Accepted Manuscript Correction of concealed penis with preservation of the prepuce I.A. Valioulis, I.C. Kallergis, D.C. Ioannidou PII:
S1477-5131(15)00122-9
DOI:
10.1016/j.jpurol.2015.03.015
Reference:
JPUROL 1906
To appear in:
Journal of Pediatric Urology
Received Date: 17 July 2014 Accepted Date: 10 March 2015
Please cite this article as: Valioulis IA, Kallergis IC, Ioannidou DC, Correction of concealed penis with preservation of the prepuce, Journal of Pediatric Urology (2015), doi: 10.1016/j.jpurol.2015.03.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Correction of concealed penis with preservation of the prepuce
a
RI PT
I.A. Valioulisa,*, I.C. Kallergisa, D.C. Ioannidoua
Department of Pediatric Surgery, Agios Loukas Hospital, Panorama, Thessaloniki,
SC
Greece
AC C
EP
TE D
M AN U
Email:
*Corresponding author: Ioannis Valioulis, G. Papanikolaou 91 57010 Pefka-Thessaloniki Greece Tel.-fax: +30 2310 200 134 Mobile phone: + 30 6946 260 288 Email: [email protected]
1
ACCEPTED MANUSCRIPT
Summary Introduction: By definition, congenital concealed penis presents at birth. Children
penile size.
RI PT
are usually referred to physicians because of parental anxiety caused by their child’s
Objective: Several surgical procedures have been described to treat this condition, but its correction is still technically challenging. The present study reports a simple
SC
surgical approach, which allows preservation of the prepuce.
M AN U
Patients and methods: During the last 6 years, 18 children with concealed penis (according to the classification by Maizels et al.) have been treated in the present department (mean age 4.5 years, range 3-12 years). Patients with other conditions that caused buried penis were excluded from the study. The operation was performed through a longitudinal midline ventral incision, which was extended hemi-
TE D
circumferentially at the penile base. The dysgenetic dartos was identified and its distal part was resected. Dissection of the corpora cavernosa was carried down to the suspensory ligament, which was sectioned. Buck’s fascia was fixed to Scarpa’s fascia
EP
and shaft skin was approximated in the midline. Penoscrotal angle was fashioned by
AC C
Z-plasty or V-Y plasty.
Results: The median follow-up was 24 months (range 8-36). The postoperative edema was mild and resolved within a week. All children had good to excellent outcomes. The median pre-operative to postoperative difference in penile length in the flaccid state was 2.6 cm (range 2.0-3.5). No serious complications or recurrent penile retraction were noted. Discussion: Recent literature mostly suggests that concealed penis is due to deficient proximal attachments of dysgenetic dartos. Consequences of this include: difficulties
2
ACCEPTED MANUSCRIPT in maintaining proper hygiene, balanitis, voiding difficulties with prepuce ballooning and urine spraying, and embarrassment among peers. Surgical treatment for congenital concealed penis is warranted in children aged 3 years or older. The basis of the technique is the perception that in boys with congenital concealed penis, the penile
RI PT
integuments are normal but they have abnormal attachments, and that incision of the
skin and dartos will allow the shaft to extend. Furthermore, incisions of the fundiform and suspensory ligaments facilitate this maneuver. With this technique, the blood
SC
supply of the penile skin is not interrupted and postoperative lymphedema, a difficult complication to deal with, is prevented. One major advantage is the preservation of
M AN U
the prepuce, giving a normal penile appearance and an excellent cosmetic result. Conclusion: The method proposed here is simple and has no serious complications. It is suggested that this condition be treated in pre-school-aged children in order to
TE D
prevent psychological impairment.
AC C
EP
Keywords: Buried penis; Concealed penis; Hidden penis; Prepuce
3
ACCEPTED MANUSCRIPT
Introduction Treatment of concealed penis continues to be a surgical challenge. Concealed penis, by definition, presents at birth. Children are usually referred to physicians at infancy because of parental anxiety. The concerns generated by this condition are usually
RI PT
closely related to the perception that parents have about their child’s penis size and future sexual function.
On physical examination the penis is hidden in preputial fat, but pressure on
SC
both sides of the penile base reveals a normal shaft. Other problems that concealed penis can cause are phimosis, difficulties with hygiene leading to balanitis, UTI,
Patients and methods
M AN U
spreading of urine and urinary retention.
