epispadias complex., (Copyright © 2020. Published by Elsevier Inc.)

Objective: To investigate the histomorphological changes of the divergent corpus spongiosum surrounding the urethral plate in hypospadias., Methods: Seventy boys with hypospadias were divided into the distal (n = 44) and proximal (n = 26) groups by the location of the ectopic meatus. The morphology of the divergent corpus spongiosum was evaluated and the histopathological studies were carried out by HE staining, Masson staining, and immunohistochemical analyses of α-SMA, CD34, TGF-β1 and androgen receptor. Western blotting was performed to measure the expression of TGF-β1 and androgen receptor., Results: The divergent corpus spongiosum was significantly thicker in the distal group than the proximal group (distal 3.14 ± 1.12 mm, proximal 1.74 ± 0.87 mm, P <.0001). Histological evaluation suggested the cavernous sinus in the hypospadias group had an abnormal structure, which was characterized by an increase in the width of the vascular lumen (control 7.20 ± 1.12 μm, hypospadias 13.75 ± 8.08 μm, P = .0068), an increased vascular wall thickness (control 5.40 ± 1.28 μm, hypospadias 14.11 ± 7.59 μm, P = .0006), a decreased vascular density (control 15.66 ± 1.17, hypospadias 7.24 ± 4.19, P <.0001) and a decreased trabecular density (control 9.80 ± 1.92, hypospadias 3.68 ± 2.87, P <.0001). The severity of the structural abnormalities was greater in the proximal group than the distal group. Immunohistochemical analysis and Western blotting showed decreased TGF-β1 and androgen receptor expression in the hypospadias group (P <.0001)., Conclusions: Histomorphological analysis showed that the divergent corpus spongiosum in hypospadias is abnormal. The structural variation is positively correlated with the severity of hypospadias., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Congenital penile agenesis is a rare condition with an incidence of 1 in 30 million, while other congenital malformations of the cavernous bodies are much less common. In a few cases in the literature, it has been reported that the reason for consulting a physician with these conditions is the insufficient erection. As a first reported case, we present a 16-year-old male patient with partial unilateral corpus cavernosum agenesis accompanying genitourinary anomalies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate the outcome of a single-center series of penile reconstruction using the radial free forearm flap in rare indications., Materials and Methods: From April 1993 until September 2016, 23 nontranssexual patients underwent phallic reconstruction by the use of a neuromicrovascular free radial forearm flap in our clinic. Patient-specific characteristics, surgical techniques, complications, and outcomes were retrospectively evaluated and interpreted., Results: The indications for surgery were: disorders of sex development (34.8%), reconstruction after oncologic surgery (34.8%), automutilation (8.7%), iatrogenic (8.7%), microphallus (8.7%), and 1 case of priapism (4.3%). Two patients (8.7%) had a total flap necrosis and 2 patients (8.7%) had a partial flap necrosis; 3 out of these 4 patients were heavy smokers. Urinary fistulae and strictures were frequent but were successfully managed by urologists in all cases. There was no statistically significant correlation between smoking, comorbidities, number of venous anastomoses, and complications., Conclusion: In departments experienced in microsurgery, the goals of penile reconstruction could also be achieved in patients with rare indications by the use of the neuromicrovascular free radial forearm flap. Despite the high rate of postoperative complications, penile reconstruction with the free radial forearm flap yields satisfying results. An intensive cooperation between the plastic-reconstructive team and the urological team is a prerequisite to achieve the best surgical result., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To improve cosmetic and functional results of buried penis correction in boys using a modified universal surgical approach - Midline Incision Rotation Flaps., Materials and Methods: We retrospectively analyzed results of 18 patients who underwent buried penis surgical treatment according to the Midline Incision Rotational Flaps technique from 2013 to 2016. The results were assessed by the surgeon 1, 3, 6 months after surgery, then yearly. Parents filled out postoperative survey after 1 month. The surgery commences with a midline longitudinal skin incision on the ventral surface. Following, a circumferential incision along the coronal edge allows to perform full degloving. Excessive subcutaneous fat tissues are removed from the peno-pubic area. Next stage is the formation of the peno-scrotal and peno-pubic angles by fixation of the skin at the base of the penis. Then, the edges of the skin flaps are opened, forming Byar's flaps. The skin defect along the ventral surface is covered with rotated triangular skin flaps with nourishing vessels. Uneven excessive skin is dissected and interrupted skin sutures are placed., Results and Discussion: The median age of patients was 1.4 years with a median follow-up of 56 months (range 36-72). 16 patients (89%) obtained good results, and 2 patients (11%) - satisfactory. The results showed that size and appearance are close to natural and satisfying to parents of the patients., Conclusion: The suggested method of buried penis repair using Midline Incision Rotation Flaps technique allows to obtain the most satisfactory both cosmetic and functional results with minimal complication risk., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Aphallia, or penile agenesis, is rare (1:30 million) 1 and associated with other urogenital anomalies. 2 Under 100 cases of aphallia have been reported worldwide. 1 Pathogenesis is uncertain but thought to be failure of formation of the genital tubercle. 2 We present a case of complete penile agenesis with anorectal and urological malformations., (Copyright © 2020. Published by Elsevier Inc.)

