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8/3/2019 Chordee in the Absence
http://slidepdf.com/reader/full/chordee-in-the-absence 1/3
CLINICAL CASE
Rev Mex Urol 2010;70(1):48-5048
1Urology Resident at the Licenciado Adolfo López Mateos RegionalHospital of the ISSSTE , Mexico City. 2Urology Surgeon, Urology Ser-
vice Staff Physician at the Centro de Cirugía Ambulatoria del ISSSTE ,Mexico City. 3Doctor in Psychology and Medical Anthropology, FES Iztacala UNAM . 4Urology Surgeon, Urology Service Staff Physician at
Chordee in the absence of hypospadias Valdepeña-Estrada RE, 2 Castellanos-Hernández H,1 Córdoba-Basulto DI,3 Bernal-García R,1 De la Cruz-Gutiérrez
SM,1 Figueroa-Zarza M,1 Velázquez-Macías RF.4
• ABSTRACT
Ventral penile curvature or chordee is common in
hypospadias but is much less frequent when the meatusis orthotopic. It rarely presents in isolated form and as
such represents approximately 4-10% of chordee cases.
Etiology and management of this condition continues tobe a subject of debate in the literature.
Key words:chordee, hypospadias, congenital, preputial.
•RESUMEN
La cuerda congénita (chordee) o curvatura peniana ven-tral es común en el hipospadias, pero lo es mucho menoscuando el meato es ortotópico, y es rara cuando se pre- senta de forma aislada, en que. representa alrededor de4% a 10% de los casos de cuerda congénita. La etiología y el manejo de esta afección continúan sujetos a debate en la literatura.
Palabras clave: cuerda, hipospadias, congénita, pre- pucial.
•INTRODUCTION
Congenital chordee or ventral penile curvatureis common in hypospadias but it is a rare abnormality
when the meatus is orthotopic.1,2,3
Its precise etiology is not yet known, even though
now it is well-accepted that various anatomical changesare related to chordee with or without hypospadias and
they require various surgical procedures. It has been
suggested that chordee is due to a congenitally shorturethra and that the urethra should be sectioned. The
theory that chordee without hypospadias is the result
of dysgenesis of the fascia surrounding the urethra has
also been proposed.
Chordee has been classied into 3 groups dependingon the affected layers. In Group I the corpus spongiosum,
dartos and Buck’s fascia are defective, in Group II the
the Licenciado Adolfo López Mateos Regional Hospital of the ISSSTE,Mexico City.Corresponding author: Dr. Hibert Castellanos Hernández Av. Universi-dad No. 1321 Col. Florida, Delegación Álvaro Obregón, Distrito Federal
Telephone: 044 55 29019733 Email: [email protected]
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Rev Mex Urol 2010;70(1):48-50
Valdepeña-Estrada RE, et al . Chordee in the absence of hypospadias
49
dartos is decient and in Group III only the dartos fascia
is affected. Corporal disproportion is another cause of
chordee which is classied as Group IV corresponding
to chordee without hypospadias.1
•CLINICAL CASE
The case of a 10-year-old boy is presented. He had no
important medical history related to his disease, was
the product of a normal second birth from a 22-year-old
mother and has a 6-year-old brother who is apparently
healthy. He sought medical attention due to strain upon
urination as well as a weakening of the urinary stream.
He had no history of infection and was referred to the
out-patient surgery center.
Physical examination revealed normal retractile
testes, a sunken penis surrounded by pubic fat,
bifurcated prepuce in the dorsal region and orthotopic
urinary meatus, absence of prepuce in the ventral region
of the penis and preputial chordee. No hypospadias was
identied at any level (Image 1).
Testicular and renal ultrasound was done to rule out
any other associated malformation and imaging results
were normal.
Preputial plasty and chordee correction were
decided upon and were carried out with the technique
described by Jednak et al. A “tennis racket” incision was
made 5 mm behind the dorsal corona (Image 2) and
Byar’s aps were formed (Image 3). Fibrous chordee
tissue at the ventral side of the penis was resected and
involvement of Buck’s fascia only was identied. Thedartos and corpus spongiosum were not involved.
The ventral region of the penis was then covered with
the aps (Image 4).