During a 6-year period (2008-2013) 18 children with concealed penis, according to
TE D
the classification by Maizels et al. [1], were presented to the present department by their parents, who were concerned about the size of their child’s penis. Children with buried penis resulting from other conditions (post-traumatic, webbed, buried in
EP
preputial fat in obese adolescents, etc.) were excluded from the study. The mean age
AC C
of the children was 4.5 years (range 3-12). Some children were referred earlier, but in order to determine some improvement or, sometimes, resolution of the problem, the policy is to wait until 3 years of age.
Operative technique All operations were performed by one surgeon (I.A.V.). The technique is as follows: a dorsal penile block is induced at the beginning of the operation: 5 ml ropivacaine 7.5% is injected at both 10 and 2 o’clock positions at the penile base at the level of the
4
ACCEPTED MANUSCRIPT symphysis pubis. A glanular stay suture is placed for traction. To facilitate upward pulling of the prepuce and penile skin, two stay sutures may also be placed in the prepuce at the 6 and 12 o’clock positions. A Foley catheter is inserted into the bladder. The median raphe is incised from the coronal level (leaving the prepuce
RI PT
intact) to the peno-scrotal junction. The incision is extended to the left and right of the penile base at a 90° circumference (Fig. 2 and Fig. 3). The penis is reflected dorsally; the dysgenetic dartos is identified and then separated from Buck’s fascia down to the
SC
pubic symphysis. The dartos is also freed from the overlying dermis and the distal
part of it is resected (Fig. 4). Dissection is carried down to the suspensory ligament,
M AN U
which is detached, and stops at the division of corpus spongiosum. While pulling the penis upwards, Buck’s fascia is fixed to the Scarpa’s fascia with two non-absorbable 4/0 stitches at 10 and 2 o’clock positions. Further, the dartos fascia is fixed dorsally to the Buck’s fascia at the point where the penile skin naturally dimples, using 4/0
TE D
absorbable sutures at 9, 12 and 3 o’clock positions. Care is taken to avoid neurovascular bundles. Interrupted 5/0 absorbable sutures are placed between penile skin and Buck’s fascia to stabilize the shaft skin and the penile skin is approximated
EP
in the midline using 5/0 running sub-epithelial absorbable sutures. Good fixation of
AC C
penile skin to underlying Buck’s fascia, both dorsally and ventrally, is crucial to prevent recurrences. A Z-plasty or V-Y plasty is used in the penoscrotal junction to cover the lower part of the penis; this is fashioned in a way to recreate the penoscrotal angle (Fig. 5). If phimosis is present, a preputial plasty is performed at the end of the operation. A Tegaderm® wrap dressing is applied around the penis, which is expected to fall off at home. The Foley catheter is removed the next day and the patient is discharged. Paracetamol 15 mg/kg three times daily is given after the operation and for the next 2-3 days.
5
ACCEPTED MANUSCRIPT
Results The median follow-up was 24 months (range 8-36). Should any problems have occurred, the parents were instructed to contact the department. No children required
RI PT
additional surgical intervention and no serious complications were noted. A slight
edema was present during the first postoperative days, but resolved within a week. In one case with a tight phimosis, which underwent a preputial plasty, the edema
SC
persisted for 2 weeks and then started to resolve. The outcome was judged by
M AN U
measurement of the penile length from the base to the tip of the penis in a flaccid state. The median pre-operative to postoperative difference in penile length was 2.6 cm (range 2.0-3.5). No recurrent penile retraction was noted. All children had a
Discussion
TE D
cosmetically satisfactory result.
Keyes published the first description of buried penis in 1919 [2]. In 1958, Byars and
EP
Tries were the first to indentify a post-circumcision trapped penis [3]. Buried penis is a relatively common clinical condition. There is no universally accepted classification
AC C
of the terms ‘concealed’ and ‘buried penis’. The classification proposed by Maizels et al. [1] seems to be more clinically relevant. According to them, buried penis (‘the penile shaft is buried below the surface of the prepubic skin’) is a condition due to either poor penile skin fixation ‘to the deep fascia’ (concealed penis) and is observed in infants or toddlers, or abundant preputial fat and is observed in obese adolescents. Other disorders resulting in the same disease are trapped penis (the shaft is entrapped in scarred prepubic skin, after trauma or, usually, overzealous circumcision) and webbed penis (associated with scrotal web). In all of the above cases, the penis is of
6
ACCEPTED MANUSCRIPT normal size. The phallus may be hidden from view also as micropenis (normally formed penis, less than two standard deviations below the mean normal length) and diminutive penis (small and/or malformed, due to several congenital conditions) [1]. Recent literature mostly suggests that concealed penis is due to deficient proximal
RI PT
attachments of dysgenetic dartos, which has either appropriate or excessive
attachments to the dorsal cavernosum [4,5,6], tethering and, sometimes, shortening of the corporeal bodies [7]. Others report an underlying cause as the low position at
SC
which the crura unite to form the penile shaft [8]. Excessive suprapubic fat contributes also. However, more than one abnormality can be present in many cases [9].
