Concealed penis: surgical management

CASE SERIES
Concealed penis: surgical management
Espinosa-Ch Giordano,1 Castro-D Juan Carlos,2 Abril Rodríguez-B3
•Abstract
•Resumen
Concealed penis, inconspicuous penis, buried penis,
hidden penis, webbed penis, or trapped penis are
synonyms of the same pathology described or clinically
manifested by a penile shaft that is hardly visible, hidden
or trapped by layers of prepuce, scrotum, and abdominal
wall.
El pene oculto, inospicuo, enterrado, escondido, empalmado, atrapado, son sinónimos de una misma patología
descrita o manifiesta clínicamente por un eje del pene poco
visible, escondido o atrapado por las capas de prepucio,
escroto y pared abdominal.
Objective: To report on ten cases of concealed penis
that were surgically treated at the Pediatric Urology
Department of the Hospital General de Zona N° 33,
utilizing the Maizels technique modified by the authors.
Methods: Ten patients (seven children and three adults)
with concealed penis were surgically treated with
modified version of Maizels technique. The modified
technique is described along with its functional and
aesthetic results.
Métodos: En este reporte de 10 pacientes con pene
escondido, tratados quirúrgicamente con técnica descrita por Maizels modificada, de siete pacientes niños y
tres adultos. Se describe la técnica empleada con modificación por los autores con resultados funcionales y
estéticos.
Keywords:
Concealed
penis,
inconspicuous, trapped, Mexico.
Palabras clave: Pene oculto, escondido, enterrado, inospicuo, atrapado, México.
hidden,
buried,
1Pediatric Urology Surgeon
2Urology Surgeon in training
3Resident
Department of Pediatric Surgery. Pediatric Urology Service.
Hospital General de Zona N° 33, IMSS. Monterrey, Nuevo León.
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Objetivo: Informar la experiencia en 10 casos tratados
quirúrgicamente en nuestro servicio de urología pediátrica
HGZ 33, que incluyen siete pediátricos y tres adultos. Utilizando la técnica de Maizels modificada por nosotros.
Rev Mex Urol 2011;71(2):128-131
Corresponding author: Dr. Giordano B. Espinosa Chávez. Calle Hidalgo 2532 Poniente, Despacho 409, Col. Obispado, 64060, Monterrey, Nuevo León, México. Telephone: 81 83 33 44 29.
Email: [email protected]
Espinosa-Ch G, et al. Concealed penis: surgical management
•Introduction
The phenomenon known as concealed penis has
different origins and descriptions. 1 This pathology covers
three distinct clinical varieties: webbed penis, concealed
penis (hidden or buried), and trapped penis. 2,3
In the webbed penis the urethra, the penis, and the
scrotum are normal but there is abnormality where
the scrotal skin joins the penis. This condition can also
be caused iatrogenically after circumcision or penile
surgery in which there has been excessive resection of
the ventral skin of the penis. 2
In concealed penis, the penile shaft is normal in length
but is covered and hidden by excessive fat at the
suprapubic level. It can be congenital or iatrogenic.
There is a defect in the elasticity of the dartos and its
deep planes impede the penis from moving. 2-4
Trapped penis is an acquired abnormality that mainly
occurs after circumcision, or that is trapped by
cicatrization resulting from hydrocele or hernia surgery.
Image 1. Concealed penis, penile shaft covered by prepuce, scrotum, and abdominal wall layers.
2-4
•Methods
A total of 10 patients underwent surgical procedure
with Maizels technique modified by the authors
within the time frame of 2006-2010. Patients were 7
boys and 3 adults with ages ranging from 2 months
to 27 years.
The 7 boys experienced urine entrapment that was
clinically characterized by bulkiness from collected
urine in the genital region with loss of penoscrotal angle
and a barely visible penis (Image1).
Technique: With the patient under general anesthesia
(children) and regional anesthesia (adults), after asepsis
and antisepsis and in dorsal decubitus position, the
following procedure was carried out:
1. Prepuce retraction exposing the glans penis for
placing of 3-0 silk fixation suture in it to facilitate
surgical management (Images 2 and 3).
2. Subcoronal incision was made 3 mm from the
coronal sulcus and penis was degloved to its base,
freeing adherences, including the suspensory
ligament (Images 4 and 5).
Image 2. Exposure of glans penis.
3. Fixation sutures were placed from the dartos
and/or aponeurosis of the abdominal wall to
the albuginea of the dorsal side of the penis;
afterwards sutures ventral and lateral to the
urethra were placed with 5-0 monocryl from
the dartos to the tunica albuginea of the penis
(Image 6).
5. Penile shaft was covered with a Byar’s flap and
skin was sutured at the mid- and subcoronal line
with simple 6-0 polydioxanone sutures
4. Fat resection of the pubic and inguinal area was
also carried out in adults
6. Gbieauze compression bandage or self-adhering
film (tegaderm) was placed
Rev Mex Urol 2011;71(2):128-131
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Espinosa-Ch G, et al. Concealed penis: surgical management
Image 3. Suture placement at tip of glans for surgical manipulation.
Image 4. Incision outline 3 mm from coronal sulcus.
Image 5. Prepuce degloving to expose penile shaft.
Image 6. Suture placement to fix dartos to penile shaft albuginea.
•Results
Straight erections with normal penoscrotal angle
were achieved in all patients and out-patient followup has continued to the present, with no reports of
complications resulting from this technique.
In the 10 patients operated on with the technique
described above, penile shaft showed lengthening
and rectification compared with preoperative size
and curvature (Images 7 and 8). In addition the urine
column was adjusted and extended through the tip of the
penis with no urine entrapment.
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Rev Mex Urol 2011;71(2):128-131
•Discussion
Concealed penis is an uncommon pathology with only
2-8 cases reported per year in large medical centers.
Espinosa-Ch G, et al. Concealed penis: surgical management
Image 7. Immediate postoperative status; lateral side of the penis.
Image 8. Immediate postoperative status; ventral .
Diagnosis is even overlooked in some hospitals, leading
to the performance of non-indicated procedures such
as circumcision that cause complex, difficult-to-repair
complications.
techniques that can be employed for the correction of
this pathology, all of which follow the same principle of
joining the penile shaft to the layers of scrotal skin.
The present article reports on an experience with 10
patients operated on at the authors’ institution with the
above-described technique and with continuous outpatient follow-up.
Indications for surgery include functional and
aesthetic aspect, micturition difficulty that can lead to
urinary retention, difficulty to carry out proper hygiene,
and recurrent urinary infections. There are a variety of
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