Objective: Scrotal hypospadias still presents a challenge for reconstructive urologists. We present a novel and 1-stage technique of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and urethroplasty for severe hypospadias repair., Methods: A 14-month old boy underwent repair of scrotal hypospadias with severe chordee. Penile straightening is achieved by division of short urethral plate combined with ventral grafting. Urethral reconstruction is done by combined buccal mucosa graft and longitudinal dorsal penile skin flap. Buccal mucosa graft is harvested and designed in a special "watch" shape, with the spherical part in the middle and 2 rectangular parts on both sides. The tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the "watch-shaped" graft with "U-shape" stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally creating new urethral plate. A longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with the urethral plate. Penile skin reconstruction is performed using available penile skin., Results: In period between July 2014 and December 2018, this technique is performed in 35 patients (aged from 10 to 22 months) with scrotal hypospadias. In the follow-up, ranged from 10 to 63 months (mean 29 months), satisfactory results were achieved in 30 boys (86%). Urethral fistula in 3 and meatal stenosis in 2 cases were successfully treated by minor revision and temporary meatal dilatation, respectively. Good result in curvature repair was obtained in all cases based on vacuum device checking and parents' reports., Conclusion: Repair of scrotal hypospadias associated with severe ventral curvature is usually done as a 2-stage procedure. A "watch" shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty is a viable and reliable option for single stage repair of scrotal hypospadias with severe chordee., (Copyright © 2019 Elsevier Inc. All rights reserved.)

A case of accessory scrotum with duplicated penis (diphallia) in a male fetus is reported because of its rarity. This case is presented with proved negative androgen receptors in the accessory genitalia. The results of excisional surgery as well as immunostaining for androgen receptors in the resected specimens are presented as well. The outcomes of prenatal ultrasonography, clinical examination of the infant, and pathologic findings of the resected accessory genitalia are also discussed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To assess functional outcomes after surgical correction of congenital and acquired penile curvatures using Yachia's technique (YT) with degloving (DG) and without degloving (WDG) of the penis., Materials and Methods: A penile deformity with angle ≥30°, difficulty in vaginal penetration, and severity of erectile dysfunction secondary to penile curvatures were the indications for a surgical treatment with YT. The preoperative characteristics of the patients, postoperative outcomes (change in angulation, palpation of sutures, penile shortening, and patient satisfaction), operative time, and hospital stay were recorded. A total of 64 patients were included in this review and divided into 2 groups: 34 in group I (YT with DG) and 30 in group II (YT-WDG)., Results: The mean operative time was 65.87 ± 21.32 minutes for group I and 48.17 ± 23.82 minutes for group II (P < .02). The mean hospital stay was 3.09 ± 0.96 and 2.87 ± 0.93 days in DG and WDG, respectively (P = .324). There were no significant differences in recurrence rates and complications (palpation of sutures: group I: 14.7% vs. group II: 13.3%; penile shortening: group I: 8.9% vs. group II: 10%). At follow-up of 20.8 months, all treated patients were able to insert the penis in the partner's vagina, were satisfied overall with sexual intercourse., Conclusion: The outcomes of the DG and WDG techniques were similar, even if the YT-WDG presents better results in terms of less healing and operative time., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To arouse the suspicious for early diagnosis and hence, proper management of megameatus with an intact prepuce (MIP), as there is no external clue for detection of such cases, which usually come to light for the first time in a boy who is about to retract his prepuce or during neonatal circumcision., Materials and Methods: Examination of neonates and infants coming to circumcision clinic to detect congenital genitourinary anomalies. Evaluation of 12,518 neonates and infants coming for ritual circumcision from 2006-2017, who were examined thoroughly to detect any incidental congenital genitourinary anomalies. Fifteen of them were diagnosed to have a MIP anomaly. They were investigated to perceive any associated median raphe (MR) anomalies. Sensitivity, positive predictive value, specificity, and negative predictive value of MR anomalies in cases of MIP were estimated and compared with other children who had a normally positioned meatus., Results: Overall incidence of MIP in this group of babies was 0.12%. Twelve of 15 cases (80%) with MIP had 19 forms of MR anomalies; mainly raphe deviation in 6 cases, hyperpigmented raphe in 6, prominent raphe in 4, and bifurcation in 3 cases. Three cases had a redundant long prepuce, and 1 had paraphimosis after preputial retraction, otherwise no other genitourinary anomalies could be detected in those cases., Conclusion: MR anomalies, mainly deviation and hyperpigmented prominent raphe, are significant indictors for the presence of an invisible MIP anomaly. Abnormally redundant long prepuce may be seen in such cases, but this is not common., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To assess the postpubertal outcome of ventral penile curvature repaired in infancy in terms of recurrence and aesthetics., Materials and Methods: Postpubertal patients treated for hypospadias and ventral penile curvature in infancy at a tertiary medical center were invited to undergo assessment of the quality of the repair. Findings were compared between patients with a straight penis after skin release and patients who required dorsal plication., Results: The cohort included 27 patients of mean age 16.5 years who were reported with straight penis after surgery. Postpubertal curvature was found in 6 of 14 patients (43%) successfully treated by skin release and 10 of 13 patients (77%) who underwent dorsal plication (P = .087). Significant curvature (≥30 degrees) was found in 1 of 14 patients in the skin-release group and 4 of 13 in the dorsal plication group (P = .16). Rates of redo urethroplasty were 2 of 14 (14%) and 5 of 10 (50%), respectively. Patient satisfaction with