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A modified surgical procedure for concealed penis.

Introduction

Concealed penis is a congenital abnormality in which the penis is buried below the surface of prepubic skin. (1,2) The penis can be palpated and visualized through pushing the skin around the penis to the pubis. This disease is more common in obese people. In recent years, concealed penis gets more and more attention, especially in developing countries, such as China. Surgical repair of the congenital abnormality is a difficult challenge for urologists. (3-8) Weight loss or removal of suprapubic fat usually fails to reach satisfactory result. Simple circumcision will make the condition worse. Complete loosening and fixing the penile shaft are key in its surgical repair. However, postoperative penile retraction remains inevitable in some cases. In present study, we showed a modified surgical procedure for concealed penis and compared the effect and feasibility of modified repair with traditional repair.

Methods

Approval for the study was granted by the ethics committee of Nanjing Medical University in China and informed written consent was received from patients.

Patients

From March 2003 to December 2012, 96 patients with concealed penis were recruited at our centre. Patient age ranged from 8 to 25 years old. Patients suffered from the short penis and obvious phimosis (Fig. 1). Upon physical examination, all patients had the stretched penile length appropriate for their age. Traditional repair was performed on 46 patients. The remaining 50 cases underwent modified repair.

Surgical procedures

All operations were performed by the same experienced urologists at our centre. After induction of general anesthesia, the patients were placed in the supine position. First, the adhesion of the prepuce was dissected to expose the glans. Then a circumferential skin incision was made along the coronary sulcus to deglove penile shaft to the base of penis. The dysplastic dartos should be loosened and resected completely to stretch and straighten penile shaft sufficiently. Then the superficial fascia, pubic periosteum and Buck fascia were sutured and fixed together with 5-0 absorbable sutures at the 12 o'clock position of base of the penis (Fig. 2). Similarly, the superficial fascia and Buck fascia were sutured together at the 3, 6 and 9 o'clock positions of base of the penis (Fig. 2). For patients undergoing modified repair, a small longitudinal median incision was made at the dorsal prepuce after the above procedures (Fig. 3a). Then the superficial fascia and Buck fascia were sutured with 5-0 absorbable sutures (Fig. 3b). During the extra procedures, the dorsal blood vessels and nerves of penis should be avoided. Lastly, all prepuce incisions were sutured interruptedly with 4-0 absorbable sutures to recover the normal appearance of prepuce (Fig. 4). Patients were followed up for 12 months.

[FIGURE 1 OMITTED]

Outcomes analysis

We compared mean operative time, intraoperative blood loss, cosmetic result of operative scar, penile retraction one month after operation, and complications. The intraoperative blood loss was determined by weighing the gauze. Specifically, only a piece of gauze was used during one operation. The same type of gauze was used in all procedures. The blood loss was calculated according to weight difference preoperatively and postoperatively. Cosmetic result was assessed with a 5-graded scale ranging from very dissatisfied to very satisfied. Data were expressed as mean [+ or -] standard deviation. All data were initially tested to check normality and homogeneity of variance. T-test was performed for comparison. Statistical significance was set at p < 0.05.

[FIGURE 2 OMITTED]

Results

All operations were completed successfully. No complications occurred. Slight edema was found in all patients and disappeared completely 1 to 2 months after the operation. No patients suffered from voiding dysfunction. After 12 months of follow-up, all patients undergoing modified repair had a normal penile length appropriate for their age. Four cases in traditional repair underwent a second surgery for obvious penile retraction.

Although extra procedures were performed, operative time and intraoperative blood loss of patients undergoing modified repair were not significantly higher than in the traditional repair group (Table 1). The cosmetic result of operative scar was similar between groups. The penile retraction rate in patients with modified repair decreased than in the traditional repair.

[FIGURE 3a OMITTED]

Discussion

Concealed penis is a common congenital abnormality, especially in obese people. Patients suffer from a short penis and obvious phimosis. (3-5,9,10) Dysplastic dartos may be the main cause, which can hinder the normal stretch of penis. Redundant suprapubic fat can aggravate this abnormality. Severe phimosis will lead to the inflammation of external urethral orifice and glans or urinary retention. (1,11) Untreated concealed penis will affect the normal development of the penis and erectile function in adults. Concealed penis should be distinguished from short penis and simple phimosis. In general, the concealed penis has well-developed corpora cavernosa and non-redundant prepuce. A wrong circumcision for concealed penis will cause the shortness or absence of the prepuce, and affect penile development.

Surgical repair is the first-line treatment for concealed penis. During the past decades, different surgical methods were taken to improve the therapeutic effect of concealed penis. (12-14) Complete loosening and fixing penile shaft are the key procedures of surgical repair. However, postoperative penis retraction remains inevitable in some cases. (12) In our modified repair, the superficial fascia and Buck fascia under the dorsal prepuce were sutured again to strengthen the fixation of the stretched and straightened penile shaft. Our results showed that the postoperative penile retraction rate decreased significantly in the modified repair than in the traditional repair. Although extra procedures were needed, simple incision and suture did not increase operative time and intraoperative blood loss. The small incision and thin and absorbable sutures reduced the operative scar maximally, which achieved similar cosmetic result compared with traditional repair.

