Penoscrotal Webbing Research Articles

Correction of congenital penoscrotal webbing in children: A retrospective review of three surgical techniques

Congenital penoscrotal webbing (PSW) is a condition that leads to penile shortening and is a common cause of delayed circumcision. While various techniques for PSW repair have been described, no comparative studies are currently available. The goal of this study was to validate and critique three commonly utilized techniques for PSW repair. A retrospective chart review was performed on all patients who underwent repair for PSW, with or without concomitant surgical procedure, by a single surgeon (MKH) over a 7-year period. Inclusion criteria were: aged <5 years, diagnosis of PSW, documented surgical approach undertaken to correct the PSW, and follow-up for a minimum of 6 months. A total of 196 patients aged 6 months-3.4 years (average 7.8 months) were included, and underwent three different types of procedure: Heineke-Mikulicz (HM) scrotoplasty, VY scrotoplasty or Z scrotoplasty. Out of 196 patients, 10 (6.7%) had complications, with four (2.7%) requiring surgical revision or correction. Two patients had excision of 'dog-ear' skin tags, one required excision of a suture tract, and the fourth required revision of skin contraction after HM repair with Z scrotoplasty. Congenital penoscrotal webbing is a common condition that often requires pediatric urology consultation. Although it is felt that the severity of the defect may not impact on the operative technique for repair of PSW, data comparing these techniques is lacking. This single-surgeon series highlighted that amongst the patients who underwent one of the three described techniques (HM, VY or Z scrotoplasty), there were no significant postoperative differences in complications or parent satisfaction. Although the ease of the HM repair for minor webbing is acknowledged, Z scrotoplasty is the authors' preference for repair given its ability to address the most severe webbing. In this comparison of three surgical techniques for the correction of PSW, it was demonstrated that each choice is safe, with no option showing a significant difference in complication rate. Surgeon preference should therefore weigh heavily when choosing the surgical approach for PSW repair.

PD22-09 RESURFACING THE PENIS OF THE HYPOSPADIAS CRIPPLE

You have accessJournal of UrologyTrauma/Reconstruction: Urethral Reconstruction (including Stricture) III1 Apr 2015PD22-09 RESURFACING THE PENIS OF THE HYPOSPADIAS CRIPPLE Mina Fam and Moneer Hanna Mina FamMina Fam More articles by this author and Moneer HannaMoneer Hanna More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1451AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES After the creation of a neourethra in patients with multiple failed hypospadias repairs (hypospadias cripples), resurfacing the penis with healthy skin is a significant challenge because local tissue is often scarred. Without adequate coverage of healthy skin, there is an increased risk of repair breakdown and poor cosmetic results. In our series, the use of a healthy scrotal fascio-cutaneous flap as well as the use of tissue expanders served as a reliable means of resurfacing the penis after complex repairs where there is a lack of healthy local tissue. METHODS We retrospectively reviewed 203 patients referred after multiple unsuccessful hypospadias repairs from 1989 to 2013. 58/203 patients did not have adequate healthy local penile skin to resurface the penis after urethroplasty. Scrotal skin was used to resurface the penis in 54/58 patients. Of these 54 patients, 50 had a scrotal fascio-cutaneous rotational flap and 4 had a Cecil two-stage repair. 6/58 underwent tissue expansion of the dorsal penile skin over a 12-16 week period prior to penile resurfacing. 2/58 patients underwent scrotal skin resurfacing and subsequent tissue expansion for their reconstructions. RESULTS Patient age ranged from 4-38 years old and the number of prior operations ranged from 3-24 operations. Follow-up ranged from 6 months to 22 years. 56/58 (96.5%) patients had successful resurfacing of the penis with scrotal skin, tissue expanders or a combination of both approaches. 5/54 (9.3%) patients who underwent penile resurfacing with scrotal skin developed post-operative cyanosis of the flap. 3/5 patients with cyanosis were salvaged with nitroglycerine ointment. After long-term follow up, 10/54 (18.5%) patients with scrotal skin resurfacing underwent flap revision due to minor complications such as scarring, presence of a “dog ear” and penoscrotal webbing. 6/10 patients who underwent flap revision required simultaneous depilation of a hairy flap. All 6 patients who underwent tissue expansion had successful skin flap reconstruction without complication. CONCLUSIONS A rotational scrotal fascio-cutaneous flap is typically well-vascularized and therefore lends to successful penile resurfacing after urethroplasty. In select cases, local expansion of dorsal penile skin provides a skin flap with excellent texture and pigmentation to resurface the penis. In our experience, the use of scrotal skin flaps, tissue expansion of the dorsal penile skin or a combination of both serve as reliable approaches in resurfacing the penis in almost any hypospadias cripple lacking healthy local skin. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e479 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mina Fam More articles by this author Moneer Hanna More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V8-08 REDUCTION SCROTOPLASTY WITH SIMULTANEOUS PLACEMENT OF INFLATABLE PENILE PROSTHESIS