the appearance of the penis did not differ significantly., Conclusion: Ventral penile curvature repaired in infancy often recurs after puberty. The need for dorsal plication has a trend-level association with recurrence of penile curvature in puberty. It might also be related to the degree of postpubertal penile curvature and the need for redo urethroplasty. Procedure type does not affect patient satisfaction with the postpubertal appearance of the penis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To report surgical and functional outcomes of buried penis surgery., Methods: Outcomes following buried penis surgery at the University of Washington were assessed from June 1, 2005 to June 1, 2016. Patient demographic and surgical data were abstracted from a retrospective chart review. All patients were attempted to be contacted by phone for long-term follow-up. Uni- and multivariate analysis was performed to evaluate for association with any complication., Results: A total of 42 men underwent buried penis repair surgery (mean short-term follow-up 8.1 months). There was an overall 33% 90-day complication rate (21 events). In univariate analysis, body mass index (BMI; P = .02) and no history of gastric bypass (P = .03) were significant predictors of any complication. In multivariate analysis, only BMI remained significant (odds ratio 1.1 for each increase in unit of BMI, 95% confidence interval 1.01-1.27). Twenty-seven patients were reached for long-term follow-up (mean 39 months). Patients reported improvements in every functional domain that was assessed. Of the patients, 85% reported they would undergo buried penis surgery again, 74% that surgery led to a positive change in their lives, and 85% that the surgery had remained a long-term success., Conclusion: Surgical correction of buried penis with penile split-thickness skin graft and limited panniculectomy is well tolerated and results in functional, long-term improvements. BMI is associated with an increased likelihood of a complication following surgery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Phallic reconstruction is an important part of management for congenital aphallia. Scrotal flap phalloplasty has been described in pediatric patients to create the appearance of a nonfunctioning phallus. We describe a modified scrotal flap technique with the addition of an acellular dermal matrix patch (AlloDerm) to provide additional girth and support to the phallus. The postoperative cosmetic outcome has been satisfactory and there is no documented complication over a 12-month follow-up. AlloDerm dermal matrix can be a safe addition to phallic reconstruction and its overall application needs to be further studied., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To characterize the spectrum of congenital penile curvature without hypospadias evaluated at our institution, and to assess the efficacy of surgical repair in prepubescent boys., Methods: The study group included 82 boys with a diagnosis of congenital penile curvature without hypospadias who elected for surgical repair from 2008 to 2010. We retrospectively reviewed clinical and operative characteristics and recorded surgical outcomes during the length of patients' follow-up at our institution., Results: Of the patients electing surgery, 32 of 82 (39%) underwent penile degloving alone for class I (skin) chordee. Ten of 82 patients (12.2%) required further excision of class II (dysgenic fascial) chordee, and 40 of 82 (48.8%) patients required some combination of techniques to correct varying degrees of class III (dysgenic fascial) chordee. A total of 22.2% of patients returning for follow-up with corporal disproportion had persistent penile curvature compared with 14.3% of boys with fascial chordee and 11.5% of boys with skin chordee. Those children treated with tunical plications and incisions alone fared worse than those children treated with some combination of the Nesbit or modified Nesbit procedure., Conclusion: Our study shows not only that the proportion of patients with a hyposplastic urethra may be smaller than previously reported but also that corporal disproportion may be more prevalent. Attention should be paid to this later group as plication without the use of Nesbit techniques may not be enough to ensure an appropriate repair., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To investigate the outcomes of two surgical interventions for Peyronie's disease (PD) with hourglass deformity: partial excision and grafting (PEG) or inflatable penile prosthesis (IPP) implantation., Materials and Methods: Retrospective data were collected from two centers: Technical University of Munich (PEG) and Tulane University Medical Center (IPP). Collected variables included patient demographics, sexual function, penile vascular measurements, and treatment outcomes., Results: A total of 50 PD patients with hourglass deformity (26 PEG [group 1] and 24 IPP [group 2]) were included in this study. Patients in group 1 had higher mean preoperative Sexual Health Inventory for Men scores (22.2 vs 10.3, P < 0001), required less erectile dysfunction treatment (35% vs 79%, P = .005), and had more nonvascular etiology (77% vs 21%, P < .0001). There were no intraoperative complications, 2 patients in group 1 had postoperative glans hypoesthesia, and 1 patient in group 2 required surgical revision. All patients in both groups had significant ≥20% improvements in penile curvature with mean changes of 68.1 degrees (12.7) in group 1 and 49.6 degrees (13.5) in group 2, P < .0001. Resolution of hourglass deformity was achieved in 85% of patients in group 1 and 100% of patients in group 2, P = .045. The mean postoperative change in Sexual Health Inventory for Men score was -0.3 (1.3) in group 1 and 16.7 (4.7) in group 2, P < .0001., Conclusion: Both options provide excellent outcomes for well-selected patients with PD and an hourglass deformity. PEG can be offered to patients with good erectile function, whereas the IPP remains the preferred option for patients with poor erections., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To present our treatment experience of buried penis, which has no consensus therapeutic technique for all cases of buried penis, by using a new technique for the repair of this condition, in which the approach is through the ventral penile root., Materials and Methods: We performed a retrospective review of 153 patients (median age: 6.5 years) who underwent repair of a buried penis between March 2005 and March 2013. The technique involves the creation of a wedge-shaped