The concealed morbidity of buried penis: a narrative review of our progress in understanding adult-acquired buried penis as a surgical condition

Technical Considerations and Outcomes for Panniculectomy in the Setting of Buried Penis Patients: A Systematic Review and Database Analysis

BACKGROUND

Often secondary to obesity, adult-acquired buried penis (AABP) is an increasingly common condition. AABP is often detrimental to urinary and sexual function, psychological well-being, and quality of life. Surgical treatment involves resection of excess soft tissue, with adjunct procedures, including a panniculectomy. However, few studies have been conducted investigating the risks of panniculectomy in the context of AABP surgical repair.

METHODS

A systematic review of PubMed, Embase, and Cochrane databases was performed, following the PRISMA 2020 guidelines. Descriptive statistics regarding patient demographics, complications, and surgical technique were conducted. After this, an analysis of AABP patients within the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was conducted.

RESULTS

Four studies including 57 patients reported panniculectomy as part of buried penis repair (PBPR). Surgical approaches included a modified trapezoid and traditional transverse incision. All authors utilized postoperative drains. Dehiscence and wound infection were the most frequent complications. Univariate NSQIP analysis revealed that PBPR patients had higher body mass index, more comorbidities, and greater wound complication rates. Multivariate analysis revealed that PBPR did not significantly increase 30-day complications compared to isolated BPR ( P > 0.05), while body mass index remained a significant predictor.

CONCLUSIONS

Surgical repair of AABP can greatly improve patient quality of life. The available literature and NSQIP-based analysis reveal that concurrent panniculectomy in AABP repair has a comparable complication profile. Future studies are necessary to better characterize the long-term outcomes of this PBPR.

Modified Frailty Index predicts postoperative complications following adult-acquired buried penis surgery: A retrospective cohort study

BACKGROUND

Given that patients with morbid obesity are predisposed to frailty, we sought to determine whether the 5-Factor Modified Frailty Index (mFI-5) predicts postoperative complications following surgery for adult-acquired buried penis, and secondarily, to compare the mFI-5 to body mass index (BMI) and American Society of Anesthesiologists (ASA) status as preoperative risk stratification measures.

METHODS

We included all patients who underwent surgical management for adult-acquired buried penis at an academic Level I trauma center between 2015 and 2023. A manual chart review was performed to collect data on patient demographics, modified frailty index variables, intraoperative data, postoperative outcomes, and complications.

RESULTS

A total of 55 patients underwent surgical repair of adult-acquired buried penis, with 26 experiencing postoperative complications (47.3%). Univariable regression analyses revealed that the mFI-5 was a significant predictor of postoperative complications (odds ratio [OR] 3.40, 95% confidence interval [CI]: 1.56-7.42, p = .002), ongoing postoperative urinary problems (OR 2.03, 95% CI: 1.02-4.05, p = .045), patient dissatisfaction with outcomes (OR 3.29, 95% CI: 1.35-8.02, p = .009), and persistent postoperative symptoms (OR 2.42, 95% CI: 1.10-5.35, p = .029). There was no significant association between ASA classification and postoperative complications (OR 1.59, 95% CI:.544-4.63, p = .398). Multivariable analysis demonstrated that the mFI-5 was an independent predictor of postoperative complications (OR 5.34, 95% CI: 1.80-15.9, p = .003) when controlling for BMI and age.

CONCLUSION

The mFI-5 is an independent predictor of postoperative complications in patients undergoing surgical repair of adult-acquired buried penis. The simplicity of the index permits efficient preoperative risk stratification of adult-acquired buried penis patients and provides important counseling information that may not be reflected by age or BMI alone.

Manifestations and etiology of cutaneous findings in cases of morbid obesity

Morbid obesity is associated with a wide range of metabolic, infective, and organic disorders related to adipose tissue overload. While careful documentation of internal autopsy findings is usual, skin manifestations may be overlooked. Skin manifestations are quite diverse and include striae distensae, skin tags, plantar hyperkeratosis, acanthosis nigricans, the sequelae of hyperandrogenism, lymphedema, panniculus morbidus, chronic venous insufficiency, stasis dermatitis, leg ulceration, intertrigo, cellulitis, pressure ulcers and 'buried penis'. Obesity has also been associated with hidradenitis suppurativa, psoriasis, atopic dermatitis, melanoma, systemic lupus erythematosus, lichen planus and acne vulgaris. Evaluating these findings at the time of autopsy may give a more complete assessment of a particular case and may also identify conditions that may have contributed to, or caused, death.

Clinical Validation of an Adult-acquired Buried Penis Classification System Based on Standardized Evaluation of the Penis, Abdomen, and Scrotum

OBJECTIVE

To clinically validate a previously developed adult-acquired buried penis (AABP) classification system that is based on a standardized preoperative physical examination that subtypes patients by their penile skin/escutcheon complex (P), abdominal pannus (A), and scrotal skin (S).

METHODS

The Trauma and Urologic Reconstruction Network of Surgeons (TURNS) database was used to create an AABP cohort. Patients were retrospectively classified using the previously described PAS classification system. The frequency of subtypes, surgical methods utilized for AABP repair, and correlations between PAS classification and surgery subtypes were analyzed.

RESULTS

The final cohort consisted of 101 patients from 10 institutions. Interrater reliability between two reviewers was excellent (κ = 0.95). The most common subtypes were P2c (contributory escutcheon+insufficient penile skin; 27%) and P2a (contributory escutcheon+sufficient penile skin; 21%) for penile subtypes, A0 (no pannus; 41%) and A1 (noncontributory pannus; 39%) for abdominal subtypes, and S0 (normal scrotal skin with preserved scrotal sulcus; 71%) for scrotal subtypes. AABP repair procedures included escutcheonectomy (n = 59, 55%), scrotoplasty (n = 51, 48%), split-thickness skin grafting (n = 50, 47%), penile skin excision (n = 47, 44%) and panniculectomy (n = 7, 7%). P, A, and S subtypes were strongly associated with specific AABP surgical techniques.

CONCLUSION

The PAS classification schema adequately describes AABP heterogeneity, is reproducible among observers, and correlates well with AABP surgery types. Future work will focus on how PAS subtypes affect both surgical and patient-centered outcomes.

Buried penis and morbid obesity

Three morbidly obese men aged 69, 49 and 45 years with respective BMIs of 46.3, 49.1 and 59.3 died suddenly from underlying cardiovascular disease. At autopsy all were found to have marked penile shortening typical of an entity known as “buried penis.” This condition arises in adulthood most commonly from morbid obesity as the penile shaft becomes enveloped by encroaching suprapubic adipose tissue. It is associated with infective, obstructive and malignant complications. Histology will be required to identify less-common causative conditions or any inflammatory or premalignant/malignant changes.