Content Summary
Shaeer's technique for congenital curing of the penis
Thousands of men around the world today have serious problems getting firm and painless erections, they suffer from congenital penile curvature. A disorder of the corpora cavernosa, a deformity but that has a solution and in this article we will try to address them, especially the Shaeer technique or one of body rotation, one of the most effective.
What is the congenital curvature of the penis?
Congenital curvature of the penis (or CPC) is caused by abnormal embryonic development in which the corpora cavernosa grow asymmetrically, causing a bowing of the organ that becomes pronounced during erection.
This penile curvature during erection in affected men is generally ventral (or forward) and can become so severe (even more than 90 degrees) that sexual intercourse can be very difficult or even impossible.
Penile curvature is a fairly common condition in the Andrology office. It can seriously affect sexual relations and may be the cause of greater psychological concern. Special care from the specialist and a sensitive approach will be required.
An asymmetry or disproportion between the two corpora cavernosa or between the corpora cavernosa and the spongy body can cause a congenital curve of the penis. Normal corpora cavernosa are symmetrical and elastic, allowing the penis to maintain a straight position during erection. However, congenital curvature of the penis is caused by shortening, which most often affects the ventral part of the penis.
In general, the urethral hole (where urine flows) has a normal location at the tip of the glans, but the foreskin may be incomplete showing a dorsal cap shape and the anterior raphe (or frenulum) presents fibrosis and shows signs of tension . In severe cases, the urethra can have trouble transporting urine outward.
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Types of congenital penile curvature
Two main types of congenital curvature of the penis can be found that will depend on the development of the spongy body (through which the urethra passes with the urine), the first is associated with a normal urethra and the second with those with a hypoplastic or shorter urethra. normal. The latter can cause serious problems with urination.
Since 1991, there is a classification to group the different types of congenital penile curvature according to the structures affected by the anatomical defect of embryonic development:
- Type I: affects the cancellous, the dartos and Buck's fascia. The urethral meatus has a normal position in the glans but there is a complete lack of development of all the layers surrounding the urethra. The urethra, without a spongy body, is very attached to the skin and therefore retracts it, causing the deformity.
- Type II: affects Buck and Dartos fascia. The urethra is surrounded by a normal spongy body, but the mesenchymal tissue (from which the fascia and Buck's darts originated) develops two bands of fibrous tissue that extend deep and laterally along the spongy tissue. Producing a retraction of the tissue.
- Type III: affects the Dartos fascia, presenting an abnormal adhesion of Buck's fascia and the spongy body to the skin of the foreskin.
- Type IV: affects the albuginea of the corpora cavernosa. The urethra and surrounding fascia develop normally, but there is an inelastic shortening and development of the tunica albuginea of the corpora cavernosa.
- Type V: only affects the spongy body but causing a fairly severe urethral shortening.
Of all these types, the most severe presentation is type I. A condition in which the cancellous is shorter than normal and the curvature of the ventral penis is largely conditioned by the lack of development of the urethra and the disproportion that it exists between the spongy and the cavernous bodies.
It is likely that within the terminology used in the medical literature for this condition it should probably be revised that the terms “congenital penile curvature” and “cord without hypospadias” have often been used interchangeably.
The term cord without hypospadias is used for those patients in whom the meatus or urinary hole is adequately located at the tip of the glans and a ventral curvature is clearly associated with congenital anomalies of the spongy body, the tissues of the ventral fascia, or both. In a recent review, Makovev et al. defined congenital curvature of the penis as a result of disproportionate development of the tunica albuginea of the corpora cavernosa, which is not associated with urethral malformation.
A different approach is needed for these two main types of congenital curvature. Awareness of possible urethral shortening or congenital lack of these structures is the most relevant clinical problem at this point.
How frequent is congenital penile curvature?
Congenital penile curvature is the second most common cause of penile curvature after La Peyronie’s disease. The published prevalence seems to indicate a frequent condition, which affects 4% -10% of men. Authors such as Ebbehoj and Metz investigated its incidence in the Danish population and reported an incidence of 0.37 per thousand male births. Other researchers such as Yachia et al. reported an incidence of less than 1%.
However, many other researchers believe that CPC has a higher incidence and prevalence than reported. The presence of CPC in childhood is difficult to identify and its actual prevalence in adults is also difficult to assess. Even today, CPC is accepted as normal or considered irreparable. Many men live with their penile abnormality in absolute and overwhelming loneliness.
Why does congenital curvature of the penis occur?
There is still no evidence of the actual cause of congenital penile curvature. However, several mechanisms have been suggested, such as the following:
- An embryological defect in the normal development of the penis (inside the maternal uterus), due to a dysregulation of testosterone that is converted by 5-alpha-reductase to dihydrotestosterone (DHT), the substance responsible for inducing the proper development of male genitalia.