cut of the ventral penile skin, followed by fixation of the subcutaneous penile skin at the base of the degloved penis to the Buck fascia at the 2- and 10-o'clock positions. The ventral outer preputial skin is split down the midline, and the dorsal inner preputial skin is cut with oblique incision., Results: All patients were followed for an average of 12 months after repair. Other than 2 cases (1.3%) of trapped penis with a ring of scar tissue, which required subsequent excision, there were no complications and the cosmetic appearance was satisfactory., Conclusion: The described ventral penile approach is a simple and effective procedure with good cosmetic outcomes and few complications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Diphallia or duplication of the penis is an extremely rare congenital anomaly. Based on the presence of one or two corpora cavernosa in each of the penises, diphallia is classified into two major groups: bifid phallus and true diphallia. Because true diphallia associated with various anomalies is dominant in published studies, little is known about bifid phallus or isolated cases. Here we present a 9-month-old boy with an isolated bifid phallus. After successful reconstruction of the penis and urethra, urinary incontinence became apparent. To the best of our knowledge, this is the first case of complete bifid phallus associated with bladder neck incompetence., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Shortening-free correction of congenital ventral penile curvature by rotation of the corpora cavernosa was first introduced in 2006 (Shaeer's corporal rotation I). The basic principle was shifting the concavity of both corpora cavernosa from the ventral aspect of the penis to the lateral aspects, in opposition. Rotation was achieved by approximating short parallel incisions on the dorsum of both corpora cavernosa. In 2008, we reported modification of the technique (Shaeer's corporal rotation II), in which the incisions spanned the whole length of the corpora cavernosa., Objective: The current modification, Shaeer's corporal rotation III (the noncorporotomy technique) simplifies corporal rotation further and addresses shortcomings., Design, Setting, and Participants: This is a retrospective study of 127 cases of congenital ventral penile curvature 25-90° operated at Kamal Shaeer Hospital, Cairo, Egypt, from 2009 to 2015., Surgical Procedure: The neurovascular bundle was mobilized, and the corpora were rotated by approximating premarked respective points on either side of the deep dorsal vein using polyester sutures without incising the tunica albuginea., Outcome Measurements and Statistical Analysis: Intraoperative postrotation angle and erect length and girth., Results and Limitations: On-table measurements showed a mean prerotation erection angle of 66.5° ± 17.9° (range: 25-90°; median 65°). Following rotation, the angle was 0.47° ± 1.8° (p<0.001) and length was 0.06 ± 0.25 cm longer (p=0.007), whereas girth was 0.77 ± 0.9 cm narrower (p<0.001). Complications included 11 cases (8.7%) of ventral wound gaping and 3 (2.4%) with mild recurrence not requiring correction. The International Index of Erectile Function was 24.99 ± 0.9, with an increase of 13.35 ± 3.4 over the preoperative state (p<0.001)., Conclusions: Shaeer's corporal rotation III enables correction of any degree of ventral congenital penile curvature, with neither shortening nor erectile dysfunction., Patient Summary: Shaeer's corporal rotation is a surgical technique for correction of severe degrees of innate downward curvature of the penis, without shortening., (Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To present a novel algorithm for definitive reconstruction of penile curvature in men undergoing inflatable penile prosthesis (IPP) surgery as an alternative to manual penile modeling and grafting procedures., Methods: Patients with erectile dysfunction and concomitant penile curvature undergoing IPP placement were divided into 2 treatment groups: (1) group 1, penile deformity known preoperatively, and (2) group 2, penile curvature recognized intraoperatively after IPP placement. Group 1 patients underwent penile plication after artificial erection and immediately before IPP insertion via the same penoscrotal incision, whereas group 2 patients were treated with a Yachia (Heineke-Mikulicz) corporoplasty over the intact cylinders. Patients completed postoperative Patient Global Impression of Improvement (PGI-I) questionnaires assessing overall satisfaction., Results: Among 405 men receiving IPP at our institution from 2007 to 2014, 30 patients received synchronous correction of penile curvature (7%). Group 1 included 23 of 30 (77%) patients, and 7 of 30 (23%) were in group 2. Overall mean initial curvature was 36°, and all patients were corrected to < 10°. Average operative times were 18 minutes longer compared with patients who underwent IPP placement alone (82 vs 64 minutes, P <.05). At an average follow-up of 13 months (range 7-32), 19 of 20 (95%) group 1 and 6 of 7 (86%) group 2 patients who completed surveys reported an improved overall condition. No patient reported chronic pain, recurrent deformity, or device malfunction., Conclusion: Penile curvature can be safely and reliably corrected at the time of IPP placement, regardless of whether the deformity was identified preoperatively., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Congenital aphallia is an extremely rare disorder with <100 cases reported globally. We report on an 11-month-old infant with aphallia and associated syrinx formation. We also review the pathogenesis, associated malformations, and current treatment guidelines for penile agenesis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: We present a novel technique using ventral slit with scrotal skin flaps (VSSF) for the reconstruction of adult buried penis without skin grafting., Technical Considerations: An initial ventral slit is made in the phimotic ring, and the penis is exposed. To cover the defect in the ventral shaft skin, local flaps are created by making a ventral midline scrotal incision with horizontal relaxing incisions. The scrotal flaps are rotated to resurface the ventral shaft. Clinical data analyzed included preoperative diagnoses, length of stay, blood loss, and operative outcomes. Complications were also recorded. Fifteen consecutive patients with a penis trapped due to lichen sclerosus (LS) or phimosis underwent repair with VSSF. Each was treated in the outpatient setting with no perioperative complications. Mean age was 51 