Classification and Treatment of the Adult Buried Penis

The Outcomes of Adult Acquired Buried Penis Surgical Reconstruction

Adult Acquired Buried Penis (AABP) is a morbid condition that often requires surgical intervention. This retrospective study of 46 patients who underwent AABP surgery from November 2017 to July 2023 evaluates surgical outcomes, functional outcomes, and patient-reported outcomes. The median follow-up (FU) was 46 months. Patients were categorized by surgical complexity using the Pariser classification, with 76.1% undergoing high-complexity procedures (Pariser ≥ III). Common comorbidities included obesity (58.7%), prior circumcision (52.2%), and hypertension (52.2%). The low-complexity group had a shorter hospital stay (p = 0.02). No other significant differences were noted between groups in terms of Body Mass Index, operative time, or FU. Sexual dysfunction (45.7%) and urinary issues (38.1%) were the main reasons for surgical consultation. Skin grafting was required in 63.0% of patients; partial graft loss was more common in full thicknes skin graft group (p = 0.04). Postoperative complications occurred in 32.6% of patients, 13.3% of which were classified severe (Clavien ≥ III). The median increase in stretched penile length was 2 cm. The recurrence rate was 21.7%. The 12-month recurrence-free survival rate was 89.1%. All groups saw significant improvements in urinary and sexual function post-surgery (p < 0.05), and high patient satisfaction was reported (90.3%). Despite the complication rate, AABP surgery significantly improves quality of life, with ongoing advancements in technique anticipated to enhance outcomes further.

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.

Puboplasty as an integral step in massive weight loss abdominal contouring: a retrospective assessment of results, stability, and patients' satisfaction

Ex-obese patients complain about abdomen and pubis deformities following massive weight loss, due to skin and soft tissue redundancy. Abdominoplasty is often the first corrective procedure performed, but residual mons pubis deformities may impair the final outcome, thus concomitant correction becomes necessary. Sixty patients were treated by the same surgeon between 2008 and 2018, 30 of them receiving only standard umbilical transposition abdominoplasty (A group), and 30 having concurrent monsplasty (AM group), namely skin excess removal, pubic suspension and skin redistribution following superolateral vectors, re-establishment of superficial fascia continuity, with or without liposuction. Retrospective comparison of the two groups included: a subjective evaluation through administration of questionnaires (BODY-Q^TM, a questionnaire assessing functional and aesthetic improvements after surgery, a questionnaire assessing the overall satisfaction), and an objective evaluation of pre- and post-operative pictures to estimate mons pubis suspension and result stability. Four minor complications were recorded: 1 wound dehiscence in A group, 3 seromas in AM group. All measured outcomes were higher in AM group, with statistically significant difference (p < 0.05) in almost all the questionnaire and BODY-Q^TM items, and the photographic assessment confirmed higher degree of mons pubis suspension and superior result stability in AM group. We presented a standardized approach to mons pubis reshaping during abdominoplasty, through a straightforward, safe and quick procedure. Our experience supports the significance of the concomitant correction of abdominal and mons pubis deformities, improving the results of the surgery from both a subjective and objective point of view.

Genital Wound Repair and Scarring

Skin wound repair has been the central focus of clinicians and scientists for almost a century. Insights into acute and chronic wound healing as well as scarring have influenced and ameliorated wound treatment. Our knowledge of normal skin notwithstanding, little is known of acute and chronic wound repair of genital skin. In contrast to extra-genital skin, hypertrophic scarring is uncommon in genital tissue. Chronic wound healing disorders of the genitals are mostly confined to mucosal tissue diseases. This article will provide insights into the differences between extra-genital and genital skin with regard to anatomy, physiology and aberrant wound repair. In light of fundamental differences between genital and normal skin, it is recommended that reconstructive and esthetic surgery should exclusively be performed by specialists with profound expertise in genital wound repair.

Optimization of Second-stage Metoidioplasty

OBJECTIVE

To describe a planned 2-staged metoidioplasty. Metoidioplasty is a genital gender-affirmation surgery aimed at creating a neophallus, scrotum (if desired), and flat male-type perineum (if desired) from natal tissues. It generally requires a planned second-stage to place testes prostheses, address complications, and perform additional surgical steps to maximally lengthen the phallus. The details of this procedure are sparsely mentioned in the literature. We found that phallus length can be optimized in the second-stage by applying surgical principles already established in the surgical treatment of adult acquired buried penis.

