The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion

Sir, We compliment and congratulate the authors of this paper for using urethral mobilisation to correct torsion associated with hypospadias, and appreciate the hard work done in compiling the data for their publication [1]. However, there are a few points in the management of congenital penile torsion and the discussion section of the article that we would like to clarify. 1. There is a spelling mistake in the Discussion, stating 'Baht' at two places, which should be 'Bhat'. 2. We appreciate the authors' application of the technique of step-by-step mobilisation of the urethra and measuring the degree of correction after each step, thus proving that mobilisation of the urethral plate, diverting the spongiosum and proximal urethral mobilisation is effective for correcting ventral penile curvature. A very similar technique of mobilisation of the urethral plate with the spongiosum, and proximal urethral mobilisa-tion for correcting both ventral curvature and penile torsion was reported previously [2–4]. 3. Although the authors mention in their technique that they mobilised the urethral plate and spongiosum, the diagram shows that mobilisation of the urethra distally was only just proximal to the hypospadiac meatus (their Fig. 1b) [1]. Possibly the authors might not have put that figure in the article, or it needs to be explained. The mobilisation of the urethral plate/hypoplastic ure-thra with spongiosum distally should be into the glans, as shown in Fig. 2 and Fig. 3 H in the reference [2]. The cause of torsion in a significant proportion of patients is an aberrant attachment of the spongiosum to the cav-ernosa, which also extends beneath the glans. The tor-sion will not be corrected unless these attachments are dissected from the glans. Mobilisation of the urethral plate and spongiosum from the meatus into the glans is a very important step in the correction of torsion, and corrects torsion in 75% of cases. This has been proposed as a third step in the algorithm mentioned by Bhat et al. [2]. Furthermore, proximal urethral mobilisation into the perineal region corrected torsion in only 22% of patients in our study [2]. Thus it follows that proximal urethral mobilisation alone is not going to correct the curvature in all cases. Each step is important in the correction of torsion. We could correct torsion in 87.5% cases by combining all these steps of