- Androgen deficiency or insensitivity to them.
- A unique study analyzing the ultrastructure of the tunica albuginea has shown widening and fragmentation of the collagen fibers, with total absence of striation and transformation into electron-dense fibrous granular material and accumulation of elastin. Collagen is necessary for the consistency of the cells of the corpora cavernosa.
Clinical presentation and evaluation of the patient
Patients suffering from congenital penile curvature generally attend the doctors’ office when they become sexually active, that is, in the second or third decade of life. Only the most severe cases of cord without hypospadias can be diagnosed in childhood due to problems with urination. These patients generally complain of curvature of the erect penis; which is often ventral or forward, sometimes lateral, and rarely dorsal or rearward. In some cases, the penis can bend in two directions (such as ventral and lateral at the same time). Dorsal curvature is extremely rare except when associated with torsion of the penis.
A minimum curvature of less than 15 ° is common and clinically irrelevant, provided the erections are painless and do not interfere with sexual intercourse. When the curvature is greater than 30 ° the patient may have difficulties with sexual relations or discomfort due to penetration, in addition to aesthetic concerns. Erectile function is normal, but can be compromised by excessive curvature.
How is a correct diagnosis made?
Medical and sexual histories are usually sufficient to establish the diagnosis of congenital curvature of the penis. This is achieved with an adequate medical interview that allows obtaining relevant information on the patient’s general state of health, family history, and the sexual and life habits he performs.
Physical examination during erection is useful in documenting curvature and excluding other pathologies such as La Peyronie’s disease, which is usually somewhat more complicated.
Self-photographs of the erect penis are recommended according to the doctor’s instructions and which the patient himself must take from home. Spontaneous erections are almost always good enough for photographs because of the difficulty it can be for the patient to get an erection inside the doctor’s office.
The intracavernous injection test can produce erections physiologically and induced, but should be avoided in young patients at high risk of priapism. It is also recommended to measure the length of the penis when performing a surgical approach and for which a secondary shortening is expected (the technique of body rotation has a minimum risk of producing this, see below).
There is no standard method of measurement and the length of the penis will depend on the contraction of the smooth muscles of the penis and prepubic fat, especially in overweight or obese patients, but it is important to perform this measurement at different times.
However, the measurement of both sides (short and long) of the stretched length is almost similar to the lon erectile girth, especially when the stretched length is pulled three times before measurement. This simple test can avoid complaints from patients and parents, as well as legal claims.
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Does penane curvature have a solution?
The reality is that yes. Congenital penile curvature is a problem that does not have to be forever in men because there are ways to correct the defect.
For many years, androgen replacement therapy has been tried without consistent results in adult patients. Therefore, surgery is the only treatment option for this condition and can be performed at any time in adult life. In fact, such a surgical procedure at an early age could avoid a negative psychological impact.
Surgical treatments for congenital penile curvature generally share the same principles as Peyronie’s disease, as they are similar disorders. Furthermore, most of the techniques used for Peyronie’s disease (PD) have been described first for congenital curvature of the penis.
Traditionally, the two main surgical options available for the penile curvature approach include:
- Shorten the longest side with excisions or incisions and plication.
- Lengthening of the shorter side of the erect penis with grafting.
Patients with penile curvature, unlike patients with La Peyronie’s disease, generally have a good length of the penis and, unfortunately, surgical techniques focus primarily on procedures that produce shortening such as plication or more plication incision.
However, some new techniques have been developed to reduce the shortening effects of traditional techniques with the same correction of curvature and patient satisfaction, and this is where a new technique appears: the technique of rotation of the corpora cavernosa. which will be discussed later.
how to measure a penis curve
Surgical techniques to correct congenital penile curvature. What should I know?
The most commonly used repair techniques for simple penile curvatures are the original Nesbit procedure, the modified Nesbit procedure, and the application. However, in recent years a new approach has been implemented, with better results and fewer subsequent complications: the technique of rotation of the corpora cavernosa.
The applications of the tunica albugínea in its many variants have reported very good results in the correction of the curvature. In patients with severe penile curvature, the Nesbit technique provides somewhat better results than simple plication techniques.
A different approach is needed for these two main types of congenital curvature of the penis. The general principles of these techniques are similar to Peyronie’s disease. However, there are some peculiarities that distinguish the congenital curve when approaching its surgical treatment. Before surgery, it is important to keep in mind the following considerations:
- The youth of the patient. Patients generally present after reaching puberty as the curvature becomes more apparent. Many young patients undergo surgery before beginning sexual intercourse. This can be quite beneficial in avoiding the anxiety that comes with knowing that intercourse may be painful or uncomfortable, not satisfactory.