M AN U
Indications for surgical correction are: difficulty in maintaining proper hygiene, resulting in recurrent balanitis; voiding difficulties with prepuce ballooning and urine spraying. However, most children present because of parental anxiety concerning the penile function and appearance [1,5,6,9]. Children at school age with
TE D
concealed penis are often embarrassed when undressing in front of peers, tormented or even ostracized by them for having a small phallus [1,10]. If this condition is left untreated, teenage boys mainly develop anxiety about their penile size. This is usually
EP
short lived and resolves if time, explanation and treatment are given to them.
AC C
However, it may alter self-esteem and gender identification and can lead to social embarrassment. Some authors name this condition ‘small penis syndrome’ [11]. It is of particular interest that in cases of penile surgery in children (buried penis, hypospadias), mothers express more anxiety and concern than fathers about their children’s future sexual function. Waiting for the hormonal changes of puberty to correct the problem spontaneously is no longer accepted. On the contrary, this emphasizes the negative effects of concealed penis on social and psychological development during childhood [1,9,12]. Effective surgical repair usually eliminates
7
ACCEPTED MANUSCRIPT any psychological impairment. Therefore, timing of the operation is important and correction should always be performed before school age, usually the third or fourth year of life. Although good results have been reported in treating this condition in neonates [13], it is preferable to operate on these children later because spontaneous
RI PT
resolution can occur due to the diminution of pre-pubic fat and elongation of the lower abdomen [14].
Historically, a variety of surgical procedures, with good results, have been
SC
published for repairing the whole spectrum of buried/concealed penis conditions
[1,4,6-16]. However, the present technique focuses only on congenital concealed
M AN U
penis. It must be emphasized that extensive knowledge of penile surgical anatomy and prompt recognition and identification of the different penile anatomic structures are of the utmost importance for the surgeons who deal with this kind of surgery. The basis of the technique is the perception that in boys with congenital concealed penis, the
TE D
penile integuments are normal but they have abnormal attachments, and that incision of the skin and dartos will allow the shaft to extend. Furthermore, incisions of the fundiform and suspensory ligaments facilitate this maneuver. Sectioning of the
EP
suspensory ligament adds extra length, especially in difficult cases.
AC C
Risk of phallic instability during erection, because of this maneuver, is small and no author mentions this eventual complication [1,7,13,15,16]. In adults, phallic instability can present after sexual trauma or congenital absence of the penile suspensory ligament [17], but no long-term data are available for patients undergoing penile suspensory ligament section during childhood. Furthermore, fixation of Buck’s fascia to Scarpa’s fascia in the position of stretched penis, according to the present technique, stabilizes the phallus. Skin anchorage to the Buck’s fascia does not allow penile retrusion.
8
ACCEPTED MANUSCRIPT Preservation of the blood vessels of the dorsal penile skin aims to prevent the postoperative lymphedema that can sometimes persist for months [13,18]. It is well known that at the coronal level exist connections between penile skin vessels and penile corporeal vessels. Leaving these connections intact, as well as the dorsal penile
RI PT
skin vessels, contributes to preventing postoperative lymphedema. Another advantage of this technique is the preservation of the prepuce. In most western societies,
preservation of the prepuce is important for identification reasons [18]. Furthermore,
SC
nowadays, it is generally accepted that boys with no preputial pathology should not
undergo circumcision because of the benefits associated with preputial preservation
M AN U
[19,20]. Furthermore, in cases of buried penis, circumcision may worsen the situation [12].
Covering of the ventral penile surface skin is achieved by a Z-plasty or V-Y plasty at the penoscrotal junction. At the present institution the V-Y plasty is usually
result [14].
