PEDIATRIC UROLOGY

CHORDEE: VARIED OPINIONS AND TREATMENTS AS

DOCUMENTED IN A SURVEY OF THE AMERICAN ACADEMY
OF PEDIATRICS, SECTION OF UROLOGY
RAYMOND A. BOLOGNA, THOMAS A. NOAH, PHILLIP F. NASRALLAH,

AND

DANIEL R. MCMAHON

ABSTRACT
Objectives. Consensus has not been established as to the best treatment of congenital chordee. Outcomes
analysis of treatment options are limited by the prevailing use of ambiguous terminology. We sought to clarify
the frequently used term significant chordee and to measure the utilization of current treatment strategies.
Methods. A survey covering current practice patterns concerning congenital chordee with hypospadias was
sent to 236 members of the American Academy of Pediatrics, Section of Urology.
Results. Correction of chordee was the primary concern in hypospadias surgery of 31% of those responding,
but it was not the primary goal of 54% of respondents. Findings indicate that significant chordee is
clinically defined as curvature greater than 20, in that 75% of respondents said they would proceed with
further intervention. Placement of plicating sutures was the most common therapy chosen for 20 chordee,
with 50% of respondents electing this approach. Consensus was reached at 30 chordee, with greater than
99% intervening at this degree of curvature. At 30 curvature, 48% used an incisional Nesbit procedure. As
the degree of curvature increased, division or mobilization of the urethral plate became the most common
intervention. With 50 chordee, urethral plate manipulation was used 34% of the time. Sixty percent of the
respondents believed the urethral plate did not often contribute to chordee.
Conclusions. Significant chordee was believed to be a curvature greater than 20 to 30. With 20, 30,
and 40 chordee, correction was most often approached dorsally. With 50 chordee, 54% approached the
problem ventrally. We hope to encourage the use of more objective measurements and terminology.
Objective measurements and long-term follow-up will improve our understanding of the natural history of
chordee and improve outcomes analysis. UROLOGY 53: 608612, 1999. 1999, Elsevier Science Inc. All
rights reserved.

he techniques of hypospadias surgery continue to evolve. Today, the standard of care for
hypospadias repair includes (a) a functional penis,
adequate for sexual intercourse, (b) urethral reconstruction providing the ability to stand to void,
and (c) a satisfactory cosmetic result. Unfortunately, published reports do not provide any objective guidelines as to what degree of congenital
chordee inhibits sexual intercourse. We sought to
determine what clinicians consider to be significant chordee and to characterize current treatment strategies. Certainly, the majority opinion is

From the Department of Urology, Childrens Hospital Medical

Center of Akron, Northeastern Ohio Universities College of Medicine, Akron, Ohio
Reprint requests: Daniel R. McMahon, M.D., Department of
Urology, Childrens Hospital Medical Center of Akron, 300 Locust Street, Suite 260, Akron, OH 44302
Submitted: August 10, 1998, accepted: September 24, 1998

608

1999, ELSEVIER SCIENCE INC.

ALL RIGHTS RESERVED

not necessarily based on scientific data and may

not represent the best practice. We strongly encourage the use of objective measurements based
on the operative artificial erection.1 The adoption
of objective measurements and terminology are
mandatory if we are to obtain a greater understanding of the natural history of chordee and improve
outcomes analysis of current treatment options.
MATERIAL AND METHODS
A survey covering current practice patterns concerning congenital chordee with hypospadias was mailed to 236 members
of the American Academy of Pediatrics, Section of Urology.
One hundred twenty-two physicians responded, for a response rate of 52%. The survey had two parts. Questions 1 to
5 provided an artists drawing of 10, 20, 30, 40, and 50 of
chordee, demonstrated by artificial erection after full degloving of the penis (Fig. 1). In an effort to focus on the severity of
chordee, no reference was made to the degree of hypospadias
or the extent of urethral dysplasia. Respondents were asked to
0090-4295/99/$19.00
PII S0090-4295(98)00656-6