INTRODUCTION AND OBJECTIVES: Placement of inflatable penile prosthesis is a common urologic surgery that dramatically aids patients with erectile dysfunction. There are a proportion of patients that have a severely redundant scrotum that can cause functional discomfort or pain due to the large size. We present a novel technique for reduction scrotoplasty with simultaneous placement of inflatable penile prosthesis. METHODS: A penoscrotal approach is taken for placement of the inflatable penile prosthesis. A ventral phalloplasty is performed using our previously described approach to excise the redundant skin at the penoscrotal web. We then follow our standard protocol for insertion of the penile prosthesis. The prosthesis pump is positioned in the most inferior portion of the scrotum. An inverted-Y reapproximation of the dartos layer is performed, and the overlying skin closed in the same fashion. This results in cephalad retraction of the scrotum, thus providing an overall reduction of scrotal sac dimensions. RESULTS: A total of seven patients have undergone reduction scrotoplasty with simultaneous placement of inflatable penile prosthesis at our institution. At last follow up, all patients have excellent cosmetic and functional outcomes. No known complications have occurred due to the reduction scrotoplasty. CONCLUSIONS: Inverted-Y reduction scrotoplasty is a feasible technique during placement of inflatable penile prosthesis. The added time during surgery is minimal, and functional outcomes are excellent. This simultaneous procedure can lead to improved quality of life for patients with concurrent erectile dysfunction and redundant scrotum.

Inconspicuous Penis

Inconspicous penis refers to a constellation of conditions that make the penis look diminutive and small. This could be secondary to short penile shaft often termed as micropenis. But more commonly, this inconspicuous appearance is secondary to other causes ranging from congenital conditions such as penoscrotal webbing or megaprepuce, developmental conditions like prepubic adiposity that overhang the penis, and iatrogenic causes like trapped penis after adhesions secondary to circumcision. In this paper, we propose to define these entities and provide their descriptions and then to describe their management including surgical correction.

Penile Advancement and Lengthening for the Management of Post-circumcision Traumatic Short Penis in Adolescents

To report on the safety of combing suprapubic fat liposuction, penile suspensory ligament severing, and Z-plasty of penoscrotal webbing for penile lengthening in cases of post-circumcision traumatic short penis in adolescents. This prospective study was conducted in 9 male patients with a mean age of 15.6 ± 1.4 years. All patients had a short penis because of traumatic amputation of the glans in 7 patients and both glanular and partial distal corporal loss in 2 patients during circumcision. All were initially treated in childhood by penile skin advancement for phallic coverage. Penile length and circumference were measured pre- and post-operatively, both in the flaccid state at maximal stretch and in the erect state. Operative technique included Z-plasty of penoscrotal web, release of suspensory ligament, and suprapubic fat liposuction. Average functional penile length measured 3 months post-operatively had significantly increased by 18-30 mm (mean: 23 ± 4 mm) in the provoked, erect state. All patients had normally developed penile corpora cavernosa and wide circumference (mean: 11.7 ± 0.2 cm). No post-operative complications occurred in any of the patients. No patients had sexual partners or were sexually active. The described technique of penile advancement and lengthening can be safely applied to patients with post-circumcision traumatic short penis.

A novel operative technique for concealed penis secondary to penoscrotal web: a case report

Contemporary surgical techniques for concealed penis defined in the literature are sophisticated and, because of this, we decided to perform a simple technique. A child with penoscrotal web was admitted to our Pediatric Surgery Clinic. The patient had recurrent urinary tract infections without urinary tract disease and, therefore, web reconstruction was thought to be useful. A modified unfurling technique and penoscrotal angle reconstruction was used. The main characteristic of our procedure can basically be described as an oblique incision of the outer foreskin leaf which guides the next steps. We report the operative and clinical course of the patient. We demonstrated that the penoscrotal web was treated simply and effectively as an outpatient procedure. In addition, in the follow-up period, we found that the patient had acceptable and cosmetic penile skin.