TE D
performed, which results in more snug penile closure but gives a better cosmetic
The parents judged the results from excellent to very good, and only one found
EP
them satisfactory. The options that they had were excellent, very good, good,
AC C
satisfactory and bad. The factors that they took under consideration were: penile length, accessibility, voiding problems and overall cosmetic result. Important factors contributing to good result were the preservation of the prepuce and the midline ventral incision, mimicking the midline raphe. The Z-lasty and Y-V plasty fade away with time. Although some authors report good results with liposuction [18], liposuction or fat pad excision are not recommended because, generally, they give temporary, limited and unsatisfactory results [14].
9
ACCEPTED MANUSCRIPT
Conclusions Early treatment of penile concealment is important for boys’ normal emotional growth and self-esteem. It also provides psychological benefits to both the child and
RI PT
parents. In addition, preservation of the prepuce gives a normal penile appearance.
Although the number of patients in the present study is small and the follow-up period short, it is believed that the proposed technique helps in dealing with this clinical
SC
entity, alleviates parents’ anxiety and provides a proper and durable solution, with
Acknowledgements Conflict of interest: none declared.
TE D
Funding: none declared.
M AN U
excellent cosmesis.
AC C
EP
Ethical Approval: This is a retrospective study. No approval was required.
10
ACCEPTED MANUSCRIPT
References [1] Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the buried penis: description of a classification system and a technique to correct the disorder. J Urol 1986;136;268-71.
RI PT
[2] Keyes EL Jr. Phimosis, paraphimosis, tumors of the penis. In: Urology. New York: D. Appleton & co; 1919. p.649.
[3] Byars LT, Tries WC. Some complications of circumcision and their surgical
SC
repair. Arch Surg 1958;76:477.
1995; 153:1668-70.
M AN U
[4] Lim DJ, Barraza MA, Stevens PS. Correction of retractile concealed penis. J Urol
[5] Cromie WJ, Ritchey ML, Smith RC, Zagaja GO. Anatomical alignment for the correction of buried penis. J Urol 1998;160:1482-4.
[6] Herndon CDA, Casale AJ, Cain MP, Rink RC. Long-term outcome of the surgical
TE D
treatment of concealed penis. J Urol 2003;170:1695-7. [7] Yu W, Cheng F, Zhang X, Ruan Y, Yang S, Xia Y. Minimally invasive technique
7.
EP
for the concealed penis lead to longer penile length. Pediatr Surg Int 2010;26:433-
AC C
[8] Joseph VT. A new approach to the surgical correction of buried penis. J Pediatr Surg 1998;30:727-9.
[9] Casale AJ, Beck SD, Cain MP, Adams MC, Rink RC. Concealed penis in childhood: a spectrum of etiology and treatment. J Urol 1999;162:1165-8.
[10] Horton CE, Vorstman B, Teasley D, Winslow B. Hidden penis release: adjunctive suprapubic lipectomy. Ann Plast Surg 1987;19:131-4. [11] Wylie KR, Eardley I. Penile size and the “small penis syndrome”. BJU Int 2007;99:1449-55.
11
ACCEPTED MANUSCRIPT [12] Wollin M, Duffy PG, Malone PS, Ransley PG. Buried penis. A novel approach. Brit J Urol 1990;65:97-100. [13] Metcalfe PD, Rink RC. The concealed penis: management and outcomes. Curr Opin Urol 2005;15:268-72.
RI PT
[14] Radhakrishnan J, Razzaq A, Manickam K. Concealed penis. Pediatr Surg Int 2002;18:668–72.
[15] Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to
SC
concealed penis: technical refinements and outcome. Urology 2007;69:1195-8.
[16] Frenkl T, Agarwal S, Caldamone A. Results of a simplified technique for buried
M AN U
penis repair. J Urol 2004;171;826-8.
[17] Li C-Y, Agrawal V, Minhas S, Ralph DJ. The penile suspensory ligament: abnormalities and repair. BJU International 2007;99:117-20. [18] Abbas M, Liard A, Elbaz F, Bachy B. Outcome of surgical management of
TE D
concealed penis. J Pediatr Urol 2007;3:490-4.
[19] Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1: 34-44.
AC C
45-51.
EP
[20] Rickwood AMK. Medical indications for circumcision. BJU Int 1999;83 Suppl. 1:
ACCEPTED MANUSCRIPT PICTURE LEGENDS
Picture 2: The two forceps hold the dartos
SC
Picture 3: The distal dartos has been resected.
