Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 573-575  

Using skin and fascial sheath of preputial sac; A new technique for surgery for congenital buried penis


Department of Paediatric Surgery, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India

Date of Submission14-Mar-2017
Date of Acceptance25-May-2017
Date of Web Publication17-Jan-2018

Correspondence Address:
Dr. Shreeprasad Patankar
35/1, Padmadarshan Society, 62/B Parvati, Off Satara Road, Pune - 411 009, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_51_17

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  Abstract 


Congenital buried penis (CBP) is a rare condition characterized by penis with normal length obscured under penopubic and penoscrotal skin and subcutaneous tissue. Though rare, this condition causes great parental anxiety because of abnormal shape and appearance of penis, dribbling of urine and poor hygiene. Abnormal distal attachment of fundiform ligament on penile shaft, large, redundant preputial sac, and severe paucity of nonpigmented penile skin are important anatomical factors responsible for CBP. We here describe a different approach for degloving of penis and achieving penile skin cover using skin and fascial sheath of preputial sac. This method is simple and easy to learn, teach and reproduce.

Keywords: Congenital buried penis, fundiform ligament, preputial sac, penoscrotal angle


How to cite this article:
Patankar S. Using skin and fascial sheath of preputial sac; A new technique for surgery for congenital buried penis. Med J DY Patil Univ 2017;10:573-5

How to cite this URL:
Patankar S. Using skin and fascial sheath of preputial sac; A new technique for surgery for congenital buried penis. Med J DY Patil Univ [serial online] 2017 [cited 2019 Sep 20];10:573-5. Available from: http://www.mjdrdypu.org/text.asp?2017/10/6/573/223369




  Introduction Top


Congenital buried penis (CBP) is interesting and rare condition described first by Keyes as penis having normal length, which lacks proper sheath of skin and lies buried under peno pubic and penoscrotal skin and subcutaneous tissue. Paucity of penile skin and redundant preputial sac are constant features of CBP.[1] Numerous surgical procedures are described for correction of CBP, some of them involve complex reconstructions and hence difficult to reproduce and learn. We here describe a simple surgical technique that uses amply available skin sheath of preputial sac to cover penile shaft after degloving and restoring penoscrotal angle. This technique is easy to understand, teach, and reproduce and gives satisfactory cosmetic results.


  Case Summaries Top


We have operated three babies with CBP in the past 2 years. One boy was 18 months old and two were 24 months old. All the babies presented with passing urine from a meatus situated at a conical shape skin protuberance situated above scrotum. Local examination showed penile shaft buried in conical, short skin mound with meatus situated at the top [Figure 1]. Nonpigmented and nonrugous penile skin extended till 10 mm from the meatus toward the base on all sides. Here, the nature of the skin changed to pigmented and rugous, scrotal skin. Penile shaft of good length and girth could be palpated through the conical skin. The tip of glans could not be visualized through the narrow meatus. Both the testes were normally descended and normal sized. Preoperative workup was normal.
Figure 1: Buried penis with conical shape of skin cover, narrow meatus

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Surgical procedure and findings

All babies were operated for corrective surgery under GA and caudal epidural block.