The patient was managed as an out-patient and
surgical progression was satisfactory. There was
improvement in the mechanical aspects of urination
as well as in genital aesthetics.
•DISCUSSION
Isolated chordee without hypospadias is rare and
represents 4-10% of cases of congenital chordee.
Etiology and management of this condition continue
to be topics of debate in the literature. 3 Developmental
arrest is a presumed cause of hypospadias and often
results in curvature with a relative shortening of ventral
structures. Sometimes ventral shortening of the skin
and dartos produces curvature.2
In 1973 Devine and Horton classied chordee
without hypospadias into groups based on the different
etiologies involved. Type I is considered to be the most
Image 1. Penis with bifurcated prepuce in dorsal region as well as ab-sence of prepuce in ventral region.
Image 2. “Tennis racket” incision 5 mm behind the dorsal corona of thepenis
Image 3. Byar’s aps to be placed in the ventral region of the penis
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50 Rev Mex Urol 2010;70(1):48-50
Valdepeña-Estrada RE, et al . Chordee in the absence of hypospadias
serious defect. This comes about when the corpusspongiosum, dartos and Buck’s fascia are decient in
the portion of the urethra that is involved. Therefore the
urethra is located directly below the skin and the brous
tissue under the urethra causes the chordee. In Type II
the corpus spongiosum is normal while the dartos and
Buck’s fascia are dysgenetic. In Type III only the dartos
is decient causing penile curvature.5
Kramer subsequently recognized that corporal
disproportion is an additional cause of penile curvature
and classied this type as Type IV chordee without
hypospadias. Congenital short urethra is also recognized
as a rare cause of congenital chordee.4
The present case is a Type II chordee withouthypospadias.
In 1937 Young proposed that chordee without
hypospadias was due to congenital short urethra and
suggested transection and reconstruction of the curved
ventral urethra.1
In 1973 Devine and Horton proposed that chordee
without hypospadias was due to abnormal development
of the fascial layers surrounding the urethra. In their
experience the majority of patients were successfully
treated by brous tissue resection while urethral
transection was rarely required to straighten the penis.5
Image 4. Ventral region of the penis covered with Byar’s aps
In 1982 Kramer recognized that corporal
disproportion was an important cause of isolated
chordee and recommended carrying out dorsal
plication following the Nesbit principle to correct this
type of chordee without hypospadias.4 However, others
suggest that elongating ventral corporal organs withgraft material is superior to plication of ventral corporal
organs in severe penile curvature.3
Successful repair of chordee without hypospadias
should produce a straight phallus with a urethral meatus
that permits normal urination.6
In the present case the technique described by
Jednak et al.6 was used. This technique originally was
employed in Type I cases with urethral involvement. In
the case described here there was no urethral
involvement but treating the dorsal coronal skin and
taking the ap to the ventral region was considered to
be the most adequate way to manage this particularcase.
•CONCLUSIONS
Congenital chordee is a rare entity when it presents
in isolated form. It can negatively affect the urination
mechanism and cause alterations in genital aesthetics.
There are multiple techniques for correcting this
pathology but each case should be individualized. Itis important to rst dene which structures are involved
to avoid carrying out extensive unnecessary procedures.
Pre-school age is the suggested age for correcting this
pathology.
BIBLIOGRAPHY
1. Yun Man T, Shao Ji C, Lu Gang H. Chordee without hypospadias: re-port of 79 chinese prepuberal patients. J Androl 2007;28(4):630-633.
2. Snodgrass W. A farewell to chordee. J Urol 2007;178 (3 Pt 1):753-4.3. Donnahoo KK, Cain MP, Pope JC. Etiology, management and surgical
complications of congenital chordee without hypospadias. J Urol1998;160(3 Pt 2):1120-2.
4. Kramer SA, Aydin G, Kelalis PP. Chordee without hypospadias in chil-dren. J Urol 1982;128(3)559-61.
5. Devine CJ, Horton CE. Chordee without hypospadias. J Urol1973;110(2):264-71.
6. Jednak R, Hernandez N, Spencer J. Correcting chordee without hy-pospadias and with decient ventral skin: a new technique. BJU Int2001;87(6):528–30.