Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting

Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life

The increase in practices related to enhancing penile size can be attributed to the belief that an improved genital appearance contributes to a man's virility, coupled with an altered self-perception of his body. It is crucial to tailor interventions to meet the genuine needs of patients by thoroughly assessing their history, psychological state, and potential surgical benefits, all while considering the associated risks of complications. This systematic review aims to summarize the available evidence on outcomes, complications, and quality of life after penile augmentation surgery, examining both minimally invasive and more radical techniques. A search of the PubMed and Scopus databases, focusing on English-language papers published in the last 15 years, was performed in December 2023. Papers discussing surgery in animal models and case reports were excluded from the present study unless further evaluated in a follow-up case series. The primary outcomes were changes in penile dimensions, specifically in terms of length and girth, as well as the incidence of surgical complications and the impact on quality of life. A total of 1670 articles were retrieved from the search and 46 were included for analysis. Procedures for penile length perceived enhancements include lipoplasty, skin reconstruction plasty, V-Y and Z plasty, flap reconstruction, scrotoplasty, ventral phalloplasty, and suspensory ligament release; techniques for increasing corporal penile length include penile disassembly, total phalloplasty, and sliding elongation. Finally, penile girth enhancement may be performed using soft tissue fillers, grafting procedures, biodegradable scaffolds, and Penuma®. In conclusion, while penile augmentation surgeries offer potential solutions for individuals concerned about genital size, the risks and complexities need to be accounted for.

No difference between split-thickness and full-thickness skin grafts for surgical repair in adult acquired buried penis regarding surgical and functional outcomes: a comparative retrospective analysis

Adult Acquired Buried Penis (AABP) is a pathological condition necessitating surgical correction, ranging from simple to complex procedures involving the utilization of full-thickness (FTSG) or split-thickness (STSG) skin grafts especially in cases of substantial viable penile skin loss. In this retrospective study, we aimed to compare the surgical, functional, and patient-reported outcomes (PROs) of graft types that were utilized to treat AABP among 39 patients at a single center between November 2017 and May 2023. Among these patients, 22 needed skin grafts, with 9 undergoing FTSG and the remainder receiving STSG. Lichen Sclerosus (LS) was the primary cause (54.6%) of AABP requiring skin grafts. Patients primarily presented with voiding (63.6%) and sexual (27.3%) dysfunction. The STSG group had a lower mean age (64.7 ± 11.6) than the FTSG group (66.7 ± 11.6; P = 0.015), with no significant differences in BMI (p = 0.643). Complex repairs (Santucci grade ≥3) were performed in 81.0% of cases, with 88.9% in the FTSG group and 75.0% in the STSG group. Operative times were similar (160.2 ± 31.7 vs 161.5 ± 50.3, p = 0.945). No significant differences in preoperative penis length were found between the FTSG and STSG groups (P = 0.918). Postoperative complications occurred in 36.4% of patients, with severe complications (Clavien grade ≥3) in 9.1%. General postoperative complications and recurrence rates did not significantly differ between groups (P = 0.397 and 0.375; respectively). Functional outcomes, evaluated using the International Index of Erectile Function and the International Prostate Symptom Score, improved significantly in both groups after surgical procedures (P < 0.001 for all). Patient-reported satisfaction for the operation was 81.3% calculated by ad-hoc questionnaire. In conclusion, no discernible differences in outcomes were observed between STSG and FTSG. Larger comparative studies with extended follow-up periods and validated questionnaires are warranted for confirmation. Physicians should consider specialized centers for AABP surgical repair due to its intricacies.

The outcomes of surgical management options for adult acquired buried penis

Functional and surgical outcomes after surgical correction of adult acquired buried penis (AABP) are limited in the current literature. We retrospectively recruited patients underwent surgical treatment of AABP in a single institution from 2017 to 2021. Surgical repair was classified according to surgical complexity following Pariser-Santucci's classification. The primary endpoint of the study was the recurrence-free rate survival. The secondary endpoints were surgical, functional and patients' reported outcomes. Overall 28 patients were included in the study. Median follow-up was 27.5 (18.5-34.5). The most common complaints at presentation were sexual (53.6%) and voiding (39.3%) dysfunction. Surgical management steps ranged from circumcision to more complex procedures, such as suprapubic fat pad excision, abdominoplasty and/or penile shaft skin grafting. Overall postoperative complications were recorded in 32.1%. High-grade complications (Clavien≥3) occurred in 7.1%. One-year recurrence-free survival was 88.7%. Postoperatively IPSS and IIEF-15 questionnaires showed a significant improvement in urinary 8 (0-12) vs 2 (0-3), p = 0.03 and sexual function 37 (23-68) vs 68 (45-72), p = 0.001 respectively. Overall, patients reported functional improvement and 93.8% experienced a positive impact of QoL. AABP surgical repair, despite the high incidence of complications, seems to allow satisfactory outcomes and a significant improvement in patients' QoL.

