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A new algorithm for management of chordee without hypospadias based on

mobilization of urethra

Article  in  Journal of Pediatric Urology · February 2008

DOI: 10.1016/j.jpurol.2007.06.008 · Source: PubMed

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Journal of Pediatric Urology (2008) 4, 43e50

A new algorithm for management of chordee

without hypospadias based on mobilization of
urethra
Amilal Bhat*, Gajendra Saxena, Nitin Abrol

Department of Urology, S.P. Medical College, Bikaner, Rajasthan 334003, India

Received 30 January 2007; accepted 26 June 2007

Available online 4 October 2007

KEYWORDS Abstract Objective: To assess the feasibility of chordee correction by mobilization of ure-
Chordee without thra with corpus spongiosum, and define the guidelines for management of chordee without
hypospadias; hypospadias.
Urethral mobilization; Patients and methods: We reviewed 25 cases of chordee without hypospadias, managed in
Urethroplasty; 1992e2005. Age of patients ranged from 3 to 28 years (mean 14.4 years). Chordee correction
Penile curvature; was performed on a case-by-case basis by skin de-gloving, mobilization of divergent corpus
Orthoplasty; spongiosum, mobilization of hypoplastic urethra, mobilization of proximal urethra up to bulbar
Reconstructive surgery urethra, dorsal plication and division/resection of hypoplastic urethra with main emphasis on
mobilization of urethra, and confirmed by Gittes test.
Results: Chordee correction was possible by mobilization of urethra after penile degloving in
76% of cases and dorsal plication after urethral mobilization in 8%. Only 16% required divi-
sion/resection of hypoplastic urethra. None of them had residual chordee in follow-up period
of 6 monthse3 years (mean of 26 months). After fistula repair and internal urethrotomy in one
patient each, a second surgery had 100% success.
Conclusions: We propose an algorithm based on mobilization of urethra that defines the etiol-
ogy and guidelines for the management of chordee without hypospadias.
ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

Introduction

Chordee without hypospadias is a comparatively rare

* Corresponding author: Department of Urology, Sardar Patel
Medical College and Associated, Group of Hospitals, C-15 Sadul
Ganj, Bikaner, Rajasthan 334003, India. Tel.: þ91 151 252 3728/
222 6327; fax: þ91 151 252 3728.
E-mail addresses: amilalbhat@rediffmail.com (A. Bhat),
gsaxenaspmc@hotmail.com (G. Saxena), nitinabrol@hotmail.com
(N. Abrol).
condition with incidence ranging from 4% to 10% of
hypospadias [1,2]. The synonyms for the condition are hy-
pospadism without hypospadias, congenital penile curva-
ture, corporeal disproportion and congenital short urethra
[3]. Most ventral chordees are ‘missed hypospadias’ with
a major hypoplasia of the tissues forming the ventral radius