[FIGURE 3b OMITTED]

In our experience in modified repair, the dysplastic dartos and distal fibrous band of penis should be resected completely to loosen and straighten the penile shaft sufficiently. The superficial fascia and Buck fascia are fixed respectively at the 3, 6, 9 and 12 o'clock positions at the base of the penis. Thyroid retractors should be used to pull the base of the penis and bilateral sides of the penis to clearly expose the operative field for the suture because most of the patients were obese. The longitudinal median incision at the dorsal prepuce and the suture outside the albuginea can avoid damage to the dorsal blood vessels and nerves. At last, the dorsal longitudinal incision should be sutured transversely to avoid postoperative stenosis of the prepuce.

[FIGURE 4 OMITTED]

Conclusions

The modified repair surgery for concealed penis had similar operative time, intraoperative blood loss, and cosmetic result of operative scar with the traditional repair. However, the postoperative penile retraction rate of patients undergoing modified repair decreased significantly than with the traditional repair. Our modified repair is effective and feasible for concealed penis. Compared with traditional repair, modified repair has better clinical outcomes.

http://dx.doi.org/10.5489/cuaj.3028 Published online October 13, 2015.

Acknowledgements: This work is supported by a grant from National Natural Science Foundation of China (81200467) and by A Project Funded by the Priority Academic Program Development of Jiangsu Higher Education Institutions (JX10231 802).

Competing interests: The authors all declare no competing financial or personal interests.

This paper has been peer-reviewed.

References

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(5.) Frenkl TL, Agarwal S, Caldamone AA. Results of a simplified technique for buried penis repair. J Urol 2004;171:826-8. http://dx.doi.org/10.1097/01.ju.0000107824.72182.95

(6.) Lee T, Suh HJ, Han JU. Correcting congenital concealed penis: New pediatric surgical technique. Urology 2005;65:789-92. http://dx.doi.org/10.1016Aurology.2004.10.075

(7.) Abbas M, Liard A, Elbaz F, et al. Outcome of surgical management of concealed penis. J Pediatr Urol 2007;3:490-4. http://dx.doi.org/10.1016/jjpurol.2007.04.006

(8.) Borsellino A, Spagnoli A, Vallasciani S, et al. Surgical approach to concealed penis: Technical refinements and outcome. Urology 2007;69:1 195-8. http://dx.doi.org/10.1016Aurology.2007.01.065

(9.) Perger L, Hanley RS, Feins NR. Penoplasty for buried penis in infants and children: Report of 100 cases. Pediatr Surg Int 2009;25:175-80. http://dx.doi.org/10.1007/s00383-008-2283-9

(10.) Redman JF. Buried penis: Congenital syndrome of a short penile shaft and a paucity of penile shaft skin. J Urol 2005;173:1714-7. http://dx.doi.org/10.1097/01.ju.0000154781.98966.33

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Correspondence: Dr. Ninghong Song, Department of Urology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Nanjing 21 0029, China; nh_song@163.com

Gong Cheng, MD; Bianjiang Liu, MD; Zhaolong Guan, MD; Yuan Huang, MD; Chao Qin, MD; Ninghong Song, MD; Zengjun Wang, MD

Dr. Gong Cheng and Dr. Bianjiang Liu contributed equally to this work and are co-first authors.

Department of Urology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, Nanjing 210029, China

Caption: Fig. 1. Preoperative appearance of the concealed penis.

Caption: Fig. 2. First, the superficial fascia, pubic periosteum and Buck fascia were sutured and fixed together at the 12 o'clock position of base of the penis. Then, the superficial fascia and Buck fascia were sutured together at 3, 6 and 9 o'clock position of base of the penis. A: lateral; B: cross section.

Caption: Fig. 3a. Small longitudinal median incision was made at the dorsal prepuce.

Caption: Fig. 3b. The superficial fascia and Buck fascia were sutured to strengthen the fixation of the stretched and straightened penile shaft.

Caption: Fig. 4. Postoperative appearance of the concealed penis.
Table 1. Clinical outcomes of 96 patients

                    TR (n = 46)          MR (n = 50)       p value

Operation time   37.8 [+ or -] 2.1    39.0 [+ or -] 1.0     0.051
  (min)
Blood loss        9.9 [+ or -] 0.6    10.1 [+ or -] 0.2     0.054
  (mL)
Cosmetic         4.83 [+ or -] 0.38   4.77 [+ or -] 0.43    0.441
  result of
  operative
  scar
Penile                4; 11.1                0; 0          0.018 *
  retraction
  (n; %)
Complication             0                    0
  (n)

TR: traditional repair; MR: modified repair. Data are shown
are mean [+ or -] standard deviation; * p < 0.05.
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Article Details
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Title Annotation:ORIGINAL RESEARCH
Author:Cheng, Gong; Liu, Bianjiang; Guan, Zhaolong; Huang, Yuan; Qin, Chao; Song, Ninghong; Wang, Zengjun
Publication:Canadian Urological Association Journal (CUAJ)
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2015
Words:1907
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