  1. We started with enlarging the meatus to expose the glans. Rather than just enlarging it with hemostatic forceps which may cause irregular cuts, we take a bold, long, sagittal slit at 12 o'clock position. This exposed glans nicely. A stay suture of 4/0 Ethilon was taken on glans for traction and manipulation, and baby was catheterized with number 8 infant feeding tube
  2. The adhesions between glans and foreskin were released till coronal sulcus. As the sagittal slit incision was deepened with blunt and sharp dissection, it could be stretched and closed in transverse direction later. This step increased the diameter of the preputial skin and fascial sheath at distal and helped the skin sheath achieve a cylindrical shape of penile shaft rather than a typical conical shape of CBP. This sagittal incision was closed later in coronal plane. This skin and fascial sheath with cylindrical shape could easily be unfolded proximally. The dorsal slit incision was closed in coronal plane later; this avoided a constricting effect at distal shaft when the sleeve shifted proximally
  3. The degloving incision is placed at the penoscrotal junction, i.e., junction of nonpigmented and nonrugous penile skin and pigmented and rugous scrotal skin. The incision is semicircular, extending from 3 o'clock to 9 o'clock position through 6 o'clock position [Figure 2]. The incision was deepened till a plane superficial to Buck's fascia. With sharp blunt dissection and degloving of shaft was done on ventral, lateral, and dorsal aspects of corpora. Thorough degloving was done proximally till penoscrotal and penopubic junction and distally till coronal sulcus. The length of penile shaft was well appreciated now and measured more than 30 mm in all the babies
  4. After this dissection, the skin and fascial sleeve covering distal shaft and glans became mobile and lax and could be pulled and everted proximally over the penile shaft. The sleeve of skin could reach the penoscrotal junction well without any tension [Figure 2]. The shiny skin of inner foreskin now covered most of the penile shaft
  5. The scrotal edge of the ventral incision was tucked to the tunica albuginea of the corporal bodies at multiple places at the level of penoscrotal junction, with 5/0 vicryl. This fixed the scrotum at the base of penis, restoring normal appearance of penoscrotal junction. The scrotal fixation also prevents recurrence. The ventral hemicircular incision was closed with 5/0 vicryl at penoscrotal junction [Figure 2]
  6. As the preputial sleeve of the skin stretched and covered the penile shaft, the dorsal slit incision got shifted to the proximal shaft region. The incision was closed in coronal plane. It allowed the skin sleeve to widen in diameter and spread onto the lateral and ventral aspect of distal penile shaft
  7. Compression dressing was given. Catheter was connected to drainage bag. IV Amoxiclav and Amikacin were given for 48 h and pain relief was provided with oral ibuprofen and paracetamol. Dressing and catheter were removed on the 5th postoperative day, and baby was discharged after he passed urine
  8. The third baby had different findings. After exposing the glans, he was found to have glandular epispadias. To perform a thorough degloving till penopubic junction on dorsal aspect, the semicircular incision at penoscrotal junction was extended onto dorsal side and converted to a full circle incision. This allowed thorough dissection and degloving of the entire length of penile shaft [Figure 2]. Pubic skin was tucked to base of penis dorsally, and scrotal skin was fixed on ventral side to restore normal appearance. The sleeve of penile and preputial skin was unfolded and used to cover the complete penile shaft. The correction of glandular epispadias was planned at later date as per wishes of parents.
Figure 2: Upper half: Incision at penoscrotal junction, deepened for degloving. Closure at penoscrotal junction. Lower half: the incision is extended to dorsal aspect to for thorough degloving

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  Discussion Top


The anatomical basis CBP is very interesting [Figure 3]. The fundiform ligament, the dartos fascia of pubic, and penoscrotal region have an abnormal distal insertion on the shaft of penis. Hence, the skin and subcutaneous tissue around the base of the penis extends up to distal portion of shaft of penis, forming a conical mound like structure completely obscuring the shaft.[1],[2],[3] There is paucity of smooth and nonhairbearing penile skin. The preputial sac is redundant may form a large sac distal to glans with narrow urinary opening distal to tip of penis.[1],[2],[3],[4] The narrow urinary meatus at tip of conical skin mound may lead to dribbling of urine, ballooning of prepuce while passing urine and sometimes local infection. The typical stumpy or conical shape of penis is cause of great parental anxiety.
Figure 3: Normal anatomy of penis and anatomy in buried penis; SL: Suspensory ligament, FL: Fundiform ligament, ABDW: Abdominal wall, PPBJ: Penopubic junction, PSCJ: Penoscrotal junction, PRSAC: Preputial sac, PSK: Penile skin sheath, M: Meatus, SCRSK: Scrotal skin