1477-5131/$30 ª 2007 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jpurol.2007.06.008
 Author's personal copy
44
of the penis distally to the division of the corpus spongio-
sum. This division of the spongiosum is the key criterion
to define the severity of this penile anomaly. It ignores
the urethral defect and is the most frequent cause of ven-
tral chordee, i.e. tethering of the hypoplastic glans to the
underlying hypoplastic urethra, tethering of the hypoplas-
tic urethra onto the underlying corpora cavernosa and
a split corpus spongiosum [4]. Devine and Horton [5] classi-
fied chordee without hypospadias into three types. Type I
represents the deficiency of corpus spongiosum, and Bucks
and dartos fasciae from the site of chordee to the glans. In
Type II the urethra is surrounded by normal corpus spongio-
sum but the Bucks and dartos fasciae are deficient. In Type
III corpus spongiosum and Bucks fascia are normal but dar-
tos fascia is deficient (Fig. 1). Kramer et al. [2] added Type
IV, which results from discrepancy in the dorsal and ventral
aspects of the corpora cavernosa, and Type V is termed
congenital short urethra [5]. Conventional methods of chor-
dee correction are penile degloving, plication procedures,
corporeal rotation, and resection of hypoplastic urethra,
tunica/dermal grafts and penile disassembly [6]. A few of
these procedures invariably incorporate division of the ure-
thra with urethral reconstruction to achieve the repair, and
as a result introduce the risk of specific complications
(stricture, diverticulum, fistula) [4]. There are no definitive
guidelines for management of chordee without hypospa-
dias, and controversy still continues over whether to
shorten the dorsal surface of corpora or lengthen the ven-
tral surface, and to transect/resect or preserve the hypo-
plastic urethra. This review was conducted to assess the
efficacy of urethral mobilization in correction of chordee
Figure 1 Chordee without hypospadias Type I, Type II and Type III. Skin Z brown, dartos fascia Z green, tunica dartos Z light
green, Bucks fascia Z blue, Tunica albuginea Z purple.
A. Bhat et al.
and define the guidelines for management of chordee with-
out hypospadias.
Patients and methods
We reviewed 25 cases of chordee without hypospadias,
which were managed from January 1992 to July 2005. Only
patients with moderate to severe chordee were included in
the study who were reported at least twice in a four-
visit follow-up protocol (1 month, 3 months, 6 months,
12 months). A single surgeon operated on all the patients.
Video recording of nine patients was also available to re-
view the operative procedure. In the same period we man-
aged 325 cases of hypospadias, which showed the ratio of
chordee with no hypospadias to hypospadias as 1:13. Age
of the patients ranged from 3 to 28 years (mean 14.4 years)
and more than 50% of cases were adolescents/adult age.
Associated anomalies were torsion of 20e90 degrees in
four patients, and inguinal hernia and undescended testis
in one patient each. Correction of chordee was done on
a case by case basis, after assessment with Gittes test, by
penile skin degloving, mobilization of divergent corpus
spongiosum, mobilization of hypoplastic urethra, mobiliza-
tion of proximal urethra up to bulbar urethra and confirmed
by Gittes test (Figs. 2e5). Dorsal plication was done if chor-
dee persisted after mobilization of proximal urethra
(Fig. 5). If chordee persisted even after applying Allis for-
ceps for plication and there was tethering of hypoplastic
urethra, then the urethra was divided/resected to correct
the chordee. Each next step of chordee correction was
 Author's personal copy
A new algorithm for management of chordee without hypospadias
Figure 2 Steps of chordee correction for Type III without hypospadias. A: Type III chordee without hypospadias. B: Moderate
chordee on Gittes test. C: Penile degloving. D: Mild glanular chordee on Gittes test. E: Mobilization of urethra and corpus spongio-
sum. F: Complete chordee correction on Gittes test. G: Raising of glanular flaps. H: Glanuloplasty done with complete correction of
chordee.
used even if there was 15-degree residual chordee. None of
the patients required ventral tunica graft to lengthen the
corpora cavernosa. Torsion in all patients could also be cor-
rected by penile degloving and mobilization of urethra with
corpus spongiosum. Spongioplasty was done by mobilizing
the divergent (Y-shaped) corpus spongiosum along with
the hypoplastic urethra, starting from normal urethra to
tip of glans (Figs. 4EeH), and suturing over the hypoplastic
urethra in midline modifying the Y-shaped corpus spongio-
sum to I shaped, to reconstruct a near normal urethra.
Then glanular flaps were sutured to complete the glanulo-
plasty, reshaping the glans as conical and bringing the me-
atus to the tip (Fig. 4I). One patient each underwent
orchidopexy and herniorrhaphy. The prepuce was used for
tube urethroplasty in four cases and the remaining patients
underwent prepucial reconstruction.
Results
There were six cases of type III, 11 cases of type II and eight
cases of type I (Table 1). Chordee was moderate (30e60 de-
gree) in 14 cases and 11 patients had severe chordee (>60
degree). In four type-III patients chordee correction was
achieved by penile degloving and two required mobilization
of corpus spongiosum. For type II, chordee correction was
possible by mobilization of hypoplastic urethra with diver-
gent corpus spongiosum in three cases, mobilization of ure-
thra up to bulbar part in four cases, and dorsal glanular tugs
in one patient along with mobilization of urethra up to bul-
bar region. Two patients who had dorsal plication earlier
required mobilization of urethra up to bulbar region to
45
correct the residual chordee. One patient required division
of urethra and interposition of skin tube, and he later had
an anastomotic stricture requiring internal urethrotomy.
Type I chordee could be corrected by mobilization of hypo-
plastic urethra and corpus spongiosum in one patient and
mobilization of urethra with dorsal glanular tugs in another.
Three patients required mobilization of proximal urethra up
to bulbar region and three patients underwent resection of
hypoplastic urethra and replacement urethroplasty. Of
these three cases, two required division of urethra for cor-
rection of chordee and one had trauma during mobilization
of hypoplastic urethra. One of the patients had fistula in
the replacement urethroplasty group.
Over all chordee correction was possible by mobilization
of urethra with penile degloving in 76% of cases, by
mobilization of urethra and dorsal plication in 8%, and by
division of urethra in 16% cases. After fistula repair and
internal urethrotomy in one patient each, a second surgery
had a 100% success rate. None of the patient had residual
chordee in a follow-up period of 6 months to 3 years (mean
26 months).
Discussion
There is no general agreement on etiology or surgical
management of this entity. Young proposed that it is due
to a congenitally short urethra and should be managed by
transection and reconstruction of hypoplastic urethra [7].
Devine and Horton in 1973 proposed that chordee without
hypospadias is due to abnormal development of the fascial
layers of the penis, and the majority of these could be
 Author's personal copy

