FCPS Paediatrics TOACS · Interactive Station

✅ Candidate's structured answer:
• Findings: Downward (ventral) curvature of the penile shaft. The urethral meatus is at the tip of the glans (normal position). No hypospadias. Foreskin intact.
• Diagnosis: Congenital chordee without hypospadias (isolated chordee).

✅ Candidate's answer:
• Chordee: Ventral (downward) curvature of the penis, due to congenital shortening of the ventral tissues (skin, dartos fascia, corpus spongiosum, or tunica albuginea).
• Chordee without hypospadias (isolated): Urethral meatus is at the tip (normal). Curvature may be mild to severe. Less common (~10% of chordee cases).
• Chordee with hypospadias: Urethral meatus is located ventrally (on shaft, glans, or perineum). The ventral curvature is usually more severe. Much more common. Surgical repair must address both the hypospadias and the chordee.
• In both types, the curvature is due to dysgenetic ventral tissues; treatment involves surgical release (penile degloving, ventral corporotomy or plication).

✅ Candidate's answer:
• Type I (cutaneous chordee): Due to deficient/scarred ventral skin only. Least common. Corrected by skin release alone (degloving).
• Type II (fascial chordee): Due to fibrosis of dartos fascia (Buck's fascia). Requires excision of fibrotic tissue.
• Type III (corporeal chordee): Most common in isolated chordee. Due to disproportion between ventral and dorsal corpora cavernosa (asymmetric development). Requires ventral corporal tunica albuginea plication or dorsal corporeal grafting.
• Type IV (urethral chordee): Associated with hypospadias – due to dysplastic corpus spongiosum and urethral plate. Requires urethral plate division or urethroplasty.
• Accurate classification is done intraoperatively after degloving and artificial erection test.

✅ Candidate's answer:
• Purpose: To objectively assess the degree and cause of penile curvature during surgery, and to confirm complete correction after tissue release.
• Procedure (Gittes test):
1️⃣ A tourniquet (rubber band or Penrose drain) is placed at the base of the penis after degloving.
2️⃣ Normal saline is injected into one corpus cavernosum using a butterfly needle (23-25G) or through a small corporotomy.
3️⃣ The penis is observed for straightness. The angle of curvature is measured (goniometer).
4️⃣ After ventral tissue release (excision of fibrotic dartos, urethral plate division, or corporal plication), the test is repeated to confirm straightening.
5️⃣ The tourniquet is released after completion.
• Goal: Straight penis (<10-15° residual curvature).

✅ Candidate's answer:
• Indications for surgery:
- Curvature >30 degrees (generally accepted threshold for functional impairment).
- Cosmetic concerns from parents/patient.
- Any degree of curvature associated with hypospadias requiring repair.
- Inability to pass a straight stream (if urethral meatus is displaced).
• Timing: Typically between 6-18 months of age (optimal 9-12 months).
- Early repair minimizes psychological impact, allows for better tissue healing, and avoids patient memory of the procedure.
- Can be performed during infancy (once the infant is >6 months and >10 kg).
- Ideally before toilet training.

✅ Candidate's answer:
• Step 1 – Circumcision and degloving: Circumcision incision and deglove the penile skin down to the penoscrotal junction. This releases skin tethering (if cutaneous chordee).
• Step 2 – Artificial erection test: Assess residual curvature.
• Step 3 – Ventral tissue excision: If curvature persists, excise dysplastic dartos fascia and fibrotic tissue from the ventral midline.
• Step 4 – Corporal plication (Nesbit technique or tunica albuginea plication – TAP): For corporeal chordee. Place 2-4 non-absorbable sutures (PDS or Gore-Tex) in the dorsal tunica albuginea to shorten the dorsal side and straighten the penis. Alternatively, ventral corporotomy with grafting (if severe curvature).
• Step 5 – Recheck artificial erection: Confirm straightness.
• Step 6 – Skin closure: Re-approximate skin, often with a circumcision unless family declines.

✅ Candidate's answer:
• Nesbit procedure (classic): Elliptical excision of tunica albuginea from the convex (dorsal) side of the corpora, followed by closure. This shortens the longer side.
• Tunica albuginea plication (TAP): Multiple parallel plicating sutures placed on the dorsal tunica albuginea without excision (e.g., Lue procedure). Less invasive, lower risk of neurovascular bundle injury.
• Advantages of TAP: Simpler, avoids tunical excision, less erectile shortening.
• Advantages of Nesbit: More durable for severe curvatures (>45 degrees).
• Both are effective; TAP is preferred for mild-moderate chordee (<45°).
• Postoperative erectile function is excellent with both.