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Thorough degloving of penis, release of all abnormal attachments of fundiform ligament, dartos fascia from the shaft of penis till penopubic and penoscrotal junction, restoration of normal appearance of penoscrotal junction and providing cosmetic skin cover are important steps in the correction of CBP. Various incisions for degloving are described, such as circumferential subcoronal incision, ventral vertical raphe incision.[1] We describe here circumferential incision placed at penoscrotal junction. It allows excellent access for degloving on ventral, lateral, and dorsal aspect. The incision can be extended on dorsal side if required for dissection at penopubic junction. It defines the border between penile and scrotal skin; this allows fixation of the scrotal skin at base of penile shaft. This prevents sliding of scrotal skin distally, prevents recurrence and restores the normal appearance of penoscrotal junction [Figure 4]. Lymphedema has been important complication with a proximal approach for degloving.[5] However, it resolves in 4–6 weeks.
Figure 4: Well appreciated penile length and penoscrotal angle. The ventral incision closure at penoscrotal junction, and preputial slit incision closed dorsally in coronal plane

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Once degloving is complete and scrotal fixation is done, deficiency of penile skin for skin cover becomes obvious. Method to achieve penile skin cover has been a contentious issue in CBP repair. There are many methods described such as foreskin flaps rotated ventrally,[3],[6],[7] vascularized musculocutaneous scrotal flaps,[8] Z plasty techniques and free grafts from groin [9] Some repairs use scrotal skin for penile skin cover, which is pigmented, rugous, and hairy. Complications such as flap necrosis, lymphatic edema, blackening of skin, loss of skin graft, and suture line dehiscence may occur and may require revision surgery. This procedure proposes to use the preputial skin which is available in abundance in the form of loose, redundant sac for providing penile skin cover. After thorough degloving and widening the distal end of skin sheath with sagittal slit incision, the preputial skin sheath becomes cylindrical and can be easily pulled proximally to cover entire penile shaft. We do not prepare any flaps, so there are no suture lines on penile shaft. The nature of preputial skin is smooth, nonhairbearing, so has been the preferred choice for achieving the penile skin cover.

This repair is a simple surgical technique for degloving, scrotal fixation, and skin cover. It does not involve reconstructive procedures hence has minimum complications. This procedure is easy to learn, teach, and modify.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The corresponding author would like to thank Dr. Bharati Kulkarni, Ex Professor and Head, Department of Paediatric Surgery, LTMC, Mumbai for her encouragement, perusal and support for this article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hadidi AT. Operative technique, buried penis: Classification surgical approach. J Pediatr Surg 2014;49:374-9.  Back to cited text no. 1
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2.
Liu X, He DW, Hua Y, Zhang DY, Wei GH. Congenital completely buried penis in boys: Anatomical basis and surgical technique. BJU Int 2013;112:271-5.  Back to cited text no. 2
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3.
Redman JF. Buried penis: Congenital syndrome of a short penile shaft and a paucity of penile shaft skin. J Urol 2005;173:1714-7.  Back to cited text no. 3
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4.
O'Brien A, Shapiro AM, Frank JD. Phimosis or congenital megaprepuce? Br J Urol 1994;73:719-20.  Back to cited text no. 4
    
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Lee T, Suh HJ, Han JU. Correcting congenital concealed penis: New pediatric surgical technique. Urology 2005;65:789-92.  Back to cited text no. 5
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Chu CC, Chen YH, Diau GY, Loh IW, Chen KC. Preputial flaps to correct buried penis. Pediatr Surg Int 2007;23:1119-21.  Back to cited text no. 6
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Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to concealed penis: Technical refinements and outcome. Urology 2007;69:1195-8.  Back to cited text no. 7
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Han DS, Jang H, Youn CS, Yuk SM. A new surgical technique for concealed penis using an advanced musculocutaneous scrotal flap. BMC Urol 2015;15:54.  Back to cited text no. 8
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Casale AJ, Beck SD, Cain MP, Adams MC, Rink RC. Concealed penis in childhood: A spectrum of etiology and treatment. J Urol 1999;162(3 Pt 2):1165-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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