DOuble LOngitudinal Megapreputium Incision TEchnique: The DOLOMITE

Megaprepuce: a systematic review of a rare condition with a controversial surgical management

Megaprepuce (MP) is a rare and challenging condition characterised by an excessive inner prepuce, paucity of penile skin and an extremely narrow phimotic ring. The aetiological factors leading to its development are poorly understood. A variety of surgical techniques have been described in the last 26 years mostly with small number of patients and short follow-up. It is also highly likely that some series have in the past included different variants of inconspicuous penis combining concealed penis, MP and webbed penis. This article is a systematic review of the literature on Megaprepuce; in particular the embryology, history, aetiology, and the surgical techniques available for the correction of this unique penile anomaly will be presented and discussed in this study.

Megaprepuce: A New Surgical Technique with Excellent Cosmetic and Functional Results

Background: Congenital megaprepuce (CMP) is a malformation consisting of redundant inner foreskin, normal penile shaft, and severe phimosis. The excess inner prepuce pushes the penile shaft deeper causing the appearance of a buried penis. We describe a novel surgical technique using dartos fascial flaps to reconstruct the prepuce giving excellent cosmetic and functional results. Patients and Methods: Penile reconstruction was performed by a single surgeon in 07 cases of CMP between January 2018 and December 2019. In all cases, the described surgical technique was used. Following surgery, cosmetic and functional outcomes were reviewed as well as the incidence of complications. The patients' ages ranged from 15 to 27 months (mean = 19). Mean hospital stay was 9 hours (range = 7-12). Operating time was between 50 and 85 minutes. Results: Postoperative appearance of the penis was satisfactory for all the parents in our group. Swelling of the penile shaft was seen in all of our patients but settled within one week of surgery. Scrotal hematoma was seen in only one of our patients, but that also did not need any intervention and settled spontaneously. During the follow-up period (mean = 14.5 months, range 6-24) no patient underwent revision surgery. In all our patients, the final appearance was of a circumcised penis. The final similarity to a normal circumcised penis was excellent in all of our patients. Correction of penoscrotal transposition was done in all patients achieving an elongated penile shaft and almost invisible postoperative scarring. Conclusion: Our modified surgical procedure to correct CMP is a safe and simple technique, providing good cosmetic results with the appearance of a standard circumcised penis. This also provides a good functional outcome with complication rate quite low. This technique is also easy to reproduce and teach compared with other complex procedures.

Congenital Megaprepuce: Literature Review and Surgical Correction

Congenital megaprepuce (CMP) is a type of buried penis characterized by extensive redundancy and ballooning of the inner prepuce as a result of preputial stenosis and phimosis. The malformation typically presents with difficulty voiding, often requiring manual expression of stagnant urine. Multiple techniques have been reported for the treatment of CMP with varying levels of positive outcomes. The authors provide a review of published literature, in addition to describing the procedure and results of our surgical technique in three children aged eleven months, two years, and twelve years. The literature review was conducted using PubMed with keywords “congenital megaprepuce,” “megaprepuce,” “buried penis,” “CMP,” and “correction.” Results were then differentiated based on presence or absence of true congenital megaprepuce and the surgical correction thereof. Regarding our cases, all patients completed the procedure with excellent cosmesis and without complication. Our technique is shown to provide consistent, excellent esthetic outcome across a wide range of ages and may be replicated by others.

Mid- to long-term outcomes of the 'anatomical approach' to congenital megaprepuce repair

INTRODUCTION

The understanding of the aetiopathogenesis and the long-term outcomes of correctional repair of congenital megaprepuce (CMP) remains unestablished. Different techniques have been described; however, optimum results have been difficult to achieve.

OBJECTIVE

The aim of our study was to review our experience of the 'anatomical approach' to the correction of CMP.

MATERIAL AND METHODS

This is a retrospective review of boys who underwent CMP repair between 2003 and 2014. All of them had the anatomical approach: A curved incision is made between the scrotal and penile skin. Circumferential dissection superficial to Buck's fascia frees the penis and allows the scrotum to assume a more caudal position. The dissection distally lifts the preputial sac that is opened ventrally. The redundant inner preputial skin is excised. After full degloving, the dorsal flap of skin is thinned. The base of the flap is anchored, and the rectangle of skin is wrapped around the shaft. The remaining diamond-shaped incision is closed in a vertical line. Postoperatively, foam dressings and urethral catheter are left in place. Symptomatology, hospital stay, postoperative complications, redosurgery, voiding and cosmesis were evaluated.

RESULTS

Sixty-one patients had surgery at 5-151 months (median 17 months). Median hospital stay was 24 h (12-168 h). Foam dressings and urethral catheter were used in 47 boys and removed in outpatient clinic after 3-7 days. There were two immediate postoperative complications requiring surgery. One due to severe oedema and constriction ring, and the other had wound infection with wound breakdown, both in patients with no dressings (P < 0.05). Follow-up was available for 58 patients, with a median of 22 months (3-79 months). Two required redosurgery (3.5%), one with poor cosmetic result and one recurrence. In all patients, a normal circumcised appearance had been achieved and in 47, cosmetic result was excellent (81%). Five patients have residual suprapubic fat, and four, excess ventral skin. One with residual suprapubic fat has reached puberty and it has resolved. All declared good stream. The same technique was used for six patients with poor cosmetic result after surgery elsewhere. The outcome is excellent for all, with median follow-up of 20.5 months (5-31 months).

CONCLUSION

The 'anatomical' repair provides the ability to create the appearance of a standard circumcision, which is generally accepted as normality. Apart from the penis itself, this technique facilitates correction of the penoscrotal transposition, giving the external genitalia the best appearance. It seems to provide good functional and cosmetic outcomes, and it holds true at mid- to long-term follow-up. Dressings and catheter can potentially prevent postoperative complications. However, a prospective study with standardised parameters is required to confirm these findings.