46 A. Bhat et al.

Figure 3 Steps of chordee correction for Type II without hypospadias. A: Moderate chordee on Gittes test. B: Moderate chordee
on Gittes after penile degloving. C: Mobilization of urethra and corpus spongiosum. D: Mild glanular chordee on Gittes test after
mobilization of urethra. E: Mild glanular chordee on Gittes test after mobilization of urethra, lateral view. F: Mobilization of ure-
thra into glans. G: Corpus spongiosum segment longer than corpus cavernosum. H: Complete correction of chordee on Gittes test
after spongioplasty. I: Complete correction of chordee on Gittes test after spongioplasty, lateral view.

treated with resection of fibrous tissue for chordee correc-
tion, transection of urethra being rarely required [5]. Nes-
bit was in a dilemma over whether ‘‘to lengthen the short
aspect or to shorten the longer one’’, but he choose the lat-
ter and described his excisional plicating procedures [8].
Hurwitz et al. were of the opinion that when the paper-
thin urethra of type I is associated with an abnormal mea-
tus, the entire dysplastic urethra should be reconstructed.
If the meatus is normal, clinical judgments must dictate
which type of urethra may be preserved and which must
be reconstructed [9]. The goal of surgical correction of
chordee without hypospadias is to provide a straight penis
without migration of urethral meatus proximally. It is im-
portant to define accurately the cause of the underlying de-
fect and to plan an appropriate and specific method of
surgical correction [2]. Most of the pediatric urologists con-
sider chordee to be significant if it is more than 20 degrees.
We aim at complete chordee correction in children, as with
the growth of the penis minor chordee may increase and
pose a problem during sexual intercourse later. A dorsal ap-
proach is preferred for mild chordee of 10, 20 or 30 de-
grees; conversely chordee of more than 50 degrees is
managed by ventral approach [10]. We plan to correct chor-
dee of even a minor degree using a ventral approach as the
ventral surface is embryologically abnormal.
Regarding the age for correction of chordee, Cendron
and Melin proposed that it should be after puberty. They
believed that curvature would improve spontaneously with
age, and secondly it might disturb the growth of the penis
to alter the tunica of the corpora cavernosa [11]. But others
advocate that if diagnosed in childhood correction should
be at that time [12]. We also follow the principle of manag-
ing the patient whenever he presents.
Different methods of chordee correction are penile
degloving, plication procedures, corporeal rotation, tu-
nica/dermal grafts, resection of hypoplastic urethra and
penile disassembly [6]. The disadvantages of the plication
procedures and corporeal rotation are that they are against
the anatomical principles of surgery, as the dorsal surface
of the corpora is developmentally normal and plication
shortens rather than elongates the embryologically abnor-
mal ventral surface. Excessive infolding or excessive exci-
sion of tunica may lead to a significant decrease in
corporal volume and tunica elasticity. Other disadvantages
are shortening of the penis, excessive blood loss due to ex-
tensive dissection and dorsal vein or corporal injury, and
nerve injury leading to impotence. The limitation of these
procedures is that correction is possible only in mild to
moderate chordee [13,14]. Hendren and Caesar reported
disappointing results and significant recurrence of chordee
 Author's personal copy

