The concealed penis, also known as indiscernible, is a phallus that has a normal size but is insufficiently exposed.
Following Hadidi’s classification, three types are differentiated (including only boys with Grade III, i.e. with excess pubic fat and absence of attachments at the peno-pubic angles).
In all surgical techniques the approach is ventral to the penis (Figure 2) (Borsellino, Hadidi), and the team led by Dr. Angulo Madero has developed an exclusively suprapubic technique (Figures 3 and 6) for the treatment of the penis hidden by pubic fat hypertrophy (primary and trapped post-circumcision). For cases of congenital megaprepuces and micropenises this technique is not valid.
Patients and methods:
We present 16 patients with a mean age of 8 ± 4 years, treated in the last 3 years. Four had a buried penis secondary to circumcision and two patients were previously treated according to the Borsellino technique. Dr. Angulo Madero’s team’s new technique includes a wide pubic z-plasty in order to achieve sufficient skin to cover the base of the penis and a suprapubic and peripenile lipectomy. A section of the suspensory ligament of the penis and fixation of the penopubic angles from the corpora cavernosa to the pubic skin with non-resorbable thread is performed. Finally, circumcision and dressing over the probe is performed.
Results
At 24 hours postoperatively, the dressing was removed, the bladder catheter was removed and the patients were discharged from the hospital. In all patients there was significant penile edema which resolved with rest and anti-inflammatory drugs. In two patients there was a partial loss of the z-plasty flap that healed by secondary intention. Months later, the patients and their parents are satisfied with the results. Four patients presented a partial recurrence, but they are satisfied and do not want a reintervention. Keloid in the zetaplasty was seen in 4 of the patients.
Discussion
An ethical problem is whether a normal penis even if it is concealed, should it be operated on? It is no less true that the hidden penis produces great anxiety in the parents of the child and if the child is an adolescent, also in the patient. This is an exclusively aesthetic procedure and the adolescent must be aware that as specialists we can only improve the appearance of the penis, but in no case do we modify its size.
On the other hand, Dr. Angulo Madero and his team consider that the proper classification of these alterations is essential for their correct treatment. For example, a micropenis, a congenital megaprepuce or a buried penis due to absence of peno-pubic attachment without fat hypertrophy will not benefit from the described technique. Unlike other techniques such as the Borsellino technique, which we offer in young children, this technique is more aggressive and is aimed at adolescents capable of understanding the risks and benefits. It is only indicated earlier in post-circumcision trapped penises, recurrence of other techniques and in xerotic balanitis.
Although there are numerous studies that perform suprapubic liposuction, we prefer lipectomy for better control of the spermatic cords, zetaplasty is useful to bring the skin closer to the base of the penis without tension. The section of the suspensory ligament of the penis gives us a few millimeters more length. It is also fundamental in the success of the treatment the adequate reconstruction of the penoscrotal and penopubic angles through the careful fixation of the penile skin to Buck’s fascia.
Another important issue is circumcision, so in patients who do not have it, it should be done after surgery, since the foreskin becomes very edematous; it should never be done before surgery since we run the risk of having little penile skin.
Although the series we present is small, and we do not have long term follow up, we like this technique, it is easy to perform and presents few complications, being perceived by parents and patients as good from the aesthetic point of view.