- In general, there is no calcification, no induration of the corpora cavernosa, and no asymmetric thickness of the albuginea on both sides of the penis (short and long). The presence of fibrous nodules in the penis refers to La Peyronie's disease and therefore, the treatment is different, but also surgical.
- The absence of calcified retractable plate on the shorter side, the normality of the septum and the internal part of the corpora cavernosa, and the absence of major deformities are notable differences with respect to La Peyronie's disease. They generally make the procedure easier.
- Normal healing is expected after the surgical procedure. Collagen disorders and healing dysfunction have not been described in these patients.
- Physical examination should pay special attention to the condition of the spongy body, the urinary meatus and the distal part of the urethra. The awareness of the possible urethral shortening or the congenital lack of these structures is the most relevant clinical problem to consider in these cases. Combinations of different techniques (urethroplasty with straightening of the penis) should be considered in the case of urethral disorders.
Surgeons who do not have experience in this type of surgery should work closely with specialized units in the treatment of reconstructive urethral surgery, especially in the most severe cases of penile curvature. These cases should be managed by a multidisciplinary team or specialist surgeons who have experience in managing the urethra to avoid problems.
What does the Nesbit technique consist of?
This technique consists of shortening the tunica albugínea on the opposite side to the curvature by means of plications (small stitches) along with some removal of a portion of tissue and graft into the tunica albuginea on the affected (or concave) side. With this, the curvature is reduced and rectified.
This technique has represented the most widely used surgical method before the appearance of the cavernous body rotation technique, developed by Dr. Shaeer in 2006.
This surgery begins by providing the patient with some local anesthesia in the genital area, thus avoiding total nerve sedation. This is beneficial in preventing adverse effects and reducing recovery time after anesthesia.
First, the erect penis is denuded by induced erection by making an annular incision in the foreskin, near its junction with the glans. This gives access to the tunica albugínea which on the convex side will receive the plications and from which part of the tissue will be removed.
Once the tissue plications have been made, the foreskin is reattached and the surgery is complete.
Application of plicatures using the Nesbit technique
Correction of the penis using the Nesbit technique
Corrected Nesbit technique
What is Shaeer's Cavernous Rotation Technique and what is it?
In 2006, Dr. Shaeer published a new technique developed in Cairo, based on the rotation of the corpora cavernosa and updated by the same author in 2008. This innovative technique reduces the shortening effects of traditional techniques with the same correction of the curvature and with very good results.
This technique consists of laterally rotating the corpora cavernosa so that the penis acquires a straighter appearance. This is achieved by accessing the corpora cavernosa by means of a double incision in the dorsal or posterior part of the penis (one for each corpora cavernosa) and performing a double suture to force them to maintain the rotation performed.
Rotation of the corpora cavernosa, published by Dr. Shaeer, is a novel and useful alternative treatment that should be considered for patients with congenital penile curvature, given its ease of performance and excellent results.
The new modifications proposed for the technique have improved much more, its cosmetic and functional results. They are particularly useful in cases of severe congenital curvature of the penis (when the curvature exceeds 60-90°).
This procedure reduces the shortening of the penis (risk that is run with other techniques) and avoids complications such as palpable nodules, scars in the corpora cavernosa and pain in the penis.
- Se denuda el pene a través de una incisión coronal y se realiza una erección artificial.
- Se diseca el paquete vasculonervioso en su totalidad y se realizan dos incisiones dorsales longitudinales en los cuerpos cavernosos, algo más separadas del septo y surco medio en la zona de máxima curva que en el resto.
- Luego se practica una doble sutura continua con monofilamento reabsorbible de larga duración 4/0: la primera une las caras internas y la segunda las externas. Esta doble sutura lograr cerrar ambos defectos a la par que imprime una rotación a los cuerpos cavernosos que endereza otras técnicas más propias del tratamiento de la estenosis de uretra o del hipospadias. La primera intervención quirúrgica, como en tantas situaciones de la medicina es la que ofrece las mayores oportunidades de curación al paciente. Por supuesto, el equipo quirúrgico debe dominar estas técnicas y estar preparado para solventar situaciones que de otro modo podrían ser perniciosas para la funcionalidad del pene.
- El acortamiento del pene que producen todas estas técnicas es algo que hay que dejar claro al indicar la intervención para evitar frustración en el paciente con el resultado quirúrgico. Este acortamiento supone uno de los mayores motivos de insatisfacción de los pacientes tras la cirugía. Por ello, algunas soluciones quirúrgicas empleadas en los últimos años como la de trasposición de albugínea en los centros Andromedi de Madrid, Sevilla y Tenerife están dando resultados excelentes en términos de corrección de la curvatura congénita de pene con mínimo acortamiento de la longitud de éste.