A new algorithm for management of chordee without hypospadias 47

Figure 4 Steps of chordee correction for type III without hypospadias with torsion. A: Type III chordee without hypospadias with
torsion. B: Severe chordee on Gittes test without hypospadias. C: Skin adherent to hypoplastic urethra. D: Moderate chordee on
Gittes test after penile degloving. E: Mobilization of urethra and corpus spongiosum. F: Minimal glanular chordee after mobilization
of urethra with corpus spongiosum on Gittes test. G: Mobilization of urethra into glans. H: Complete correction of chordee after
mobilization of urethra into glans. I: Glanuloplasty and spongioplasty. J: Complete correction of chordee on Gittes test after gla-
nuloplasty and spongioplasty.

after long-term follow up by Nesbit himself [15], although
Chertin et al. reported that dorsal tunica albuginea plica-
tion is a simple and effective method with good long-term
results for correction of chordee without any damage to
neurovascular bundles or detrimental effect on erection
[16]. The success rate reported with dorsal plication of tu-
nica for correcting chordee varies from 85% to 100%. But the
long-term results of this technique reported by others were
poor, and some authors have even raised concern that dor-
sal plication in childhood may result in penile shortening
and subsequent erectile dysfunction [17e21]. We use dorsal
plication only in cases where we find minimal chordee after
mobilization of urethra by glanular tug or only one or two
sutures without much folding of the tunica.
Resection of hypoplastic urethra and replacement ure-
throplasty again is an extensive procedure and carries risks
of stricture, fistula, diverticulum, torsion, meatal stenosis
and retrusive meatus [4]. The disadvantages of the graft
procedures are risk of graft contracture, limitation of being
used for small ventral defects and the fact that excessive
grafting may disturb the corporal structures including pe-
nile growth [12]. None of our patients required a graft
but this option is open for patients of corporeal dispropor-
tion type IV. Satisfactory release of ventral chordee can
readily be accomplished by either excision of underlying
fascial tissue or mobilization of the anterior urethra with
replacement of the urethral meatus at the glans without
construction of neo-urethra [22]. Gross reported his
experience with wide mobilization of urethra and one-stage
repair of chordee without hypospadias [23]. Mobilization of
the urethra can be done up to the penoscrotal junction or
up to the bulbar region, according to length needed due
to severity of chordee, keeping the ratio of 4:1. Atala
et al. recommended a 5:1 ratio to prevent compromise of
blood supply to the urethra in hypospadias [24]. In chordee
without hypospadias it may be mobilized a little longer,
since mobilization is with corpus spongiosum and the distal
end of the urethra remains attached to the glans keeping
both blood supplies intact. Dipaola et al. managed 26 chor-
dee patients without hypospadias with dorsal plication in
type III, extensive mobilization of the urethra in type II
and vascularized neo-urethra in type I cases [25]. Mobiliza-
tion of the urethra along with the corpus spongiosum for
correction of chordee is the best option, eliminating the
above-mentioned complications and having the advantage
of utilizing the hypoplastic urethra with spongioplasty. We
could correct the chordee in 76% of cases by mobilization
of urethra and only in 8% of cases was plication used. There
is less risk of shortening of the penis if dorsal tunica plica-
tion is done after mobilization of urethra, as partial correc-
tion of chordee is achieved by mobilization of urethra. Only
16% required division of hypoplastic urethra, and 4% of
these were due to damage to hypoplastic urethra during
mobilization. Mobilization of urethra is difficult in type I
as it is adherent to both corpora as well as to the skin.
There is a risk of urethral fistula in the case of injury to
 Author's personal copy

