Methods
hypospadias, edema, congestion, necrosis, torsion, penile degloving
EDEMA, WOUND INFECTION, CONGESTION, PENIS, NECROSIS, TORSION, COMPLICATIONS
This study is a prospective interventional non-randomized study. It included 150 uncircumcised patients in the pediatric age group who presented to Elshatby University Hospital with a concealed penis between June 2018 and June 2021. The main complaint of the parents of the studied patients was appearing small size penis, unapparent penis, difficult cleaning, and/or un-satisfaction.The inclusion criteria included patients with a buried penis at or below the pubic skin level with a stretched penile length for all of them within the normal range according to their ages as titrated in the literature [Patients with any associated anomalies like hypospadias, torsion, penoscrotal web, micropenis, mega-prepuce, or chordae were excluded from the study.The included patients were distributed non-randomly into three groups. The procedure was chosen according to the operative findings as dartos dissection and excision were recommended in patients with a thick abnormal dartos alone, phallopexy was recommended in case of absence of normal penile fixation alone and a combination of both techniques was recommended when the two pathologies were found. Group A included patients who were treated by anchoring the penile skin dermis to Buck's fascia (phallopexy) at the penile base without excision of dartos fascia, group B included patients who were treated by complete dissection and excision of dartos fascia only and group C included patients who were treated by phallopexy as in patients of group A but after complete dissection and excision of dartos fascia.All of the studied patients had routine pre-operative laboratory investigations including CBC, CT, BT, PT, PTT, and INR. Informed consent was signed by the parents or caregivers after a complete explanation of the study design, its publication as well as any possible complications.All of the studied patients were operated on under general anesthesia with skin preparation using povidone-iodine. The prepuce was also retracted backward and cleaned completely from any smegma with povidone-iodine.The procedure was started by the application of two forceps mosquitos at the preputial mucocutaneous junction with formal circumcision leaving about 5 mm of the mucosal collar from the sub-coronal level (Fig. The steps of the procedure. Complete penile degloving in the sub-dartos plane was then started with meticulous dissection of the skin and dartos fascia out of Buck's fascia down to the level of penoscrotal junction ventrally and penopubic angle dorsally taking care of both neurovascular bundle and skin vascularity. On the dorsal aspect; the fundiform ligament—which is usually attached to the distal or mid-penile shaft—was identified and dissected to increase the penile length. The dissection was completed circumferentially releasing all of the abnormal bands anchoring the dartos fascia to Buck's fascia (Fig. To avoid penile re-retraction; one of the following techniques was done (Fig. After removal of the retracting forceps; the skin was repositioned over the degloved penis and was sutured distally to the mucosal collar in a sub-cuticular fashion using Vicryl 6/0 (Fig. Removal of the dressing was done on the 1st postoperative day with repeated application of local antibiotic cream three times daily for 1 week in addition to oral anti-inflammatory (NSAIDs) and anti-edematous for 5 days.The follow-up was carried out at the outpatient clinic by the resident of pediatric surgery who was blinded by the surgical technique. Follow-up of the appearance of the penile skin (congestion, necrosis), wound infection, edema, and or re-retraction at the end of the 1st post-operative week and then monthly for 6 months was done. Also. Comparing the follow-up results between the three studied groups was carried out using the appropriate statistical method.