FIGURE 1. Sketches depict 10 to 50 of chordee. The corresponding graphs (ae) represent the respondents
selections from the answer key. (Which response best characterizes your approach? 1, no intervention; 2, plicating
sutures only; 3, incisional Nesbit procedure; 4, excisional Nesbit procedure; 5, division or mobilization of the urethral
plate; 6, corporal rotation; 7, ventral incision and grafting.)

select one of seven options for intervention for each degree of

chordee (Fig. 1). The seven options included (a) no intervention, (b) plicating sutures only, (c) incisional Nesbit procedure (modified Nesbit, transverse incisions with tunica albuginea plication, vertical incision, and transverse closure of the
tunica albuginea), (d) excisional Nesbit, (e) division or mobilization of the urethral plate, (f) corporal rotation,2 and (g)
ventral incision and grafting. Questions 6 to 11 pertained to
opinion regarding the natural history of chordee and the morbidity and significance of chordee repair (see Appendix).

RESULTS
Chordee correction is not the primary concern in
hypospadias repair for 54% of respondents. However, it is the primary concern in hypospadias surgery for 31% of respondents. Fifteen percent of
respondents did not answer this question.
Addressing patients presenting with 10 of chordee, 92% of respondents would not intervene. Five
percent of respondents would perform plicating
sutures, 1% an incisional Nesbit procedure, and
2% an excisional Nesbit procedure (Fig. 1a).
Most pediatric urologists appear to define significant chordee as curvature greater than 20,
and 75% of respondents indicated they would proceed with direct intervention. With 20 chordee,
placement of plicating sutures was the most common therapy, chosen by 39% of respondents. Incisional and excisional Nesbit procedures were seUROLOGY 53 (3), 1999

lected by 29% and 7% of respondents, respectively.

Consensus was reached at 30 chordee, with
greater than 99% intervening in response to this
degree of curvature. At 30 curvature, an incisional
Nesbit procedure was employed by 49% of respondents, plicating sutures by 22% of respondents,
and an excisional Nesbit procedure by 13% (Fig.
1b and c).
Sixty percent of respondents believed that the
urethral plate did not often contribute to chordee.
As the degree of curvature increased, however, division or mobilization of the urethral plate became
the most common intervention. At 40 chordee,
urethral plate manipulation was used slightly more
often than the incisional Nesbit procedure (33%
versus 32%), and ventral grafting was used 12% of
the time. With 50 chordee, urethral plate manipulation was used 34% of the time. An incisional
Nesbit was selected by 23% of respondents, and
ventral grafting was the choice of 20% (Fig. 1d
and e).
Responses to question 7 revealed that after the
first maneuver to correct 50 chordee, which resulted in 30 chordee, 89% of the respondents
would proceed with further intervention. If 20
chordee remained, 58% of the respondents continued with additional maneuvers (see Appendix,
question 7).
609

Sixty-four percent of respondents believed that

after degloving the penis, between 5% and 20% of
their patients remain with significant chordee. Sixteen percent of the urologists noted that 50% to
90% of their patients remain with significant chordee after degloving the penis.
Most (85%) believed that chordee does not improve with age. Iatrogenic erectile dysfunction was
believed to be more common after an incisional
Nesbit procedure by 8% of respondents and more
common after an excisional Nesbit procedure by
25% of respondents.
COMMENT
Successful hypospadias surgery should provide
(a) a functional penis, adequate for sexual intercourse, (b) urethral reconstruction providing the
ability to stand to void, and (c) a satisfactory cosmetic result. Unfortunately, published reports do
not provide objective guidelines as to the degree of
congenital chordee, in an infant or child, that inhibits sexual intercourse when that individual becomes an adult. In addition, published reports lack
long-term follow-up of chordee correction. Consequently, consensus has not been established as to
either the degree of chordee requiring correction
or the best technique for repair. Our survey records
the opinion of many who are actively involved in
caring for patients with hypospadias. However,
since the literature regarding the natural history
and treatment outcomes of chordee is poorly developed, one should consider the possibility that
the majority opinion may be in error.
Correction of chordee was the primary concern,
in the repair of hypospadias, of 31% of the respondents. More than half (54%) of respondents believed chordee correction was not the primary concern in the reconstruction of hypospadias. This
divergence of opinion is based on dissimilar views
of the risks and benefits of treating congenital
chordee. Most would agree with Duckett3 that the
decision for a particular repair should not be made
until the anatomy is fully appreciated and the penis
straightened. The issues of debate are what constitutes an adequately straightened penis and what is
the safest method of obtaining this goal.
Most respondents (64%) believed that significant
chordee persists after degloving the penis and resecting the dysgenetic spongiosa (if done) in 5% to
30% of patients. This majority view is consistent
with the literature.3 Chordee was thought to persist in greater than 50% of patients by 16% of respondents. The dramatic disparity in the percentage of patients said to have significant chordee may
be due to variation in the severity of chordee
treated or different opinions regarding the definition of significant chordee.
610