years (range, 26-75 years), and mean body mass index was 42.6 kg/m(2) (range, 29.8-53.9 kg/m(2)). The majority of patients (13 of 15, 87%) had a pathologic diagnosis of LS. Mean estimated blood loss was 57 cc (range, 25-200 cc), mean operative time was 83 minutes (range, 35-145 minutes), and all patients were discharged on the day of surgery. The majority of patients (11 of 15, 73.3%) remain satisfied with their results and have required no further intervention. Recurrences in 3 of 15 (20.0%) were due to LS, panniculus migration, and concealment by edematous groin tissue; 2 of these patients underwent subsequent successful skin grafting., Conclusion: VSSF is a versatile, safe, and effective reconstructive option in appropriately selected patients with buried penis, which enables reconstruction of penile shaft skin defects without requiring complex skin grafting., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: To investigate the effect of penile degloving in combination with penoscrotal angle reconstruction for the correction of concealed penis., Technical Considerations: A foreskin circumcision incision was made along the coronal sulcus. After a sharp dissection under the superficial layer of tunica albuginea, the penile shaft was degloved to release the fibrous bands of the tunica dartos. Through a longitudinal incision or Z-plasty at the penoscrotal junction, securing of the tunica albuginea to the proximal tunica dartos was performed. The penoscrotal angle was reconstructed. This procedure effectively corrected the concealed penis, while correcting other problems such as phimosis. From August 2008 to August 2013, we performed 41 procedures for concealed penis. Correction was successful in all patients with an improved median length of 2.1 cm in the flaccid state. Follow-up ranged from 6 months to 2 years, and satisfactory cosmetic outcomes were obtained without scars or erectile discomfort., Conclusion: Our technique includes degloving and penoscrotal angle reconstruction, which provides proper visualization for fixation of the penile base. The longitudinal or Z-plasty incision also opened the degloving dead cavity, which was good for drainage. The procedure is straight forward with good functional and cosmetic outcomes and is thus ideal for correction of the concealed penis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To report a modified penoplasty technique for concealed penis in children., Methods: Between January 2006 and June 2012, 201 cases of concealed penis were surgically repaired with modified penoplasty. The modified penoplasty technique consisted of 3 major steps: (1) degloved the penile skin and excised the inner prepuce, (2) advanced penoscrotal skin to cover penile shaft, and (3) fixed the penis base and reconstructed the penoscrotal angle., Results: Two hundred one cases of concealed penis were enrolled in this study over a period of 6 years. Mean age at the time of surgery was 5.3 years (range 1-13 years) and mean operative time was 40 minutes (range 30-65minutes). All patients were routinely followed up at 1, 3, and 6 months after surgery. Most patients developed postoperative edema and were resolved within 1 month, whereas 20 cases developed prolonged postoperative edema, especially at the site of frenulum, which took 3 months to be resolved. Ten cases had retraction after surgery. No erection difficulties were recorded. Patients/parents reported better hygiene and improved visualization and accessibility of penis after surgery and were satisfied with the cosmetic outcome., Conclusion: The result of this study shows that the modified penoplasty technique is a simple, safe, and effective procedure for concealed penis with satisfied cosmetic outcome., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Urethral duplication is a rare congenital anomaly. This case study intends to define a new anatomic variation of an accessory urethra. The case is a 5-year-old boy who presented with dorsal chordee requiring operative intervention. At surgery, an accessory urethra on the dorsum of the penis was detected. It was observed that the distal part of the accessory urethra had no external opening and the proximal part had no connection with the native urethra. The accessory urethra was completely excised without complication. To our knowledge, this type of accessory urethra is the first reported case in the English literature., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To clarify whether spongioplasty decreases the complications rate and the degree of penile curvature in TIP urethroplasty., Methods: From 2007 to 2011, 47 patients underwent TIP repair. Thirty-seven underwent spongioplasty, while 10 did not because their bifurcated spongy tissues could be not clearly identified. We investigated whether spongioplasty reduced the incidencerates of complications such as urethrocutaneous fistula. We also evaluated whether spongioplasty contributed to resolving or decreasing penile curvature. In addition, we assessed how many of the patients that underwent spongioplasty did not have to undergo dorsal plication., Results: Among the 47 patients who underwent TIP repair, postoperative complications occurred in 3 (8%) of the 37 patients that underwent spongioplasty and 1 (10%) of the 10 who did not. Spongioplasty did not decrease the complications rate of TIP repair. As 15 of the 47 patients demonstrated a straight penis before spongioplasty, the effect of spongioplasty on the correction of penile curvature was analyzed in 32 patients. Dorsal plication was avoided in 19 patients (59%) because their penile curvature had been decreased to within the permissible range (<15°) by spongioplasty., Conclusion: We conclude that spongioplasty can not replace dartos flap coverage of the neourethra after TIP urethroplasty because it did not produce a significant reduction in the complications rate; however, spongioplasty could be used as an additional procedure because it reduced the degree of penile curvature and allowed dorsal plication to be avoided in more than half of the hypospadiac patients that displayed moderately severe curvature., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To accurately measure the correction obtained by the release of the skin and dartos fascia and that obtained by mobilization of the urethral plate and resection of the underlying fibrous tissue (according to Koyanagi and Mollard), in the release of chordee., Methods: From February 1996 to February 2011, 234 patients underwent surgery for proximal hypospadias by 1 surgeon. Lateral photographs