RI PT
Picture 1:.Incision lines (broken lines).
AC C
EP
TE D
M AN U
Picture 4: Final aspect of the penis.
ACCEPTED MANUSCRIPT
EP
TE D
M AN U
SC
RI PT
To be printed in color only in the web.
AC C
Fig. 1. Concealed penis in a 7-year-old boy. It is evident that there is no circumferential groove around the penile base.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Fig. 2. Incision lines (broken lines)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
Fig. 3. The two forceps hold the dartos
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 4.The distal dartos has been resected
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Fig. 5. Final aspect of the penis
S1477-5131(15)00122-9
DOI:
10.1016/j.jpurol.2015.03.015
Reference:
JPUROL 1906
To appear in:
Journal of Pediatric Urology
Received Date: 17 July 2014 Accepted Date: 10 March 2015
Please cite this article as: Valioulis IA, Kallergis IC, Ioannidou DC, Correction of concealed penis with preservation of the prepuce, Journal of Pediatric Urology (2015), doi: 10.1016/j.jpurol.2015.03.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Correction of concealed penis with preservation of the prepuce
a
RI PT
I.A. Valioulisa,*, I.C. Kallergisa, D.C. Ioannidoua
Department of Pediatric Surgery, Agios Loukas Hospital, Panorama, Thessaloniki,
SC
Greece
AC C
EP
TE D
M AN U
Email:
*Corresponding author: Ioannis Valioulis, G. Papanikolaou 91 57010 Pefka-Thessaloniki Greece Tel.-fax: +30 2310 200 134 Mobile phone: + 30 6946 260 288 Email: [email protected]
1
ACCEPTED MANUSCRIPT
Summary Introduction: By definition, congenital concealed penis presents at birth. Children
penile size.
RI PT
are usually referred to physicians because of parental anxiety caused by their child’s
Objective: Several surgical procedures have been described to treat this condition, but its correction is still technically challenging. The present study reports a simple
SC
surgical approach, which allows preservation of the prepuce.
M AN U
Patients and methods: During the last 6 years, 18 children with concealed penis (according to the classification by Maizels et al.) have been treated in the present department (mean age 4.5 years, range 3-12 years). Patients with other conditions that caused buried penis were excluded from the study. The operation was performed through a longitudinal midline ventral incision, which was extended hemi-
TE D
circumferentially at the penile base. The dysgenetic dartos was identified and its distal part was resected. Dissection of the corpora cavernosa was carried down to the suspensory ligament, which was sectioned. Buck’s fascia was fixed to Scarpa’s fascia
EP
and shaft skin was approximated in the midline. Penoscrotal angle was fashioned by
AC C
Z-plasty or V-Y plasty.
Results: The median follow-up was 24 months (range 8-36). The postoperative edema was mild and resolved within a week. All children had good to excellent outcomes. The median pre-operative to postoperative difference in penile length in the flaccid state was 2.6 cm (range 2.0-3.5). No serious complications or recurrent penile retraction were noted. Discussion: Recent literature mostly suggests that concealed penis is due to deficient proximal attachments of dysgenetic dartos. Consequences of this include: difficulties
2
ACCEPTED MANUSCRIPT in maintaining proper hygiene, balanitis, voiding difficulties with prepuce ballooning and urine spraying, and embarrassment among peers. Surgical treatment for congenital concealed penis is warranted in children aged 3 years or older. The basis of the technique is the perception that in boys with congenital concealed penis, the penile
RI PT
integuments are normal but they have abnormal attachments, and that incision of the
skin and dartos will allow the shaft to extend. Furthermore, incisions of the fundiform and suspensory ligaments facilitate this maneuver. With this technique, the blood
SC
supply of the penile skin is not interrupted and postoperative lymphedema, a difficult complication to deal with, is prevented. One major advantage is the preservation of
M AN U
the prepuce, giving a normal penile appearance and an excellent cosmetic result. Conclusion: The method proposed here is simple and has no serious complications. It is suggested that this condition be treated in pre-school-aged children in order to
TE D
prevent psychological impairment.
AC C
EP
Keywords: Buried penis; Concealed penis; Hidden penis; Prepuce
3
ACCEPTED MANUSCRIPT
Introduction Treatment of concealed penis continues to be a surgical challenge. Concealed penis, by definition, presents at birth. Children are usually referred to physicians at infancy because of parental anxiety. The concerns generated by this condition are usually
RI PT
closely related to the perception that parents have about their child’s penis size and future sexual function.