The controversy is not merely an academic issue.

Patients with similar anatomy are treated in very
dissimilar ways by different surgeons. Eight percent of respondents would intervene when addressing a patient with 10 of chordee, and 3%
would perform an incisional or excisional Nesbit
procedure. This aggressive approach is difficult to
reconcile with the opinion of 15% of our respondents who believed that chordee generally improves with maturation. These respondents often
commented that mild chordee was particularly
likely to improve without therapy. Advocates of
this more conservative approach reference observations that penile curvature is a normal embryologic phenomenon, is more common in premature
infants, and has been observed to improve in extrauterine life.4
Most (75%) respondents indicated that they consider 20 of chordee to be significant. The most
common procedure for 20 chordee, not responsive to skin and dartos mobilization, was dorsal
tunica albuginea plication (39%). A more aggressive incisional or excisional Nesbit procedure was
chosen somewhat less frequently (29.5%). At 30
chordee, 99% of respondents would intervene,
50% of whom would perform an incisional Nesbit
procedure, 14% a formal excisional Nesbit procedure, and 13% would elect to mobilize or divide
the urethral plate. Baskin and Duckett5 reported on
182 pediatric patients who underwent dorsal tunica albuginea plication (a form of incisional Nesbit procedure). A mean follow-up of 2.7 years was
available on 80% of the patients in that study. Of
those patients, 6 were noted to have a mild residual
ventral bend. No other complications were discerned during follow-up.5 Nooter et al.6 report on
22 patients with a congenital chordee with the
mean age of 25.7 years and an angle of curvature
from 20 to 90. All these patients underwent a
tunica albuginea plication; postoperative erectile
function was normal in all patients, and curvature
was corrected in all patients. Other series of postpubertal patients with congenital penile curvature
report success rates of 65% to 100% for plication
techniques, 95% to 100% for modified Nesbit techniques, and 89% to 100% for Nesbit procedures.6 8
Despite these high success rates, Mouriquand et
al.8 write that they avoid plication of the dorsal
tunica albuginea, because the long-term results are
unknown, and it may be the source of secondary
deformities during penile growth. Of our respondents, 8% were concerned that erectile dysfunction
would be more common after an incisional Nesbit
procedure, and 25% replied that they were concerned that iatrogenic erectile dysfunction would
be more common after an excisional Nesbit procedure. Recent anatomic studies document that the
dorsal nerve bundles branch from the 11- and
UROLOGY 53 (3), 1999