were taken during successive saline erection tests for 205 patients. The first test was performed at the beginning of the operation, the second test after the release of the skin and dartos fascia, the third test after possible mobilization of the urethral plate and resection of the underlying fibrous tissue, and the last test at the end of surgery., Results: Preservation of the urethral plate was possible in 191 patients (93%). Analysis of the lateral photographs showed that stripping of the penis resulted in complete correction of all chordee <45°. For curvature >90°, stripping of the penis was insufficient in 88% of the cases. However, mobilization of the urethral plate with resection of the underlying fibrous tissue resulted in very low correction (10°-20°), although the blood supply to this plate was preserved., Conclusion: The results of the present study have shown that correction of the curvature that accompanies proximal hypospadias is obtained mainly by release of the skin and dartos fascia., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Context: Penile curvature can be congenital or acquired. Acquired curvature is secondary due to La Peyronie (Peyronie's) disease., Objective: To provide clinical guidelines on the diagnosis and treatment of penile curvature., Evidence Acquisition: A systematic literature search on the epidemiology, diagnosis, and treatment of penile curvature was performed. Articles with the highest evidence available were selected and formed the basis for assigning levels of evidence and grades of recommendations., Evidence Synthesis: The pathogenesis of congenital penile curvature is unknown. Peyronie's disease is a poorly understood connective tissue disorder most commonly attributed to repetitive microvascular injury or trauma during intercourse. Diagnosis is based on medical and sexual histories, which are sufficient to establish the diagnosis. Physical examination includes assessment of palpable nodules and penile length. Curvature is best documented by a self-photograph or pharmacologically induced erection. The only treatment option for congenital penile curvature is surgery based on plication techniques. Conservative treatment for Peyronie's disease is associated with poor outcomes. Pharmacotherapy includes oral potassium para-aminobenzoate, intralesional treatment with verapamil, clostridial collagenase or interferon, topical verapamil gel, and iontophoresis with verapamil and dexamethasone. They can be efficacious in some patients, but none of these options carry a grade A recommendation. Steroids, vitamin E, and tamoxifen cannot be recommended. Extracorporeal shock wave treatment and penile traction devices may only be used to treat penile pain and reduce penile deformity, respectively. Surgery is indicated when Peyronie's disease is stable for at least 3 mo. Tunical shortening procedures, especially plication techniques, are the first treatment options. Tunical lengthening procedures are preferred in more severe curvatures or in complex deformities. Penile prosthesis implantation is recommended in patients with erectile dysfunction not responding to pharmacotherapy., Conclusions: These European Association of Urology (EAU) guidelines summarise the present information on penile curvature. The extended version of the guidelines is available on the EAU Web site (www.uroweb.org/guidelines/)., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

We report on a rare case of aphallia in an X, Y-born male treated at our institution. The child underwent phalloplasty at 5 years of age using the De Castro phalloplasty technique and an abdominal skin flap. Although moderate distal necrosis was seen, the overall immediate and 12-month postoperative results were highly encouraging for our patient. Thus, this technique should be seen as a temporizing reconstructive option for patients with aphallia. Long-term follow-up is necessary to determine whether the neophallic size augments with axial growth and the need for additional intervention to facilitate onset of sexual activity., (Published by Elsevier Inc.)

Background: Hypospadias is a challenging field of urogenital reconstructive surgery, with different techniques currently being used., Objective: Evaluate international trends in hypospadias surgery., Design, Setting, and Participants: Paediatric urologists, paediatric surgeons, urologists, and plastic surgeons worldwide were invited to participate an anonymous online questionnaire (http://www.hypospadias-center.info)., Measurements: General epidemiologic data, preferred technique in the correction of hypospadias, and preferred technique in the correction of penile curvature were gathered., Results and Limitations: Three hundred seventy-seven participants from 68 countries returned completed questionnaires. In distal hypospadias (subcoronal to midshaft), the tubularised incised plate (TIP) repair is preferred by 52.9-71.0% of the participants. Meatal advancement and glanuloplasty (MAGPI) is still a preferred method in glandular hypospadias. In the repair of proximal hypospadias, the two-stage repair is preferred by 43.3-76.6%. TIP repair in proximal hypospadias is used by 0.9-16.7%. Onlay flaps and tubes are used by 11.3-29.5% of the study group. Simple plication and Nesbit's procedure are the techniques of choice in curvature up to 30°; urethral division and ventral incision of the tunica albuginea with grafting is performed by about 20% of the participants in severe chordee. The frequency of hypospadias repairs does not influence the choice of technique., Conclusions: In this study, we identified current international trends in the management of hypospadias. In distal hypospadias, the TIP repair is the preferred technique. In proximal hypospadias, the two-stage repair is most commonly used. A variety of techniques are used for chordee correction. This study contains data on the basis of personal experience. However, future research must focus on prospective controlled trials., (Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Treatment recommendations for strictures after phalloplasty are lacking., Objective: Our aim was to evaluate the outcome of urethroplasty for strictures after phalloplasty and to provide treatment recommendations based on this experience., Design, Setting, and Participants: One hundred and eighteen urethroplasties were performed in 79 patients. Mean patient age was 37.6 yr. Mean follow-up was 39 mo., Intervention: Different types of urethroplasty were used: meatotomy, Heineke-Mikulicz principle (HMP), excision and primary anastomosis (EPA), free graft urethroplasty (FGU), pedicled flap urethroplasty (PFU), two-stage urethroplasty (TSU), and perineostomy followed by urethral reconstruction (PUR)., Measurements: Stricture recurrence was defined as the need for additional instrumentation or surgery., Results and Limitations: Mean stricture length was 3.6 cm. Stricture location was at the meatus, phallic urethra, anastomosis, fixed part, and different locations in 18, 28, 48, 15, and 9 urethroplasties, respectively. Stricture recurrence was observed in 44 urethroplasties (41.12%). Stricture recurrence rate for meatotomy, HMP, EPA, FGU, PFU, TSU, and PUR was 25%, 42.11%, 42.86%, 50%, 40%, 30.3%, and 61.9%, respectively., Conclusions: The main stricture location after phalloplasty is the anastomosis between the phallic and the fixed part. Urethroplasty for strictures after phalloplasty is associated with a relatively high recurrence rate., Trial Registration: EC UZG 2007/434., (Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Dorsal hood prepuce is a common congenital anomaly of the penis. Neoplasms of the prepuce are very rarely seen in children. We present an interesting case of a penile myofibroma encountered during circumcision of a dorsal hood foreskin in an 8-month-old infant., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives: To evaluate the postoperative effectiveness of ventral lengthening with a tunica vaginalis flap. Correcting penile curvature is an essential step in proximal hypospadias surgery. It is logical to lengthen the ventral radius using a graft; however, penile curvature would recur owing to a graft contracture with inadequate vascularization. Although a tunica vaginalis is considered a suitable material to be used as a flap instead of a graft, clinical application of this technique is uncommon. Information regarding the usefulness and effectiveness of this procedure is required., Methods: Between 2003 and 2008, we repaired 146 patients with hypospadias and the urethral plate was transected in 39 patients because of severe curvature. Significant severe curvature persisting even after transection of the plate was corrected with ventral corporeal lengthening procedures using a tunica vaginalis flap in 15 patients and postoperative results were evaluated., Results: Straight penile erection was identified in all 15 boys at home by their parents. In 7 of the 15 boys, artificial erection was performed at the time of additional surgery; 5 degrees of curvature was found in 2 patients and 0 degree in 5., Conclusions: At the second session of surgery, we observed that penile straightening was maintained without recurrence of curvature. Additionally, the area in which the tunica vaginalis flap was placed on the ventrum did not contract. Therefore, lengthening the ventral aspect using a tunica vaginalis flap might be an important alternative for correction of severe penile curvature in hypospadias surgery., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objectives: To define the responses of stretched penile length (PL) to intramuscular testosterone enanthate (TE) treatment in prepubertal boys with hypospadias., Methods: We examined 17 Japanese boys with hypospadias at 1.4 +/- 1.3 (mean +/- SD) years of age. Their PLs were 2.79 +/- 0.37 cm and -1.16 +/- 0.88 SD of the mean. The etiology of hypospadias included sex chromosome disorders of sex development in 5, mastermind-like domain-containing 1 deficiency in 1, and unknown cause in the others. No mutation was identified in the SRD5A2 or AR gene. All the boys received as many as three intramuscular injections of TE 25 mg every 4 weeks (one injection in 3 boys, two in 5, and three in 9)., Results: The TE treatment significantly increased PL by 1.01 +/- 0.50 cm and 2.27 +/- 0.99 SD (cm, P = .0002; SD, P = .0002). Age, body surface area (BSA), and PL before the treatment did not significantly correlate with the effect of TE treatment on PL. The effect of TE treatment on PL at the first injection in Japanese boys with hypospadias (0.35 +/- 0.20 cm and 0.91 +/- 0.62 SD) was significantly less than that in micropenis at 2.6 +/- 3.1 years of age (0.64 +/- 0.26 cm and 1.37 +/- 0.68 SD) (cm, P = .0008; SD, P = .02)., Conclusions: These data indicate that (1) the intramuscular TE treatment significantly increases PL for hypospadias in prepubertal boys, with no demonstrable SRD5A2 or AR mutation; (2) age, BSA, and PL before the treatment are not significantly contributing factors to the effect of TE treatment; and (3) the effect of TE treatment for hypospadias is significantly less than that for micropenis., (Copyright 2010 Elsevier Inc. All rights reserved.)

A male infant born at 32 weeks of gestation and weighing 1.44 kg had penile agenesis, bifid scrotums, an anorectal anomaly, and suspected omphalocele. An operation revealed complete urethral agenesis, duplicated and blind bowels, a vesicointestinal fistula without exstrophy, and a urachal fistula; however, no omphaloceles were detected. To our knowledge, this is the first report on aphallia accompanied with completely separated scrotum and a vesicointestinal fistula without exstrophy; this condition is associated with urorectal septum malformation sequence (URSMS) and covered cloacal exstrophy. The possible embryogenesis is discussed in this study.

Objectives: To present the results of ventral plication for the repair of dorsal curvature., Methods: A total of 33 patients (mean age 38 months, range 7 months to 15 years) with a dorsal curvature of >30 degrees degrees underwent ventral plication. A subcoronal incision was performed, followed by degloving of the skin to the penile base. The point of maximal curvature was noted and marked during an erection test. Two polypropylene 5-0 plication sutures were placed in the tunica albuginea of both corporeal bodies, just lateral and adjacent to the corpus spongiosum. Proper alignment and a straight penis were confirmed with a repeat erection test. The skin incision was closed with absorbable sutures. Surgical success was determined by parental and physician satisfaction with the final outcome during follow-up., Results: No immediate or late complications (mean follow-up 25 months, range 3-65) developed. A straight penis was achieved in 28 of 33 patients (85%). Four patients with residual curvature did not require a second procedure, and the fifth patient successfully underwent reoperation using the same technique., Conclusions: The results of our study have shown that ventral plication is a simple and efficient technique for the repair of dorsal penile curvature.