On physical examination the penis is hidden in preputial fat, but pressure on
SC
both sides of the penile base reveals a normal shaft. Other problems that concealed penis can cause are phimosis, difficulties with hygiene leading to balanitis, UTI,
Patients and methods
M AN U
spreading of urine and urinary retention.
During a 6-year period (2008-2013) 18 children with concealed penis, according to
TE D
the classification by Maizels et al. [1], were presented to the present department by their parents, who were concerned about the size of their child’s penis. Children with buried penis resulting from other conditions (post-traumatic, webbed, buried in
EP
preputial fat in obese adolescents, etc.) were excluded from the study. The mean age
AC C
of the children was 4.5 years (range 3-12). Some children were referred earlier, but in order to determine some improvement or, sometimes, resolution of the problem, the policy is to wait until 3 years of age.
Operative technique All operations were performed by one surgeon (I.A.V.). The technique is as follows: a dorsal penile block is induced at the beginning of the operation: 5 ml ropivacaine 7.5% is injected at both 10 and 2 o’clock positions at the penile base at the level of the
4
ACCEPTED MANUSCRIPT symphysis pubis. A glanular stay suture is placed for traction. To facilitate upward pulling of the prepuce and penile skin, two stay sutures may also be placed in the prepuce at the 6 and 12 o’clock positions. A Foley catheter is inserted into the bladder. The median raphe is incised from the coronal level (leaving the prepuce
RI PT
intact) to the peno-scrotal junction. The incision is extended to the left and right of the penile base at a 90° circumference (Fig. 2 and Fig. 3). The penis is reflected dorsally; the dysgenetic dartos is identified and then separated from Buck’s fascia down to the
SC
pubic symphysis. The dartos is also freed from the overlying dermis and the distal
part of it is resected (Fig. 4). Dissection is carried down to the suspensory ligament,
M AN U
which is detached, and stops at the division of corpus spongiosum. While pulling the penis upwards, Buck’s fascia is fixed to the Scarpa’s fascia with two non-absorbable 4/0 stitches at 10 and 2 o’clock positions. Further, the dartos fascia is fixed dorsally to the Buck’s fascia at the point where the penile skin naturally dimples, using 4/0
TE D
absorbable sutures at 9, 12 and 3 o’clock positions. Care is taken to avoid neurovascular bundles. Interrupted 5/0 absorbable sutures are placed between penile skin and Buck’s fascia to stabilize the shaft skin and the penile skin is approximated
EP
in the midline using 5/0 running sub-epithelial absorbable sutures. Good fixation of
AC C
penile skin to underlying Buck’s fascia, both dorsally and ventrally, is crucial to prevent recurrences. A Z-plasty or V-Y plasty is used in the penoscrotal junction to cover the lower part of the penis; this is fashioned in a way to recreate the penoscrotal angle (Fig. 5). If phimosis is present, a preputial plasty is performed at the end of the operation. A Tegaderm® wrap dressing is applied around the penis, which is expected to fall off at home. The Foley catheter is removed the next day and the patient is discharged. Paracetamol 15 mg/kg three times daily is given after the operation and for the next 2-3 days.
5
ACCEPTED MANUSCRIPT
Results The median follow-up was 24 months (range 8-36). Should any problems have occurred, the parents were instructed to contact the department. No children required
RI PT
additional surgical intervention and no serious complications were noted. A slight
edema was present during the first postoperative days, but resolved within a week. In one case with a tight phimosis, which underwent a preputial plasty, the edema
SC
persisted for 2 weeks and then started to resolve. The outcome was judged by
M AN U
measurement of the penile length from the base to the tip of the penis in a flaccid state. The median pre-operative to postoperative difference in penile length was 2.6 cm (range 2.0-3.5). No recurrent penile retraction was noted. All children had a
Discussion
TE D
cosmetically satisfactory result.