✅ Candidate's answer:
• Early complications (<6 weeks):
- Bleeding / hematoma.
- Wound infection, wound dehiscence.
- Edema (self-limited).
- Urinary retention (rare).
- Meatal stenosis (if meatus involved).
• Late complications:
- Recurrent chordee (5-15%): Residual or recurrent curvature – may require reoperation.
- Penile shortening: Perceived loss of length (5-10 mm) due to dorsal plication.
- Erectile dysfunction: Rare after childhood plication procedures.
- Penile numbness: Transient or permanent (rare, due to neuropraxia).
- Palpable suture knots (with non-absorbable sutures).
- Urethrocutaneous fistula – only if urethroplasty performed (uncommon in isolated chordee repair).

✅ Candidate's answer:
• Excellent prognosis – >90% of patients have a straight penis after surgery.
• Recurrence: Low (5-15%) but possible, especially if severe chordee was not adequately corrected intraoperatively or if the patient undergoes significant penile growth during puberty. Most recurrences are mild (<20°) and may not require reoperation.
• Erectile function: Normal in vast majority. Parental reassurance: Surgery is performed before puberty; the child will not remember the procedure.
• Cosmesis: Good to excellent. Residual scar (circumcision) is well tolerated.
• Follow-up: Annual visits until puberty, then as needed. Assess for recurrent curvature, erectile function, and psychosocial adjustment.
• Patient satisfaction: High.

✅ Candidate's answer:
• Isolated chordee without hypospadias is rarely associated with major upper tract anomalies.
• However, a thorough examination is necessary:
- Testes: Rule out undescended testis or retractile testis.
- Scrotum: Look for bifid scrotum or other abnormalities (may suggest disorder of sex development).
- Perineum: Exclude imperforate anus.
• Imaging is not routinely indicated for isolated chordee with normal urination and no other anomalies.
• If chordee is associated with hypospadias or bifid scrotum, a renal ultrasound is recommended to rule out vesicoureteral reflux, UPJ obstruction, or other anomalies (associated in 5-10%).
• Genetic evaluation if ambiguous genitalia or syndromes suspected.

✅ Candidate's structured answer:
• “Your baby has a downward curve of the penis (chordee). This is a congenital condition present since birth. The urethra (urine tube) is in the normal position at the tip, so this is not hypospadias.”
• “The curvature is significant (>30 degrees). If left uncorrected, it could cause difficulty with normal function when he grows up.”
• “Surgery is recommended at around 9-12 months of age. It is a day-surgery or short-stay procedure under general anesthesia.”
• “During the operation, the surgeon will straighten the penis by shortening the longer side (dorsal plication).”
• “Regarding circumcision: In Pakistan, circumcision is a standard practice. However, I strongly advise you to delay circumcision until the chordee repair surgery. Do not get a routine circumcision done separately. The reason is that during chordee repair, the foreskin is used for degloving and exposure. If a routine circumcision is performed first, it removes the necessary skin and makes the chordee repair much more difficult and less successful. Therefore, we will perform the circumcision at the same time as the chordee repair (under the same anesthesia), so your son will have both procedures together without needing a second operation.”
• “The success rate for straightening the penis is >95%. There is a small risk of recurrence (5-10%) or a mild residual curve that does not affect function.”
• “After surgery, you may see swelling and bruising for 1-2 weeks. Most children recover quickly and have no pain after the first few days.”
• “This surgery does not affect urinary control or fertility. Your son will have normal function in adulthood.”

✅ Candidate's answer:
• Congenital chordee without hypospadias (as in this case).
• Chordee with hypospadias – urethral meatus located ventrally (subcoronal, penile, penoscrotal, perineal).
• Penile torsion – rotational deformity, not isolated ventral curvature.
• Megalourethra – congenital dilation of urethra, often with curvature.
• Epispadias – urethral meatus on dorsal aspect; associated with dorsal chordee (curves upward).
• Peyronie's disease – acquired, not congenital; presents in adulthood.
• Penile fracture (traumatic curvature) – history of trauma.
• Lichen sclerosus (balanitis xerotica obliterans) – acquired scarring, usually presents later in childhood with phimosis and possible curvature.