Ventral Phalloplasty

Figure 1Redundant scrotal skin extending to the mid-to-distal third of the penile shaft can be safely removed. Preoperative protocol is followed as well as standard skin preparation. After drapes are applied, preferably an extremity drape, the head of the phallus is grasped and upward traction is applied until maximum stretch is achieved. Inferior and ventral traction is then applied to the mid-scrotal area at the level of the medium raphe, typically with an allis clamp. This defines the extent of the penoscrotal web that is best appreciated with lateral views. There is great variability in the insertion of the scrotal skin to the ventrum of the phallus

A New Technique of Concealed Penis Repair

Phimosis associated with concealed penis is not amenable to ordinary circumcision. To our knowledge we describe a new technique to repair concealed penis. From September 2003 to January 2008, 57 consecutive patients with concealed penis were treated using our technique. Median age at surgery was 33 months (range 7 months to 34 years). The technique consists of 3 steps. Step 1 is a ventral incision to slit the narrow ring of the prepuce and expose the glans. Step 2 is a circumferential skin incision made between 2 edges of the ventral diamond-shaped skin defect, followed by midline incision of the dorsal inner prepuce to make 2 skin flaps connected to the glans. Step 3 is skin coverage. Two skin flaps are brought down and sutured together on the ventral side of the penis. The suture line between the penile shaft skin and the flap eventually becomes elliptical. Medical records were reviewed for voiding function, scar formation, and replies from older patients and the parents of younger children about impressions of the surgical results. Median followup was 26 months. No patient had voiding problems. Lymphedema persisted due to suture line constriction in 2 patients who underwent incision of the constriction. All older patients and the parents of younger children were satisfied with the surgical results. Our new method is easy to design and perform to correct concealed penis. It provides a good cosmetic appearance and seems to be applicable in all cases with deficient penile shaft skin.

Ventral phalloplasty

To present a simple technique during penile prosthesis implantation that promotes the perception of increased phallic length. The penoscrotal web is defined. A "check mark" incision is made with excision of scrotal tissue. Excellent exposure is provided for implantation of the cylinders, pump and reservoir. Wound closure is performed longitudinally. This technique is a modified extension of surgeries described in the pediatric literature for webbed penis. Loss of penile length following penile implantation surgery is worrisome for patients suffering from erectile dysfunction (ED). This technique helps with patient satisfaction, cosmetic results, and improves perception of penile length. Ventral phalloplasty is a safe, technically simple procedure that may be performed in concert with penile prosthesis implantation or as a stand alone procedure under certain circumstances.

ORIGINAL RESEARCH—SURGERY: Concomitant Ventral Phalloplasty During Penile Implant Surgery: A Novel Procedure That Optimizes Patient Satisfaction and Their Perception of Phallic Length After Penile Implant Surgery

ABSTRACT Introduction Despite previous reports showing consistently elevated patient satisfaction with penile implantation, it is our impression that patients who have had a prosthesis placed often complain of penile shortening postoperatively. Aim We sought to evaluate if the release of the penoscrotal web would optimize patient perception and satisfaction regarding penile length after such procedure. Main Outcome Measure Utilizing a questionnaire, we evaluated patient satisfaction, focusing on phallic size. Methods Ninety patients (mean age 62) underwent penile prosthesis placement during a 17-month period. Forty-three were carried out with takedown of penoscrotal web during a 17-month period (group 1). Of group 1, 39 patients had an inflatable implant placed (inflatable penile prosthesis) and 4 had a semirigid implant. The patients were directly inquired with a seven-item questionnaire 3 months after the procedure. These results were then compared to a group of 37 patients that had penile implants placed without release of the penoscrotal web (group 2). All the patients involved in the study had a high insertion of the scrotum ventrally (penoscrotal web). Results Of the patients, 42/43 (98%) (group 1) reported good overall satisfaction of the surgical procedure; 36/43 (84%) reported some degree of increase in penile length; 5/43 (12%) reported no significant change in their perception of penile length postoperatively. The remaining two patients reported a decreased penile length. The clinical records from group 2 demonstrated 31/37 (84%) of the patients complained of penile shortening, and only one patient reported an increase in penile length. Postoperative complications in group 1 consisted of wound hematoma (2/43) and focal superficial wound dehiscence (3/43). The operative time for group 1 patients was approximately 12 minutes (mean 11.7) longer. Conclusions Release of penoscrotal web is a simple, safe, and reproducible procedure that can enhance patient perception of penile length and further improve satisfaction.