Keyes published the first description of buried penis in 1919 [2]. In 1958, Byars and
EP
Tries were the first to indentify a post-circumcision trapped penis [3]. Buried penis is a relatively common clinical condition. There is no universally accepted classification
AC C
of the terms ‘concealed’ and ‘buried penis’. The classification proposed by Maizels et al. [1] seems to be more clinically relevant. According to them, buried penis (‘the penile shaft is buried below the surface of the prepubic skin’) is a condition due to either poor penile skin fixation ‘to the deep fascia’ (concealed penis) and is observed in infants or toddlers, or abundant preputial fat and is observed in obese adolescents. Other disorders resulting in the same disease are trapped penis (the shaft is entrapped in scarred prepubic skin, after trauma or, usually, overzealous circumcision) and webbed penis (associated with scrotal web). In all of the above cases, the penis is of
6
ACCEPTED MANUSCRIPT normal size. The phallus may be hidden from view also as micropenis (normally formed penis, less than two standard deviations below the mean normal length) and diminutive penis (small and/or malformed, due to several congenital conditions) [1]. Recent literature mostly suggests that concealed penis is due to deficient proximal
RI PT
attachments of dysgenetic dartos, which has either appropriate or excessive
attachments to the dorsal cavernosum [4,5,6], tethering and, sometimes, shortening of the corporeal bodies [7]. Others report an underlying cause as the low position at
SC
which the crura unite to form the penile shaft [8]. Excessive suprapubic fat contributes also. However, more than one abnormality can be present in many cases [9].
M AN U
Indications for surgical correction are: difficulty in maintaining proper hygiene, resulting in recurrent balanitis; voiding difficulties with prepuce ballooning and urine spraying. However, most children present because of parental anxiety concerning the penile function and appearance [1,5,6,9]. Children at school age with
TE D
concealed penis are often embarrassed when undressing in front of peers, tormented or even ostracized by them for having a small phallus [1,10]. If this condition is left untreated, teenage boys mainly develop anxiety about their penile size. This is usually
EP
short lived and resolves if time, explanation and treatment are given to them.
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However, it may alter self-esteem and gender identification and can lead to social embarrassment. Some authors name this condition ‘small penis syndrome’ [11]. It is of particular interest that in cases of penile surgery in children (buried penis, hypospadias), mothers express more anxiety and concern than fathers about their children’s future sexual function. Waiting for the hormonal changes of puberty to correct the problem spontaneously is no longer accepted. On the contrary, this emphasizes the negative effects of concealed penis on social and psychological development during childhood [1,9,12]. Effective surgical repair usually eliminates
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resolution can occur due to the diminution of pre-pubic fat and elongation of the lower abdomen [14].
Historically, a variety of surgical procedures, with good results, have been
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published for repairing the whole spectrum of buried/concealed penis conditions
[1,4,6-16]. However, the present technique focuses only on congenital concealed
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penis. It must be emphasized that extensive knowledge of penile surgical anatomy and prompt recognition and identification of the different penile anatomic structures are of the utmost importance for the surgeons who deal with this kind of surgery. The basis of the technique is the perception that in boys with congenital concealed penis, the
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penile integuments are normal but they have abnormal attachments, and that incision of the skin and dartos will allow the shaft to extend. Furthermore, incisions of the fundiform and suspensory ligaments facilitate this maneuver. Sectioning of the
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suspensory ligament adds extra length, especially in difficult cases.
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Risk of phallic instability during erection, because of this maneuver, is small and no author mentions this eventual complication [1,7,13,15,16]. In adults, phallic instability can present after sexual trauma or congenital absence of the penile suspensory ligament [17], but no long-term data are available for patients undergoing penile suspensory ligament section during childhood. Furthermore, fixation of Buck’s fascia to Scarpa’s fascia in the position of stretched penis, according to the present technique, stabilizes the phallus. Skin anchorage to the Buck’s fascia does not allow penile retrusion.
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skin vessels, contributes to preventing postoperative lymphedema. Another advantage of this technique is the preservation of the prepuce. In most western societies,
preservation of the prepuce is important for identification reasons [18]. Furthermore,
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nowadays, it is generally accepted that boys with no preputial pathology should not
undergo circumcision because of the benefits associated with preputial preservation
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[19,20]. Furthermore, in cases of buried penis, circumcision may worsen the situation [12].
Covering of the ventral penile surface skin is achieved by a Z-plasty or V-Y plasty at the penoscrotal junction. At the present institution the V-Y plasty is usually
result [14].
