Infection was mild and controlled by continuing the oral and local antibiotic for 7 days.
Many classification systems have been proposed for buried penis. Maizels et al. 2 described a classification consisting of four categories based on the mechanism of concealment: buried penis (due to poor skin suspension in a child or a prominent prepubic fat in an adolescent), webbed penis (penoscrotal web), trapped penis (the shaft of the penis is trapped in scar skin usually after circumcision), and micropenis (a normally formed penis that is less than two SDs below mean in stretched length). Jung et al. 12 classified hidden penis as concealed, buried, webbed, and entrapped penis. They suggested that concealed penis is due to deficiency of the outer penile skin or inelasticity of the dartos fascia and that buried penis is due to poor penile skin fixation at the penile base or excessive suprapubic fat, a webbed penis is characterized by a ventral fold of the skin that joins the distal shaft and scrotum obscuring the penoscrotal angle, and an entrapped penis is covered by scar tissue that occurred secondary to circumcision.
In our study according to this classification we had 45 buried penis, 30 concealed penis, and 19 trapped penis, which was diagnosed by proper clinical examination; patients with micropenis and webbed penis were excluded from the study. The indication for surgical repair of buried penis includes improper hygiene, repeated urinary tract infection, or family concern regarding future fertility 6,10,11. In the present study most of the cases came for routine neonatal circumcision and were diagnosed with buried penis or concealed penis and advised to undergo the circumcision and correction of buried penis at 6 months; the other indications for correction were mainly due to preputial adhesion in 15 patients, followed by cosmetic appearance of the penis in 12 patients and improper hygiene in seven patients.
Our study showed that circumcision has been performed in up to 68% of the patients without preoperative diagnosis of the condition.
There is still controversy on the timing of surgery in cases of buried penis. Eroglu et al. 13 described that patients with buried penis should not undergo surgery until they have completed puberty, as this is a developmental condition and will improve with growth and puberty. However, Ferro et al.14 and Philip and Nicholas 15 advised early correction of buried penis to avoid negative psychological impact and to resolve both the dysuria and the cosmetic abnormality. We agree with Ferro et al.14 and Philip and Nicholas 15 in that correction of buried penis should be performed early once diagnosed, not only because of the psychological impact it can cause and the difficulty in maintaining hygiene but also because the surgical repair is much easier and is associated with less morbidity.
The principals of surgical correction of buried penis involve complete degloving of the penis, release of abnormal dartos band 3,10,11,13,16, and application of fixation suture between Buck’s fascia and skin 3,10.
Cromie et al. 3 used a circumferential incision 1 cm away from the corona and released all dysgenitic abnormal Dartos fascia. They then sutured the penile skin to Bucks’ fascia at 2 and 10 O’clock positions laterally to avoid injury to the neurovascular bundle. They treated 74 patients with this technique, with excellent results. None of their cases required additional procedure. Frenkl et al. 17 used a similar technique with fixation at 3 and 9 O’clock positions; they treated 79 patients. The overall recurrence rate was 16.5 and 3.5% and required repeated repair. Chu et al. 19 and Alexander et al. 18 did not recommend fixation of the penile skin to Buck’s fascia and relied on the natural healing process for fixation of the skin to Buck’s fascia.
In our study we used a technique similar to that described by Frenkl et al. 17, but we performed fixation at three points, 3, 9, and 12 O’ clock positions, to maintain the penopubic angle with excellent results. We found abnormal Dartos bands in all cases. Redman et al. 6, however, did not observe any abnormalities of the dartos fascia or any tethering bands in their personal series of 31 boys. We agree with Hadidi 20 in that abnormal long inner prepuce is a constant finding in all cases of buried penis. Maizels et al. 2 and Frenkl et al. 17 advise liposuction, especially in obese children, but Brisson et al. 10 and Perger et al. 11 did not recommend liposuction or lipectomy. In our study we did not perform lipectomy or liposuction in any of our cases.
In case of insufficient skin coverage many surgical techniques have been used, such as ventral V plasty 18, Z plasty 5, unfurling of the prepuce 3,4, free skin graft 21, scrotal flap 22,23, or island pedicle flap. In our study we performed unfurling of the prepuce in four cases and pyars flap in 20 cases. In our study most of the cases (74.4%) could be corrected without the need for skin graft or flap.
The long-term outcome of surgical correction of buried penis is excellent in improving the penile appearance and hygiene 24. Most of the complications are temporary and usually resolve with conservative measures. These include penile edema, hematoma, and superficial infection 3,25. In our study most of the early complications were penile edema, mild bleeding, and superficial infection that responds well to the conservative measures.
In our study the mean follow-up was 1 year, with excellent results, better appearance, and good accessibility in most of the cases.
Early surgical correction of buried penis is safe and associated with minimal complications. Although there are numerous operative procedures that have been described for the management of buried penis, we found that simple degloving of the penis and fixation of the penile skin to Bucks’ fascia at the base of the penis at 3, 9, and 12 O’clock positions can correct the condition and achieve good cosmetic and is associated with fewer complications.
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Conflicts of interest
There are no conflicts of interest.© 2018 Annals of Pediatric Surgery