Objective: We describe our experience with single and 4-layer small intestine submucosa in the repair of proximal hypospadias and severe chordee., Methods: Between 2000 and 2004, 15 boys with proximal hypospadias and/or severe ventral chordee underwent SIS grafting to correct the curvature. Single layer and 4-layer small intestine submucosa were used for corporal grafting. Reassessment was performed by artificial erection at the time of the 2nd-stage reconstruction or at follow-up visit., Results: 1st-stage chordee repair with corporal body incision and graft coverage was performed on 15 patients between June 2000 and March 2004. Single layer SIS was used in 6 cases and 4-layer was used in 9 cases. Twelve of the 15 boys underwent a planned 2nd-stage urethroplasty. Median age at 1st-stage repair was 12 months. A 15-month-old boy underwent single stage chordee correction and penoscrotal hypospadias repair. Two boys without hypospadias underwent chordee correction with SIS. There were no complications related to the use of SIS for chordee repair. Median age of the 12 boys at 2nd-stage hypospadias repair was 24 months. At the time of the 2nd-stage procedures, the graft site did not show more significant scarring than has been our experience in 2-stage procedures performed without SIS. No patients had recurrence of chordee with follow up ranging from 2 to 75 months., Conclusions: Our outcomes suggest that small intestine submucosa is safe and effective for corporal body grafting in the correction of severe chordee, especially in the setting of a multistage hypospadias and chordee repair.

Penile curvature is a defect associated with both mental distress and sexual dysfunction. Of the different surgical methods for correction, plication techniques are considered the least technically demanding. However, the use of non-absorbable sutures in the tunica albuginea carries a potential for formation of bothersome subcutaneous nodules. Herein we describe our experience using a simple cavernotomy incision to bury the plication knot to avoid this complication.

Urethral duplication is a rare congenital anomaly. Most male patients with complete urethral duplication are diagnosed at childhood with presentation of double urinary streams or urinary dribbling. Incomplete urethral duplication does not result in obvious symptoms except intermittent discharge from the epispadiac urethral opening. Here we report a case of incomplete urethral duplication presenting with severe dorsal penile curvature since adolescence and consequent difficulty with sexual intercourse. We not only corrected the penile curvature but also removed the epispadiac tract followed by a tenuous cord, which suggest that this cord may limit the development of the corpus carvernosum asymmetrically.

Objectives: To introduce a novel questionnaire by which we attempted to identify the most suitable candidates for augmentation phalloplasty surgery for penile dysmorphophobia and to objectively estimate the outcome., Methods: A total of 45 physically normal young adult men who presented with complaints of a "small penis" and were seeking surgical correction were included in the study. In addition to the ordinary evaluation, all completed the questionnaire devised by our department, the Augmentation Phalloplasty Patient Selection and Satisfaction Inventory (APPSSI). The APPSSI aims to quantitatively assess the severity of the condition and the degree of the patient's willingness to undergo penile augmentation and to numerically measure the postoperative result. The APPSSI consists of four questions, with each having five possible answers (scale 0 to 4). Questions 1 through 3 were asked preoperatively (suitability assessment) and questions 1, 2, and 4 postoperatively (outcome evaluation). The eligibility threshold for surgery was a preoperative score of 6 or less. The preoperative scores ranged from 0 (surgery justified) to 12 (surgery not justified), and the postoperative scores ranged from 0 (disappointed) to 12 (excited). The Student t test was used for statistical analysis, and P <0.05 was considered to indicate statistical significance., Results: Of the 45 patients, 13 (28.8%) with an APPSSI score of 6 or less (mean 3.18) underwent penile lengthening (n = 7), lengthening-enlargement (n = 4), or celioplasty-penile lengthening (n = 2). Postoperatively, the score increased by 4.36 (mean 7.54, P <0.001), and the condition improved by 25% to 50% in 11 patients, 66.6% in 1, and remained unchanged (0%) in 1 patient., Conclusions: The APPSSI questionnaire properly identified patients who significantly benefited from augmentation phalloplasty. Nevertheless, because of the small sample size and nonrandomized study, the questionnaire's validation requires a larger number of patients tested in a randomized manner by more researchers to become a valuable clinical instrument and patient eligibility criterion for this type of surgery.

Objectives: Although plication of the tunica albuginea with nonabsorbable sutures is an effective method in correcting congenital penile curvature (CPC), suture-related complications may happen. We investigated the long-term outcome and patient satisfaction of a modified tunical plication technique using absorbable sutures., Materials and Methods: From January 1999 to July 2005, 114 consecutive patients with CPC treated with a modified tunical plication technique by a single surgeon were retrospectively reviewed. With the modified corporeal plication technique, two, interrupted, U-shaped sutures with 2-zero polyglactin were applied to create bumps on the tunica albuginea. The long-term outcome and patient satisfaction were assessed by a post hoc questionnaire interview., Results: Among the 114 patients, complete straightness of the penis was achieved in 65 (57%) patients, and 33 (29%) patients reported a 15-degree or less residual or recurrent curvature at 6 mo postoperatively. Although 32 (28%) patients experienced suture failure (median time: 38.5 d), only half of them had a residual or recurrent curvature greater than 15 degrees. Younger patients (<24 yr) had a higher chance of suture failure than elder patients (p=0.03). Among the 103 patients completing the questionnaire, no palpable suture knots, suture granuloma, erectile discomfort, or erectile dysfunction was reported (median follow-up time: 41.5 mo). Eighty-three (81.5%) patients were either very or moderately satisfied with the surgical outcome., Conclusions: The modified technique using double, interrupted, U-shaped sutures and absorbable suture material is a simple and effective method for treating CPC. Suture-related complications rarely happen. The long-term outcome is satisfactory, and most patients are pleased with the procedure.