MATERIAL AND METHODS

We conducted a retrospective chart review of patients after metoidioplasty between August 2015 and June 2020, and isolated those that underwent second-stage metoidioplasty. Each procedure was done by 1 of 4 surgeons in a single practice in 2 locations, San Francisco, CA, and Austin, TX. Details of procedures required, complications, and demographic information were recorded.

RESULTS

Out of the 75 patients that had undergone metoidioplasty, 37 (37 of 75, 49%) underwent a second-stage metoidioplasty. Reduction of upper scrotal blocking tissue was the most common procedure performed during a second-stage metoidioplasty (31 of 37, 84%), followed by escutcheonectomy/penile lift (30 of 37, 81%), bilateral implant placement (20 of 37, 54%), chordee repair (13 of 37, 35%), and unilateral implant placement (1 of 37, 3%). 6 of the 37 patients (16%) developed major complications. 5 of the 37 (5 of 37, 15%) second-stage patients required a redo second-stage metoidioplasty.

CONCLUSION

Second-stage metoidioplasties are commonly performed on patients to optimize results of phallic lengthening and release, and to repair complications that arise after single-stage metoidioplasty. Escutcheonectomy/penile lift, placement of scrotal implants, repair of chordee, and upper scrotal blocking tissue reduction are procedures that are often performed during a second-stage metoidioplasty.

Uncovering the Hidden Penis: A Nomenclature and Classification System

INTRODUCTION

A hidden penis can interfere with normal hygiene, prevent effective voiding, restrict sexual activity, and cause great embarrassment to the patient. The terms "hidden," "buried," and "trapped" penis are used interchangeably. To date, there is no classification system that adequately characterizes the spectrum of this condition. In this study, we propose a simplified nomenclature and classification system for adult-acquired hidden penis.

METHODS

We performed a retrospective review of all adult patients treated surgically for hidden penis by the senior author from 2009 to 2019. Patients were classified into either "buried" or "trapped" categories. A "buried" penis was defined as a hidden penis concealed by suprapubic fat without fibrous tethering. These patients were managed with panniculectomy, monsplasty, or both. In contrast, those with a "trapped" penis presented with scarred or fibrous tissue, which required surgical lysis, phalloplasty, and penile skin resurfacing.

RESULTS

Thirteen patients met the inclusion criteria. The cohort was aged 53 ± 15.7 years with a mean body mass index of 37.4 ± 4.3 kg/m2. Two patients required repeat operations, yielding a total of 15 operative encounters. Six were defined as buried, and 9 as trapped. Inability to achieve erection was the most common preoperative complaint in those with buried penis (67%), whereas difficulties in voiding were most common with trapped penis (78%). Patients with trapped penises had a significantly larger body habitus than those with a buried penis (39.8 vs 34.2 kg/m2, P = 0.0088). Operative duration and length of hospital stay were comparable between the trapped and buried penis groups (206 vs 161 minutes, P = 0.3664) (5 vs 1 day, P = 0.0836). One third experienced wound complications, but this was not significantly different between buried and trapped penises (17% vs 44%, P = 0.5804). Postoperatively, 5 patients experienced spontaneous erections, and 7 were able to void while standing.

CONCLUSIONS

Patients with a trapped penis present with a different preoperative symptom profile and body type than those with a buried penis. Our nomenclature and classification system offer a simple and clear algorithm for the management of hidden penis. Large cohort studies are warranted to assess differences in clinical outcomes between trapped and buried penises.

