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Journal of Andrology,

Copyright C American

Vol. 15, Supplement Society of Andrology

1994

Nesbit's

M. NASIR

From

Procedure

SULAIMAN AND

of Urology,

for Penile

J. CLIVE

Southmead

Curvature

GINGELL

Hospital, Bristol BSIO 5NB, United Kingdom.

the Department

ABSTRACT: Between January 1982 and June 1992 83 patients with penile curvature due to Peyronie's disease or congenital curvature underwent a modified Nesbit's procedure for coital difficulties. This represented approximately 23% of the total number of patients referred to the male sexual dysfunction clinic with penile deformity. A confidential postal questionnaire was sent to all of the operated patients in order to determine the longterm results of surgery. Seventy-eight of the 83 patIents were contacted, aged 16-71 years (mean = 48 years). Sixty-two of the 78 (79%) were satisfied with the result of surgery and would be prepared to have the operation

again. Twenty-two of the 78 were not having Intercourse. As a result of this survey we have identified a group of people with initial satisfactory results who have since developed erectile failure. These have been offered either self injection therapy with a vasoactive agent or penile prostheses if they do not respond or do not wish to self inject. Key words: Peyronie's disease, congenital curvature of penis, Nesbit's operation. J Androl 1994;15:54S-56S

Since

nis types results the Peyronie's

the

description

by Nesbit

(1965)

of his operative of the pe(1979) to for both to determine postoperative

technique to straighten congenital curvature and its application by Pryor & Fitzpatrick disease, were we have used Although we were this technique initial interested of penile longer term curvature. satisfactory, results.

Materials and Methods

All the patients' case notes were retrieved three patients were operated upon (age

and reviewed. Eightyyears, mean = 48 years). A questionnaire was devised (Table 1) and sent to each patient for reply. Seventy-eight of the 83 patients were successfully contacted; 5 remain untraced. Twelve patients had congenital curvature of the penis (age 16-30 years, mean =23 years), in which the main curvature was ventral in eight and lateral in four. In patients with Peyronie's disease the curvature was dorsal in 45, ventral in 3, lateral in 6, and combined in 12. The reason

16-71

for surgery was that intercourse was difficultand/or unpleasant in 53 (6 8%) or penetration was impossible due to the degree of

curvature

in 25 (32%).

Operative Technique

Under general or if previously or regional anesthesia the patient is circumcised circumcised a subcoronal circumferential mcito: Dr. J. Clive Gingell, Department Bristol BS1O 5NB, United Kingdom. April 13, 1993; accepted

Correspondence Southmead Hospital,

of Urology,

No-

Received

vember30,

for publication 1993.

for publication

sion is made to allow sleeve retraction of the penile skin to the base of the penis. A 12F Jacques catheter is used as a tourniquet around the base of the penis, and an erection is induced by the rapid infusion of saline via a 19-gauge butterfly needle inserted into one of the corpora. The high pressure infusion is delivered via a saline bag in a Fenwall pump mechanism. The erection produced demonstrates the degree of curvature. The infusion is then discontinued and Buck's fascia is incised longitudinally opposite the point of maximum curvature to expose the underlying tunica albuginea. If, as is usual, the deformity is dorsal, then both corpora are exposed as described. An Allis forceps is then applied to each corpus, taking a "bite" of the tunica sufficient to straighten the penis when it is re-infused to produce an erection. In more severe degrees of curvature, two or more forceps need to be applied to each corpus to allow correction. Discs or ellipses of tunica albuginea are excised corresponding to the area underneath the forceps, care being taken not to remove any underlying erectile tissue (Fig. 1). The tunica albuginea is closed by a suture of continuous 3-zero dexon lubricated in paraffin. An artificial erection is then reinduced to check that the degree of curvature has been corrected and the penis is straight. If this is the case, then the cuff is released after removal of the butterfly needle and suture of the puncture site to prevent extravasation. After final diathermy hemostasis Buck's fascia is re-approximated with continuous 4-zero catgut. The same suture material is used for interrupted sutures to close the skin. An 0.5% plain marcaine penile block is performed and a light gauze dressing is applied. The penis is held against the lower abdomen by suitable elasticated underpants. The urethra is rarely mobilized from the underlying corpora except when the dorsal curvature is in the distal one third of the penile shaft and approaching 90%. An indwelling urethral catheter is only employed if there is a preceding history of "prostatism." The patient is discharged home after overnight stay and prophylactic antibiotics are not given.

54$

Sulaiman and Gingell

Table 1. Questionnaire

.

Nesbit's Procedure

for Penile Cu,vature

55$

QUESTIONNAIRE

Before 1) Were

Surgery you able to have intercourse before the operation? of the degree to penetrate because YES() NO() NO() NO() NO()

2) If YES was this difficult/painful 3) If NO was this because it was

because impossible

of deformity?

due to the degree of the problems of curvature? with penetration?

YES() YES() YES()

4) Had you lost your erections After Surgery with the result

before

surgery

encountered

1) Are you happy

of the operation?

YES() YES() YES()

NO() NO() NO()

2) Are you able to have

Intercourse?

3) If YES is this satisfactory?

4) If NO why not?

5) Are you unduly 6) If you are unable

concerned to have

by the shortening intercourse since

of the penis? the operation please state why.