1-oclock positions and extend completely around

the tunica to the junction of the corpora spongiosum and corpora cavernosa. Injury to these
branches may affect penile sensation. On the basis
of these findings, the 12-oclock position has been
advocated as the ideal site for dorsal plication.9
As the degree of chordee increased, division and
mobilization of the urethral plate became the most
common procedure. At 40 and 50 of chordee,
manipulation of the urethral plate was chosen by
33% and 34% of respondents, respectively. With
the most severe chordee, a ventral approach was
preferred by most respondents, and ventral grafting was selected by 20% of respondents.
For many years, the urethral plate was universally implicated in the pathophysiology of congenital chordee with hypospadias. On the basis of this
assumption, chordee repair generally included division of this dysplastic tissue. More recently,
there has been increasing support for the hypothesis that chordee is related to primary corporal disproportion.2,4,10 This transition in thinking has
contributed to the increased application of onlay
and incised plate urethroplasties. In this paradigm,
correction of curvature is addressed with a dorsal
approach. Baskin and Duckett5 report that a functional penis may be achieved without division of
the urethral plate in approximately 90% of hypospadias patients. Conversely, Devine et al.11 maintain it is illogical to intervene on the dorsal radius
of a penis, as hypospadias involves only the ventral
radius. According to Devine et al., dorsal intervention leaves pathologic tissue, which may lead to
recurrent chordee as the child matures. Belman12
has advocated a ventral approach because it does
not risk damage to the dorsal neurovascular bundle, although, he allows, it does limit the application of an onlay repair. Additionally, investigators
maintain that more aggressive ventral dissection
may result in secondary scarring or residual curvature.11,13
Finally, the responses to question 7 introduce a
possible contradiction as to what degree of chordee
requires intervention. Respondents indicated that
when a patient with a 50 chordee obtains a 20
curvature from surgical repair, 42% believed that
this was adequate reconstruction for penile function and would attempt no further intervention.
Yet, if a patient initially presents with 20 chordee,
75% of respondents would intervene with surgical
reconstruction.
Outcomes analysis of treatment options are hindered by the prevailing use of ambiguous terminology. The use of terms such as significant chordee
and straight enough should be replaced with objective measurements. The intraoperative artificial
erection provides an ideal opportunity to accurately measure and record the severity of chordee
UROLOGY 53 (3), 1999

FIGURE 2. Objective measurement of chordee using a

protractor during hypospadias repair.

(Fig. 2). Currently, we perform an artificial erection in all cases of hypospadias. The approximate
degree of chordee is determined with a protractor
and is recorded in 5 increments. Future advances
depend on accurate reporting of pre- and postoperative degrees of chordee, the surgical intervention employed, and long-term follow-up. Accurate
reporting will help establish whether the goal of
hypospadias surgery, a functional penis, is being
obtained.
CONCLUSIONS
Correction of chordee is not the primary goal of
hypospadias surgery for most respondents. Most
pediatric urologists consider 20 to 30 of chordee
to be significant. A dorsal approach is preferred for
20, 30, and 40 of chordee. Conversely, with 50
of chordee, a ventral approach is most common.
Accurate documentation and reporting of objective data are mandatory if we are to expand our
understanding of the natural history of treated and
untreated congenital chordee.
REFERENCES
1. Gittes RF, and McLaughlin AP III: Injection technique
to induce penile erection. Urology 4: 473 475, 1974.
2. Koff SA, and Eakins M: The treatment of penile chordee
using corporeal rotation. J Urol 131: 931934, 1984.
3. Duckett JW: Hypospadias. AUA Update Series XII:
130 135, 1993.
4. Kaplan GW, and Brock WA: The etiology of chordee.
Urol Clin North Am 8: 383388, 1981.
5. Baskin LS, and Duckett JW: Dorsal tunica albuginea
plication for hypospadias curvature. J Urol 151: 1668 1671,
1994.
6. Nooter RI, Bosch JL, and Schroder FH: Peyronies disease and congenital curvature: long-term results of operative
treatment with the plication procedure. Br J Urol 74: 497500,
1994.
7. Hollowell JG, Keating MA, Snyder HM, et al: Preservation of the urethral plate in hypospadias repair: extended ap611