Adult Acquired Buried Penis: A Hidden Problem in Obese Men

Buried penis is a condition where the penis is hidden by abdominal or suprapubic skin or fat. In adult men, buried penis occurs as an acquired condition most commonly caused by morbid obesity. The clinical characteristics of three obese men with adult acquired buried penis are described and the associated features of the buried penis are reviewed. In addition to morbid obesity, a buried penis can result from other etiologies, such as hidradenitis suppurativa, iatrogenic causes such as elective surgeries, infections, lichen sclerosus, penoscrotal lymphedema, and traumatic events. Lower urinary tract symptoms, such as voiding, and post-voiding problems are the most common presenting complaints; however, bacterial and fungal infections, phimosis, psychological issues, and sexual dysfunction, are also buried penis-related symptoms. The evaluation of a man with adult acquired buried penis begins with a detailed history for condition-related symptoms. Examination of the patient, both standing and supine with an attempt to demonstrate the penis using digital compression of the surrounding skin and fat, should be performed to determine the extent of the problem and whether comorbid conditions-such as infection and lichen sclerosus-are present. Both buried penis and lichen sclerosus can predispose to the development of penile squamous cell carcinoma; the diagnosis of this tumor can be delayed in men with adult acquired buried penis since an adequate penile examination is difficult or impossible. A multidisciplinary approach-including surgeons, primary care physician, registered dietitian nutritionist, and psychiatrist-should be considered for a patient with a buried penis. The surgical management is individualized and based on not only the extent of the problem but also whether an associated condition, such as urethral stricture, is present. Most patients are pleased with the functional and aesthetic outcome following surgery.

The Surgical Treatment of Adult Acquired Buried Penis Syndrome: A New Classification System

BACKGROUND

Adult acquired buried penis syndrome may be associated with an inability to void, sexual dysfunction, and recurrent infection. Previously published classification systems rely on intraoperative findings, such as penile skin quality.

OBJECTIVES

The purpose of this study was to evaluate outcomes after adult acquired buried penis repair and to develop a classification system based on preoperative assessment.

METHODS

The authors reviewed data from patients who underwent buried penis reconstruction at a single institution. Patient history and physical examination guided the development of a classification system for surgical planning.

RESULTS

Of the 27 patients included, the mean age was 56 ± 15 years and mean body mass index was 49 ± 14 kg/m2. Patients were classified into 4 groups based on examination findings: (I) buried penis due to skin deficiency, iatrogenic scarring, and/or diseased penile skin (n = 3); (II) excess abdominal skin and fat (n = 6); (III) excess skin and fat with diseased penile skin (n = 16); and (IV) type III plus severe scrotal edema (n = 2). Surgical treatment (eg, excision and grafting, mons suspension, panniculectomy, translocation of testes, and/or scrotectomy) was tailored based on classification. Complications included wound breakdown (n = 3), cellulitis (n = 4), and hematoma (n = 1). Nearly all patients (96%) reported early satisfaction and improvement in their symptoms postoperatively.

CONCLUSIONS

Classifying patients with buried penis according to preoperative examination findings may guide surgical decision-making and preoperative counseling and allow for optimized aesthetics to enhance self-esteem and sexual well-being.

LEVEL OF EVIDENCE: 4

Acquired Buried Penis in Adults: A Review of Surgical Management

INTRODUCTION

Acquired buried penis (ABP) is a urologic condition that has significant morbidity and negative effect on quality of life, including but not limited to sexual function, hygiene, micturition, and self-image. This disease process is characterized by a wide degree of variability and severity that requires a patient-specific approach and significant flexibility on the surgeon's behalf.

AIM

To review and present the current evaluation and surgical management of this rare and complex patient population.

METHODS

A structured review of the English language literature from 1970 to June 2018 was performed using the PubMed and MEDLINE medical databases. Queried terms included "buried penis," "concealed penis," "hidden penis," "adult buried penis," "cicatricial penis," "trapped penis," "inconspicuous penis," "scrotoplasty and obesity," "penile release," "penile skin graft," "penile reconstruction," and "pubic lift." Papers were individually reviewed for their utility and applicability to the management of adult ABP. Manuscripts focusing on pediatric patients were excluded.

MAIN OUTCOME MEASURE

Current surgical management options for adult ABP are heterogenous but focus on preserving shaft length while improving cosmesis and voiding function.

RESULTS

Surgical versatility remains critical for successful outcomes. However, recent advances in surgical techniques for correction of adult ABP focus on the use of skin grafting to cover the shaft, along with lipectomy and/or scrotoplasty to further aid penile exposure. Collaboration with multiple surgical services is often required to achieve optimal outcomes.

CONCLUSION

ABP is a complex urologic condition with equally complex surgical treatment options. Care must be taken when planning a surgical intervention, and support from plastic or general surgery may be required. However, with careful selection, surgical correction frequently leads to significant improvement in function and quality of life. Smith-Harrison LI, Piotrowski J, Machen GL, et al. Acquired Buried Penis in Adults: A Review of Surgical Management. Sex Med Rev 2020;8:150-157.