YES()

NO()

7) Given

the same

circumstances

would up?

you have the operation

again or advise

someone

else to?

YES() YES()

NO() NO()

8) Do you wish 9) Any other

to be seen for follow

comments.

FROM: Name

Results

All patients were seen 6 weeks after the operation If they were and sat-

course,

subsequently isfied with course they questionnaire (78/83) 1992.

followed

up at 3 months.

the result of surgery and were having interwere discharged from further follow-up. The was sent to all of the contactable patients upon between of follow-up ranged January 1982 and June at the time of receipt of 6 and (79%) have 132 months (mean with the again were happy the operation

operated The period

the questionnaire

=

between

62/78 would

50 months). Overall results of surgery and given were the same specifically Sixteen

circumstances. concerned of the

Thirty-one of the 78 (40%) by the shortening of the penis, 78 (21%), although having inter-

however.

described it as unsatisfactory for the reasons given 2. In this group it is encouraging to note that 10 of the 16, given the same circumstances, would be prepared to undergo the same surgery again. There were 22 of the 78 patients who were not having intercourse at the time of review, due to the development of secondary impotence in 18 patients and return of curvature in 4. To date, of the patients seen for review who were not having intercourse, seven have been established on a self-injection program with papaverine (age 57-67 years, mean = 63 years). Four have had the insertion of penile prostheses and two are waiting for this procedure. Nine patients have been reviewed and do not wish either self injection or penile prostheses. In this group 15 of 22 (6 8%) would have the operation again given the same circumstances as they were able to have intercourse initially for a variable

in Table

56S

Table 2. Reasons satisfactory given for describing intercourse as not

Journal of Andrology

.

Supplement

1994

Penile shortening Impaired sensation Unhappy with circumcision Return of curvature Self injection with papaverine Partner unhappy Total

6 3 3 2 1 1 16

excised

period failure

of time before subsequently or recurrent curvature.

developing

erectile

Discussion

There are a variety of surgical procedures devised for correcting the curvature of the penis involved in Peyronie's disease, including plaque excision and substitution with a dermal graft (Devine and Horton, 1974), human dura The (Kelami, simplest 1977), and tunica vaginalis (Das, and most straightforward operation, 1980). howFIG. 1. Nesbits procedure showing cuff at base of penis and erection induced by saline infusion to demontrate curvature corrected by the excision of two ellipses of tunica.

ever, is either the modified Nesbit's procedure, popularized by Kelami, or some form of plication (Lemberger et al, 1984). or plication One of the problems with is that this is accompanied a Nesbit operation by some degree of our to warn pathe

was

not

available has brought were having

in the

early

part

of this

series

and

this

of penile shortening. It is clear from a review tients that this is significant and it is essential

review initially injection propriate.

to light some patients satisfactory intercourse, and have since

who although subsequentbeen offered self

ly developed

impotence or the insertion Although the

patient preoperatively that this is the case. We have adopted circumcision as a routine in order to avoid postoperative edema complaints (Bailey et al, 1985) and relate to this. Disordered some of the patients' sensation of the glans plaque itself or by if the curvature is alter sensation apwith the the of this study, degree

of penile prostheses when apNesbit's procedure is an effective disease and is necessary, to determine et al, 1985). congenital particularly the longer curin term

operation for both vature, a prolonged the former older of surgery outcome

Peyronie's follow-up age group (Bailey

penis may be caused by the Peyronie's dissection of the dorsal nerve complex ventral. Circumcision, however, does preciation patient vasoactive of the preoperatively. agents were glans and At not should the available by inducing since become was employed beginning

be discussed to assess

References

Bailey MJ, Yande S, Walmsley, Pryor JP. Surgery

for Peyronie's disease:

of curvature of the penis outpatient clinic; this has viously autophotography camera nique degree

an erection in the our routine. Prewith a Polaroid of this determine routinely techthe employ

a review

of 200 patients. Br J Urol 1985;57:746-749.

Das S. Peyronie's disease: excision and autografting with tunica vaginalis. J Urol l980;124:818. Devine CJ, Horton CE. Surgical

(Kelami, 1983); one is that it is not possible of rigidity of the prostaglandin of curvature patient responds penis.

disadvantage to accurately We now

treatment

of Peyronie's

disease

with

the

dura.

intracorporeal sess the degree whether the

El (PGE 1; 10-20 tg) to asand importantly to determine fully. If this is the case in impotence the patient postoperatively, due to Peyronie's disthe option of having a the penis and then unin if necessary,

dermal graft. J Urol 1974; 111:44-49. Kelami A. Surgical treatment of Peyronie's Eur Kelami Urol 1977;3:l91-192. in evaluation A. Auto photography

disease using human

of functional penile disorders.

someone with secondary ease, we prefer to give Nesbit's dertaking procedure self injection

1983;21:628-629. Lemberger RI, Bishop MC, Bates CP. Nesbit's operation for Peyrome's disease. BrJ Urol 1984;56:721-723.

Nesbit RM. Congenital curvature of the phallus: J Urol report of three cases with description of corrective operation. 1965;93:230-233.

Urology

to straighten

preference

to the insertion

of penile

prostheses.

This choice

Pryor JP, Fitzpatrick JM. A new approach to the correction of the penile deformity in Peyronie's disease. J Urol 1979;122:622-623.

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