Penile Degloving and Dorsal Dartos Flap Rotation Surgery in the Management of Severe Isolated Penile Torsion in a 6-Year-Old Boy

Penile torsion is a rare congenital anomaly that is usually characterized by a counterclockwise rotation of the penile shaft or glans. Although several surgical techniques for its correction have been proposed, the consensus of choosing the most efficient technique remains controversial. Herein, we report our operational approach that successfully corrected a severe (>90 degrees) isolated penile torsion in the form of penile degloving and dorsal dartos flap rotation surgery.


INTRODUCTION
Penile torsion is a rare congenital rotational defect of the penile shaft and glans on the longitudinal penile axis usu ally in a counterclockwise direction (1). Penile torsion is commonly seen in association with hypospadias or chor dee while isolated penile torsion is rarely seen (2). Al though the precise etiology of this anomaly is unclear, it is thought that penile torsion occurs because of the abnor mality of the skin and dartos fascia attachment or abnor mal development of the dartos fascia that causes disori entation of the penile shaft and corporeal rotation around its longitudinal axis (1). Recently, Zhou et al. proposed that the asymmetric development of the corpora cavernosa represented a major etiological factor of this anomaly (3). Regarding the degree of rotation, isolated penile torsion is divided into mild (<45 degrees), moderate (45-90 degrees) and severe (>90 degrees) forms (4). The precise incidence of isolated penile torsion is unknown but is believed to be in the range of 2-27% (5-7). However, surgical correction is required in only ~4% of patients (6).
Many operative techniques have been described for the correction of penile torsion including penile deglov ing and realignment technique, suturing the tunica albug inea to the pubic periosteum, dorsal dartos flap rotation, correction by mobilization of urethral plate and urethra, resection of Buck's fascia, modified Nesbit procedure, and diagonal corporal plication (1,3,4,6,(8)(9)(10)(11). However, the consensus on the most efficient and appropriate technique is still missing.
Herein, we report our operational approach for correc tion of severe (>90 degrees) isolated penile torsion in the form of penile degloving and dorsal dartos flap rotation surgery.

CASE REPORT
A 6yearold uncircumcised boy presented with isolated penile torsion. Physical examination showed >90 degrees penile torsion, directed in a counterclockwise fashion with spiral deviation of the penile median raphe ( Figures  1A-D). The surgical correction of penile torsion was car ried out under general anesthesia. A circumferential sub coronal incision was taken and the penile skin and dartos were degloved to the penile root with division of all ad hesion tissues. To achieve an artificial erection, we used a normal saline solution through a butterfly needle into one corporal body. The dorsal dartos flap technique was composed of dissection of the dorsal penile skin and dorsal dartos flap creation, which was rotated around the side of the penile shaft opposite to the direction of penile rotation and attached to the ventral aspect of the penile shaft. The operative technique was completed by a simple rearrange ment of the skin on the shaft of the penis (Figure 2A). This operative technique has led to a complete correction of penile torsion, which was demonstrated by the presence of slit of the urethral meatus in one line with scrotal ra phe ( Figure 2B). Urinary catheter was not used during and after the procedure and no complications were recorded. Postoperative course of the patient was uneventful.
Oneyear followup revealed a satisfactory correction of the abnormal rotation in our patient.

DISCUSSION
For a long time after initial description of penile torsion by Verneuil in 1857, there has not been a proper recommenda tion for its operative correction (12). Recently, several re searchers recommended a penile degloving as an adequate surgical procedure for correcting mild penile torsion (<45 degrees) while in moderate and severe degrees of penile torsion, other operative techniques were suggested. These approaches may, however, be associated with significantly higher risk of postoperative complications (1,3,4,6,(8)(9)(10)(11).
The dorsal dartos flap, previously used to cover the suture line urethroplasty in hypospadia surgery, proved as an effective technique for moderate and severe penile torsion (4,13,14). This technique was initially present  ed by Fisher and Park in 2004 and implied performing a complete degloving of the penis, mobilization of a wide, wellvascularized dorsal dartos flap, its rotation around the right side of the penile shaft and fixation to the ventral aspect, causing clockwise penile rotation (4). This opera tive technique is completed by a simple rearrangement of the skin on the shaft of the penis (4).
The reported success rate of this technique in the com plete correction of penile torsion was 100% in the Fisher and Park series (4), 97% in Marret et al. series (15), and only 64% in the Bauer and Kogan series (13). However, these authors found that 9/25 patients with incomplete penile torsion correction had a residual torsion of <10 degrees, which did not require an additional operative treatment (13). All these studies concluded that dorsal dartos flap ro tation technique provides excellent shortterm results.

CONCLUSIONS
Based on our experience and previous data, we confirm that the dorsal dartos flap rotation techniq isa suitable approach for the treatment of moderate and severe forms of penile torsion. It is a safe procedure that is free of major complications.