Corpora cavernosa rotation technique
The step by step of the technique of rotation of the corpora cavernosa
A longitudinal dorsal incision was made in the dorsal part of each corpora cavernosa, and by double suturing the internal and external parts of the incision, a rotation of the corpora cavernosa is induced, resulting in excellent straightening of the penis.
Step 1
After administering local anesthesia to the penis (as with all penile, congenital, or acquired curvature correction techniques) and disinfecting the area to be operated, the penis is ready for surgery.
Step 2
Neurovascular dissection was not considered necessary in Dr. Shaeer’s original technique. However, this neurovascular bundle (or neurovascular bundle) can be dissected dorsally, especially if any additional plication or procedure is needed, avoiding any potential neurological and vascular damage.
Step 3
Two superficial longitudinal incisions must be made in the dorsal part of the corpora cavernosa, involving the external longitudinal layer of the tunica albuginea, preserving the internal circular layer.
These two incisions should be slightly curved instead of parallel, with a greater separation in the central part of the incision. In fact, the more severe the curvature, the greater the separation required.
Step 4
First, the surgeon closes the medial or internal edges with a continuous suture. Then a second continuous suture will approach the lateral edges.
Ideally, according to Dr. Shaeer’s recommendations, polyglactin 910 (Vicryl), poliglecaprone 25 (Monocryl), and polydioxanone (PDS) sutures appear to have a very long rupture strength retention profile and could be a good option.
Step 5
Here, the surgeon induces a post-surgical and artificial erection for the measurement of the penis and thus, to evaluate the residual curvature that could be left and the changes that could be made. The shortening of the length of the penis is usually quite small.
Step 6
Buck’s fascia and skin are closed with fast-absorbing sutures, a urethral catheter, and a compression dressing.
Frequently Asked Questions About Dr. Shaeer's Cavernous Rotation Technique
Very good results have been published with this technique, such as:
• More than 90% straightening of the penis was observed in all cases.
• With a minimum shortening of the penis (less than one centimeter).
• High patient satisfaction in the recovery of their sexual life.
• No postoperative complications.
Among its advantages are:
• Does not leave scars. The cavernous body rotation technique does not cause scars or leave marks that could ruin the appearance of the penis due to the careful surgical approach and the delicate process of closing the open tissue, they are thin sutures.
• It does not leave nodules on the dorsal part of the penis, as it happens with other techniques. Nodules appear when the tissue is reattached in an inappropriate way and an exaggerated healing process occurs, resulting in accumulations of palpable tissue under the skin.
• The curvature correction is anatomical and smooth. With the cavernous body rotation technique, the penis can again have uniform erections and the patient does not usually perceive exaggerated or uncomfortable tensions. At first glance, a penis that has undergone this surgery is indistinguishable from one that has never undergone surgery.
• There is no shortening of the penis. This characteristic is by far one of the most important of this technique. The penis can achieve erections with the same length as before surgery, not less. This is because at no time does rotating the corpora cavernosa involve shortening or reducing the corpora cavernosa of the incurred area.
The steps to receive this surgical intervention consist of:
1. Examination in consultation with photographs of the erect penis so that the doctor can examine how large the abnormal penile curvature is and thus be able to evaluate the actions to be taken to correct it.
2. Local anesthesia is applied in the surgical intervention, this ensures that the procedure is completely painless.
3. The operation is performed and the patient can return home.
The procedure in question usually lasts between 4 and 16 hours in total, from the moment the patient arrives at the hospital until the patient leaves the hospital. It will all depend on the patient's needs and the time it takes to feel good enough to return home.
It is not necessary for the patient to stay in the hospital, but it is necessary to have some care with the operative wound for a few days.
Ideally, the patient should wait a few days to resume his sex life. This is in order to prevent injury in the newly operated area. Sustained erections, intercourse, or masturbation may be somewhat painful for a couple of days after the procedure.
By far the main disadvantage of the conventional technique for reducing congenital curvature of the penis, the Nesbit technique, is that it produces a shortening in the length of the erect penis and that in many cases it can be greater than one centimeter.
This feature can make many patients fear of undergoing the operation. However, with the cavernous body rotation technique, the decrease in penis size is usually quite small and almost always imperceptible.
Medical references and bibliography
- Penile Curvature European Association of Urology
- EAU – GUIDELINES ON PENILE CURVATURE European Association of Urology
- TRATADO DE ANDROLOGÍA - DR. NATALIO CRUZ 2ND. EDITION, SPAIN - 2011
- H. PORST, Y. REISMAN. THE ESSM SYLLABUS OF SEXUAL MEDICINE EUROPEAN SOCIETY FOR SEXUAL MEDICINE. 2012. PAGES 927 – 951
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