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performed, which results in more snug penile closure but gives a better cosmetic
The parents judged the results from excellent to very good, and only one found
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them satisfactory. The options that they had were excellent, very good, good,
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satisfactory and bad. The factors that they took under consideration were: penile length, accessibility, voiding problems and overall cosmetic result. Important factors contributing to good result were the preservation of the prepuce and the midline ventral incision, mimicking the midline raphe. The Z-lasty and Y-V plasty fade away with time. Although some authors report good results with liposuction [18], liposuction or fat pad excision are not recommended because, generally, they give temporary, limited and unsatisfactory results [14].
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Conclusions Early treatment of penile concealment is important for boys’ normal emotional growth and self-esteem. It also provides psychological benefits to both the child and
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parents. In addition, preservation of the prepuce gives a normal penile appearance.
Although the number of patients in the present study is small and the follow-up period short, it is believed that the proposed technique helps in dealing with this clinical
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entity, alleviates parents’ anxiety and provides a proper and durable solution, with
Acknowledgements Conflict of interest: none declared.
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Funding: none declared.
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excellent cosmesis.
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Ethical Approval: This is a retrospective study. No approval was required.
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References [1] Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the buried penis: description of a classification system and a technique to correct the disorder. J Urol 1986;136;268-71.
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[2] Keyes EL Jr. Phimosis, paraphimosis, tumors of the penis. In: Urology. New York: D. Appleton & co; 1919. p.649.
[3] Byars LT, Tries WC. Some complications of circumcision and their surgical
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repair. Arch Surg 1958;76:477.
1995; 153:1668-70.
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[4] Lim DJ, Barraza MA, Stevens PS. Correction of retractile concealed penis. J Urol
[5] Cromie WJ, Ritchey ML, Smith RC, Zagaja GO. Anatomical alignment for the correction of buried penis. J Urol 1998;160:1482-4.
[6] Herndon CDA, Casale AJ, Cain MP, Rink RC. Long-term outcome of the surgical
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treatment of concealed penis. J Urol 2003;170:1695-7. [7] Yu W, Cheng F, Zhang X, Ruan Y, Yang S, Xia Y. Minimally invasive technique
7.
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for the concealed penis lead to longer penile length. Pediatr Surg Int 2010;26:433-
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[8] Joseph VT. A new approach to the surgical correction of buried penis. J Pediatr Surg 1998;30:727-9.
[9] Casale AJ, Beck SD, Cain MP, Adams MC, Rink RC. Concealed penis in childhood: a spectrum of etiology and treatment. J Urol 1999;162:1165-8.
[10] Horton CE, Vorstman B, Teasley D, Winslow B. Hidden penis release: adjunctive suprapubic lipectomy. Ann Plast Surg 1987;19:131-4. [11] Wylie KR, Eardley I. Penile size and the “small penis syndrome”. BJU Int 2007;99:1449-55.
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ACCEPTED MANUSCRIPT [12] Wollin M, Duffy PG, Malone PS, Ransley PG. Buried penis. A novel approach. Brit J Urol 1990;65:97-100. [13] Metcalfe PD, Rink RC. The concealed penis: management and outcomes. Curr Opin Urol 2005;15:268-72.
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[14] Radhakrishnan J, Razzaq A, Manickam K. Concealed penis. Pediatr Surg Int 2002;18:668–72.
[15] Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to
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concealed penis: technical refinements and outcome. Urology 2007;69:1195-8.
[16] Frenkl T, Agarwal S, Caldamone A. Results of a simplified technique for buried
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penis repair. J Urol 2004;171;826-8.
[17] Li C-Y, Agrawal V, Minhas S, Ralph DJ. The penile suspensory ligament: abnormalities and repair. BJU International 2007;99:117-20. [18] Abbas M, Liard A, Elbaz F, Bachy B. Outcome of surgical management of
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concealed penis. J Pediatr Urol 2007;3:490-4.
[19] Cold CJ, Taylor JR. The prepuce. BJU Int 1999;83 Suppl. 1: 34-44.
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45-51.
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[20] Rickwood AMK. Medical indications for circumcision. BJU Int 1999;83 Suppl. 1:
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Picture 2: The two forceps hold the dartos
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Picture 3: The distal dartos has been resected.
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Picture 1:.Incision lines (broken lines).
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Picture 4: Final aspect of the penis.
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Fig. 1. Concealed penis in a 7-year-old boy. It is evident that there is no circumferential groove around the penile base.
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Fig. 2. Incision lines (broken lines)
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Fig. 3. The two forceps hold the dartos
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Fig. 4.The distal dartos has been resected
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Fig. 5. Final aspect of the penis
