Ventral curvature, commonly referred to as chordee, has a variety of components, including the ventral shaft skin, Buck fascia, the urethral plate, and disproportion of the corpora.¹ In addition to and prior to performing a urethroplasty, correction of the ventral curvature is a crucial step in hypospadias repair. This leads to reported improved sexual function and quality of life in adulthood.

Various techniques have been described to straighten the penis. Treatment of severe ventral curvature, often defined as greater than 45°, with dorsal plication has been associated with higher rates of recurrence when compared with ventral lengthening procedures.² Specifically, ventral lengthening methods include multiple ungrafted superficial incisions of the tunica albuginea, known as fairy cuts, and a corporoplasty created by a single full-thickness incision from the 3 to 9 o’clock position ventrally requiring coverage of the larger defect.

There are many different options available when performing corporoplasty. Graft options include autografts, typically dermal grafts, or use of acellular matrix products, including Alloderm, ACell Cytal (Figure 1), and Cook’s porcine small intestinal submucosa graft. These grafts provide a scaffold containing growth factors to stimulate neovascularization and new tissue proliferation. Prepackaged graft tissue is more readily available and avoids donor site morbidity. These scaffolds have been used effectively as corporal grafts with straight erections still present at least 6 months after initial surgery.^3,4 In a larger series with 28 patients who underwent small intestinal submucosa grafting during a first-stage repair, none developed recurrent curvature after a mean follow-up of 3 years.⁵

Figure 1. Intraoperative graft for corporoplasty using single-layer Cytal. Used with permission from Dr Tim Boswell.

The use of tunica vaginalis (TV) as a flap has proven effective over time, exhibiting less morbidity compared to autografts. While TV tissue can also be used as a graft, employing it as a flap retains the native blood supply, theoretically reducing contracture. We recently reported results of a prospective cohort of 44 patients who underwent corporoplasty with a TV flap (Figure 2). Most these patients had a meatus at the penoscrotal junction or the perineum, and median ventral curvature was 90°. They were followed for a median of 5 years after repair, with only 7% developing recurrent ventral curvature.⁶ Although this study stands out for its size and relatively long follow-up period, other studies have also shown TV flaps have lower rates of recurrent curvature when compared with various grafts.⁷

Figure 2. Tunica vaginalis flap (arrow) for corporoplasty. Used with permission from Dr Kathy Huen.

Both TV flaps and grafts, particularly acellular matrix grafts, provide durable results that are significantly better than dorsal plication procedures. In our current practice, we have shifted toward the use of ACell Cytal graft due to the low costs, ease of access, decreased morbidity from flap dissection, and overall reduction in anesthesia time. Long-term follow-up is crucial as recurrent curvature tends to manifest after puberty.^8,9 Collaborative efforts in multi-institutional studies are essential to determine the ideal tissue for corporoplasty in hypospadias, ensuring optimal patient outcomes.