Results of a Simplified Technique for Buried Penis Repair

The buried penis can cause secondary phimosis, recurrent balanitis and social embarrassment. We report our results using a simplified technique for repair. A retrospective chart review of 83 consecutive patients undergoing buried penis repair between March 1995 and March 2001 was performed. Indications for surgery included recurrent balanitis, secondary phimosis, difficulty holding the penis during voiding, spraying of the urinary stream, or parental or patient concern for social embarrassment. The technique involves fixation of the subcutaneous penile skin at the base of the degloved penis to Buck's fascia of the penile shaft at the 3 and 9 o'clock positions. For the 79 patients included in the study average followup was 4.4 years. Group 1 consisted of 26 patients who underwent circumcision at the time of buried penis repair. Six patients had hypospadias and 13 had penoscrotal webbing that was repaired simultaneously. Three patients (11.5%) had recurrent buried penis that required a repeat procedure and 1 (3.8%) required revision of the circumcision only. Three patients (11.5%) with penoscrotal webbing had mild recurrence requiring no further treatment. Group 2 consisted of 49 patients who underwent revision of the circumcision at the time of buried penis repair. Seven patients (14.3%) had mild recurrence that did not require further treatment. Group 3 consisted of 4 patients who underwent liposuction at the time of buried penis repair. One patient experienced lymphedema of the ventral distal shaft skin, which required subsequent excision. The buried penis repair is a simple and effective outpatient procedure with few complications and recurrences. It can be used as a primary or secondary procedure and affords good cosmetic results.

Long-Term Outcome of the Surgical Treatment of Concealed Penis

The term concealed penis describes a spectrum of disorders ranging from penoscrotal webbing to a completely buried penis. A number of surgical procedures have been described to correct this condition but little has been written about long-term results. We report our long-term results of the surgical correction of concealed penis based on a survey of parents. A retrospective review of patients treated from 1995 to 1999 identified 18 males with a minimum of 21 months of followup whose parents were available for evaluation via telephone interview. The parents were questioned about the initial problems that they associated with concealed penis, such as appearance and accessibility of the penis, ease of hygiene, severity of concealment and negative feelings about the appearance of the penis. Parents were also questioned about the results of surgery and how the surgical result improved or failed to improve their concerns. Specifically, they were questioned about whether the surgery helped to alleviate negative concerns, improve hygiene and make the penis more assessable. Of the 18 patients 14 were infants/toddlers (group 1) and 4 were adolescents (group 2). Group 1 patients with a mean age of 2 years were evaluated at a mean of 41.7 (range 21 to 76) months and group 2 patients with a mean age of 12 years were evaluated at a mean of 38.8 (25 to 63) months after surgery. Before surgery 57% of patients in group 1 and 50% in group 2 complained of difficulty with hygiene. Of the parents 64% of group 1 and 75% of group 2 described their child as having a completely hidden penis. On the other hand, only 57% of parents in group 1 expressed negative feelings about the appearance of the penis compared to all parents in group 2. Following surgery group 1 patients fared better reporting improvements in hygiene (87%), accessibility (86%) and improved appearance of the penis (100%). Results from surgical intervention were less successful in group 2, with improved hygiene in 50%, improved penile accessibility in 75% and improved appearance in 50% of patients. Interestingly, all group 2 parents would still recommend the same surgery to a friend with the same problem despite less than perfect results compared to 79% of group 1 parents who would recommend surgery to others. Our long-term outcome survey data demonstrate that surgical correction of concealed penis addresses an array of presenting complaints. According to the parents of patients surgery is almost uniformly successful in toddlers and less often successful in adolescents. However, despite its limited success in older patients, most parents thought that surgery was a positive intervention and would recommend it to a friend with a similar condition.

Congenital emphysema, cryptorchidism, penoscrotal web, deafness, and mental retardation - a new syndrome?

The clinical features of an 8-year-old boy with congenital emphysema, cryptorchidism, a penoscrotal web, deafness, constipation and mental retardation are described. Review of the literature did not reveal another report of this unusual combination of features.

AUGMENTATION PHALLOPLASTY

Aesthetic procedures can increase the girth and visual length of the penis. Dermal-fat grafts increase penile circumference without the complications that result from fat injections. Release of the suspensory ligaments with skin advancement may increase flaccid penile length. Suprapubic lipectomy and Z-plasty of a penoscrotal web enhance penile appearance. Accurate diagnosis and meticulous technique are mandatory.