plication and further experience with the onlay island flap

urethroplasty. J Urol 143: 98 101, 1990.
8. Mouriquand PD, Persad R, and Sharma S: Hypospadias
repair: current principles and procedures. Br J Urol 76(Suppl
3): 9 22, 1995.
9. Baskin LS, Erol A, Li YW, et al: Anatomical studies of
hypospadias. J Urol 160: 1108 1115, 1998.
10. Cendron J, and Melin Y: Congenital curvature of the
penis without chordee. Urol Clin North Am 8: 389 396,
1981.
11. Devine CJ: Controversies in hypospadias surgery: the
urethral plate. Dialog Pediatr Urol 19: 8, 1996.
12. Belman AB: Hypospadias update. Urology 49:
166 172, 1997.
13. Baskin LS, Duckett JW, and Leu TF: Penile curvature.
Urology 48: 347356, 1996.
APPENDIX
Questions 6 to 12 from the survey are as follows:
6. Significant chordee persists after degloving the penis
and resecting the dysplastic spongiosa in what percentage of
your patients?
7. A patient is found to have 50 chordee after degloving
and resecting the dysplastic spongiosa. After your initial maneuver, repeat artificial erection demonstrates 30 chordee,
would you perform additional maneuvers or accept this degree of chordee? ___ Now, after your second maneuver, artificial erection demonstrates 20 chordee, would you perform
additional maneuvers or accept this degree of chordee?
8. Chordee generally should improve as the patient matures?
9. Iatrogenic erectile dysfunction will be more common in
patients who have undergone an incisional Nesbit procedure?
10. Iatrogenic erectile dysfunction will be more common in
patients who have undergone an excisional Nesbit procedure?
11. Correction of chordee is my primary concern in hypospadias surgery?
12. The urethral plate often contributes to chordee?
EDITORIAL COMMENT
Ah, the art of medicine!
This survey proves how inexact a science we practice. The
authors make the point that the average practicing pediatric
urologist needs to be more objective in the assessment of chordee. Using a protractor is a sound suggestion; however, the
underlying question remains, What degree of chordee is clinically significant?
Most of us who practice pediatric urology have little opportunity to see the patients after puberty whose hypospadias we
corrected in early childhood unless a problem occurs. There-

612

fore, we may not be particularly good at determining the answer to that question. Does the general urologist often see men
with residual chordee after childhood hypospadias repair?
Having practiced in one community for 22 years, during
which time I have done at least one third of the total hypospadias repairs, one might suspect that I have seen patients who
later, as adults, were functionally troubled by chordee. Only a
few! I have seen patients who required reoperation for complications of hypospadias, including persisting chordee, but
these were almost all children. Vandersteen and Husmann1
recently reported a 10-year retrospective review of posthypospadias chordee of patients at least 10 years after surgery. In
those 10 years at the Mayo Clinic, only 34 patients were referred for what was termed recurrent chordee. Of 22 patients who fit the criteria for their review, 19 underwent the
procedure elsewhere (so I would conclude we really do not
know if the chordee was adequately treated initially). All 22
had proximal hypospadias initially. So, what happens to the
vast majority of these patients? Do they outgrow mild persisting chordee? I personally do not believe they do. However, I
have no objective data to support that opinion, since I do not
see them later. Or, are our efforts satisfactory in producing
functional penises? Or, to ask the question again, how much
chordee is truly significant?
Remember that part of the Hippocratic oath about first doing no harm? Do we really know that we are avoiding all the
sensory nerves when we perform dorsal plication? Baskin et
al.2 have concluded that we can by confining our adventures to
the midline. Is that realistic for the small penis of a 6-monthold boy, the age I believe hypospadias repair is best carried
out? Would any of the men reading this epistle want to risk
any of their erotic sensation for the theoretical advantage of a
perfectly straight penis? Yet, 8% of the respondents would try
to correct chordee of 10%, all by performing some dorsal maneuver. Would they also intervene in those who have glanular
tilt (the SST abnormality)? What functional disability will
these boys have?

A. Barry Belman
Childrens National Medical Center
Washington, DC

REFERENCES
1. Vandersteen DR, and Husmann DA: Late onset recurrent
penile chordee after successful correction at hypospadias repair. J Urol 160: 11311133, 1998.
2. Baskin LS, Erol A, Ying WL, et al: Anatomical studies of
hypospadias. J Urol 160: 1108 1115, 1998.

UROLOGY 53 (3), 1999