Circumferential full-thickness skin grafting: An excellent method for the treatment of short penile skin in adult men

Objective

Short penile skin due to excessive circumcision is a complex condition requiring surgical care. The study aims to investigate the effect of full-thickness skin grafting (FTSG) in treating short penile skin.

Methods

A retrospective analysis was performed on 24 patients with insufficient penile skin. The included patients underwent full-thickness skin grafting from the scrotum and the groin region in the Genital Plastic Surgery Center between February 2014 and September 2021. Morphology of the penis, length of the penis, complication, and donor area healing status was observed by the authors. Additionally, the International Index of Erectile Function Questionnaire (IIEF-5) and the patient's evaluation of penile appearance were investigated.

Results

An aesthetically pleasing appearance of the penis was obtained by FTSG in 24 patients. The length of penis was improved after surgery (5.70 cm ± 1.24 cm vs. 6.05 cm ± 1.33 cm, P value < 0.05). All patients had good healing of the penile area without serious complications. Only 2 cases showed minor partial necrosis and recovered soon after proper treatment. A high patient's evaluation of penile appearance was received (4.08 ± 0.71, mean ± SD) and the scores of IIEF-5 increased significantly after surgery (18.38 ± 2.24 vs. 21.08 ± 1.79, P-value < 0.05).

Conclusions

FTSG from the scrotum and inguinal skin provides good aesthetic and functional results for treating short penile skin. FTSG, particularly the scrotum-derived skin graft, offers a great supplement to penile skin. It could be suggested as a promising method of treating insufficient penile skin, which meets both functional and aesthetic needs.

Multidisciplinary approach and management of patients who seek medical advice for penile size concerns: a narrative review

We aimed to provide an overview of the strategies available to manage patients concerned about their penile size and to provide useful surgical hints regarding the most common penile enlargement approaches, based on our surgical expertise in this field. A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning penile enlargement issues. The search strategy included a range of keywords; e.g. penis, penile, enlargement, augmentation, lengthening, girth. Management of penile size-related concerns represents a real challenge for the urologist, especially when dealing with patients suffering from penile dysmorphophobic disorder (PDD). A multidisciplinary preoperative assessment, including a psychiatric/psychological evaluation, may help in discerning those patients who would benefit the most from counselling/conservative management from those who would benefit from surgery instead. Conservative approaches include the use of vacuum-based and penile-stretching devices, which have shown encouraging levels of efficacy and safety. Over the last decades, different surgical strategies have been developed, aimed at either increasing flaccid penile length or improving penile girth. Penile lengthening procedures are more established, and satisfactory results can be achieved by experienced, large referrals' volume, surgeons. To date, there is lack of consensus regarding the penile girth enhancing techniques, and therefore these should be regarded as experimental. A multidisciplinary approach is necessary to identify patients with PDD, who should not be offered surgical intervention and should be referred for psychiatric/psychological counselling instead. The surgical approach should be tailored to the subject's unique anatomy and underlying conditions.

Male esthetic genital surgery: recommendations and gaps to be filled

The reason behind the spread of penis enlargement practices over time is rooted in the virility that the appearance of the genitals can give a man, as well as an altered perception of his own body. The approach should be to modulate the interventions on the real needs of patients, carefully evaluating the history, the psychological picture, and possible surgical advantages. The aim of this study was to shed light on cosmetic surgery of male genitalia through minimally invasive and more radical techniques, with the purpose of laying the foundation for possible indications and recommendations for the future. A non-systematic literature review using the PubMed and Scopus databases was conducted to retrieve papers written in English on cosmetic surgery of the penis published over the past 15 years. Papers discussing cosmetic surgery in patients with concomitant pathologies associated with sexual dysfunction were excluded. The main outcomes recorded were change in penile dimensions in term of length and girth and surgical complications.