48 A. Bhat et al.

Figure 5 Steps of chordee correction for Type II without hypospadias. A: Moderate chordee on Gitte’s test without hypospadias.
B: Midline incision on ventral surface. C: Penile degloving and poorly developed corpus spongiosum. D: Moderate chordee Gittes
test after penile degloving. E, F: Mobilization of hypoplastic and proximal urethra. G: Moderate chordee Gittes test after mobili-
zation of urethra. H: Mobilization of urethra into glans. I: Minimal chordee after mobilization of urethra into glans. J: Mobilization
of neurovascular bundle. K: Site and size of incision for tunica albuginea plication. L: Incision in tunica albuginea. M: Suture ap-
plication in tunica albuginea. N: Complete correction of chordee after tunica plication on Gittes test. O: Complete correction
of chordee after spongioplasty and glanuloplasty. P: Complete correction of chordee and skin closure.

hypoplastic urethra during dissection. Creating a plane of injury to the urethra. Injecting saline or adrenaline solution
dissection around the normal urethra proximally and then helps in dissection of the skin from hypoplastic urethra. We
dissecting distally helps in mobilizing the urethra along routinely do spongioplasty and glanuloplasty in all cases.
with corpus spongiosum, with less risk of bleeding and Spongioplasty adds to the length of the urethra and so helps

Table 1 Types of chordee without hypospadias, and procedures performed

Procedure No. of cases State of corpus spongiosum No. of cases Type
Penile degloving 4 Well developed 4 III
Penile degloving þ mobilization of corpus spongiosum 2 Well developed 2 III
a. Penile degloving þ mobilization of hypoplastic 4 Poorly developed 3 II
urethra and corpus spongiosum Not developed 1 I
b. ‘a’ þ mobilization of proximal urethra 7 Poorly developed 4 II
Not developed 3 I
Penile degloving þ dorsal plication 2 Poorly developed 1 II
Not developed 1 I
Penile degloving þ division/resection of urethra 4 Poorly developed 1 II
Not developed 3 I
Secondary cases 2 Poorly developed 2 II
of penile degloving þ mobilization of urethra
 Author's personal copy

A new algorithm for management of chordee without hypospadias 49

in correction of chordee. Mobilization of hypoplastic ure- Conclusions

thra and spongioplasty reconstructs a near-normal urethra,
making repair as per anatomical principles of surgery, cor-
rects the chordee and also helps in prevention of urethral
fistulae. Glanuloplasty has a dual advantage of correcting
the glanular part of chordee and giving a conical shape to
the glans. Utilizing the above-mentioned advantages, we
propose an algorithm (Fig. 6) to manage chordee without
hypospadias, which defines etiology and guidelines for man-
agement of this congenital anomaly.
Mobilization of hypoplastic urethra and proximal healthy
urethra up to the bulbar part gives an additional length to the
urethra, according to the age of the child, which is sufficient
to correct the chordee in most cases. Mobilization of
divergent corpus spongiosum and spongioplasty with glanu-
loplasty also helps in correction of chordee, restoring near-
normal anatomy of the urethra. A new algorithm is proposed
for the management of chordee without hypospadias.

Figure 6 Flow chart for management of chordee without hypospadias.

 Author's personal copy

50 A. Bhat et al.

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