At The Forefront of Penile Surgical Reconstruction: A Bibliometric Study of the 100 Most-Cited Articles

PURPOSE

The citation count of a scientific article is considered as the recognition it received from this field. The purpose of this bibliometric analysis was to identify the top 100 most-cited scientific articles in penile surgical reconstruction.

METHODS

The Web of Science database was used to extract the top 100 most-cited articles. Individual articles were reviewed to identify the authorship, published journal, journal impact factor (IF), primary disease, article type, institution and country of origin, and year of publication.

RESULTS

The top 100 most-cited articles were published between 1947 and 2013. The number of citations ranged from 23 to 233. Journal of Urology contributed the most articles (n = 36). Articles with a high level of evidence like prospective analysis (n = 5), systematic review and meta-analysis (n = 2), and guideline (n = 1) were all published after 2000. The average citation per year of articles published in high-IF journals was significantly higher than that of other articles (p = 0.0129). There was a positive linear correlation between citation count per year and publication year (r² = 0.26, p < 0.001). Among the top 100 articles, 74 articles were interlinked via citation of each other. The major topic of co-citation network was the application of flaps in penile reconstruction.

CONCLUSIONS

The analysis of top 100 most-cited articles facilitates the comprehensive recognition of current focus in the field of penile surgical reconstruction, which is the exploration of flaps and development of new techniques in penile reconstruction. In the future, more attention should be paid to evidence-based medicine to provide high-level evidence for research.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Recent advances in understanding and managing Lichen Sclerosus

Lichen sclerosus (LS), or balanitis xerotica obliterans as it was previously known, is a chronic inflammatory lymphocyte-mediated scarring dermatosis that often affects the preputial skin and glans, leading to phimosis and urethral strictures if left untreated. We present a narrative review of the literature assessing its aetiology and pathogenesis and discuss its links to penile cancer and its medical and surgical management. Possible hypotheses for the development of LS include chronic exposure to trapped urine, leading to changes in the epithelial structure. This is supported by the fact that circumcision is often curative in the early stages of the disease. Although circumcision can be curative, the use of topical steroids is typically the first-line treatment and may preserve the foreskin and forgo the need for circumcision altogether. Patients should be made aware of a possible association with penile cancer. Although the majority of cases can be treated by medical therapy and circumcision, a significant number of patients may also require penile reconstructive procedures.

Surgical management and outcomes of adult acquired buried penis with and without lichen sclerosus: a comparative analysis

PURPOSE

Adult acquired buried penis (AABP) can present with concomitant Lichen Sclerosus (LS), a chronic dermatosis that may affect surgical outcomes. Our aim was to evaluate outcomes of patients undergoing AABP repair with and without LS.

METHODS

A retrospective cohort study was performed for AABP repair patients at a single institution from 1/1991 to 12/2017. Patient characteristics and surgical and peri-operative outcomes, including success, erectile function, and complications, were collected.

RESULTS

Sixty-seven AABP patients with mean follow-up of 16.1 ± 20.4 months were identified. Overall surgical success was 91%. Overall surgical complication rate was 50.7% (23.9% Clavien-Dindo ≥ 3). Forty-two (62.7%) patients had concomitant LS. A higher proportion of patients with LS required a STSG (90% vs 60%, p = 0.005). There was no difference in surgical success (90.5% vs 92.0%, p = 0.999), overall complication rate (57.1% vs 40.0%, p = 0.212), Clavien-Dindo ≥ 3 complications (23.8% vs 24.0%, p = 0.999) or early complications (35.7% vs 32.0%, p = 0.797) between patients with and without LS, respectively. However, a higher proportion of patients with LS experienced late complications (33.3% vs 8.0%, p = 0.020), which were mainly related to wound healing. Satisfaction with erectile function was higher among patients with LS (59.5% vs 320%, p = 0.043).

CONCLUSION

AABP patients with LS behave somewhat differently than their non LS counterparts. They are more likely to require skin graft during surgical treatment. Though surgical success and complications are similar, they do experience a higher rate of late complications from impaired wound healing. Work on improving wound healing in this population should be considered.

Buried penis repair: tips and tricks

Obesity is increasing in prevalence worldwide and an increasingly commonly encountered condition is adult acquired buried penis (AABP). We review the current management of AABP and relevant literature. Management of AABP requires a combination of genitourinary reconstructive techniques and plastic surgery techniques that are unique to this condition. We offer our experience and tips and tricks for the treatment of AABP.