Suprapubic Fat Pad Research Articles

Minimally invasive monsplasty

In this video, we present our technique for a minimally invasive monsplasty using a sling. This is a variation of Shaeer's technique, previously published on by Dr Shaeer. He has demonstrated excellent success with this and we have adapted it with a commercial sling and a midline incision.Buried penis repair can be a very difficult surgery with significant morbidity. In patients with a relatively soft suprapubic fat pad, we attempt to unbury the penis with a relatively simple and minimally invasive surgery.While this technique does not provide as robust a repair as a traditional buried penis repair, it is significantly less morbid and can produce good functional results with much shorter operative time and quicker recovery. Most patients are discharged same day and experience minimal pain. We believe this technique is best suited for patients with a soft, small to moderate fat pad, and who may be poor candidates for a larger surgery.

(344) The Surgical Outcome of Buried Penis Surgery

Abstract Introduction Buried penis is a condition where the penis retracts and becomes hidden beneath the skin. It has a significant impact on quality of life of the patient and can present with a variety of symptom including lower urinary tract symptoms and erectile dysfunction. Whilst there are several causes, obesity is the most common in adults. Objective The aim of this study is to assess the variety of different operations performed with patient and surgeon satisfaction rates. Methods This is a retrospective study on patients with a buried penis operated on between 2010 and 2020. Data retrieved included presenting complaints, previous surgery, co-morbidities, surgical details and patient and surgeon satisfaction rates with cosmesis. Results A total of 141 patients were recruited with buried penis (median age 54, range 20-80). The presenting complaints were inability to void standing n = 30, erectile dysfunction n = 18, small penis n = 94. Aetiological factors included diabetes n=47, vascular disease n=62, penile cancer surgery n= 3 and BXO n= 13. The BMI was recorded in 44 patients (range 23-52) with 7 being morbidly obese (BMI >40). 47 patients had only a weight was recoded with a median of 114kg (range 68-169kgs). A total of 96 (68%) patients had had previous surgery prior to referral and in particular circumcision in 49 patients. The operations performed on the 141 patients were circumcision n=40, scrotoplasty n=35, V-Y plasty n=11, skin grafting n=34, suprapubic fat pad excision n=77, abdominoplasty n=25, malleable penile prosthesis n=7, inflatable prostheses n=7 and division of suspensory ligament n=24. The post-operative length of stay was median 3 days (range 0-52 days) but for abdominoplasty and grafting this was a median of 5 days (range 1-52 days). There were 27 complications (19%); infections (n=15), dehiscence (n=5), haematomas (n=2) The mean follow up was 506 days (range 0-4313 days) with a surgical satisfaction rate of 87% and patient satisfaction of 79%. Of note the highest dissatisfaction occurred in patients having circumcision or suprapubic fat pad removal. Conclusions Buried penis is a complex condition with patients likely requiring a combination of surgical techniques. Circumcision alone usually does not treat the problem and may make things worse. A prolonged hospital stay with significant wound complications may occur but the majority of patients are happy with the final outcome. Disclosure No

(407) Buried Penis in Morbidly Obese Patient: Surgical Technique of Fat Pad Excision, Malleable Penile Prosthesis Insertion and Penile Split Skin Graft

Abstract Introduction Buried penis has a significant impact on quality of life affecting voiding and sexual function. Central and suprapubic deposition of adipose tissue related to obesity is a common cause. Objective This video shows the surgical approach of a complex case of buried penis managed with a suprapubic fat pad excision and simultaneous malleable penile prosthesis insertion. Methods We present a case of buried penis in a morbidly obese patient (BMI:43) with a history of two previous gastric bypass surgery and an apronectomy. affecting micturition and sexual function. A skin incision is made with a transverse incision at the level of the anterior superior iliac spine and a curvilinear inferior border. The apex of the inferior border should be approximately 2 finger breadth above the level of the penopubic junction. The incision is extended down to the rectus sheath and the spermatic cords at the lateral boundaries and the penile shaft at the midline are exposed. A malleable implant is inserted using the infrapubic approach and a split skin graft harvested to replace the unhealthy penile shaft skin. The dermis of the skin edges are secured to the rectus sheath with 0/0 vicryl sutures and the wound is closed in layers. Results Post-operative recovery was complicated by partial necrosis of the skin graft. At 3 months, the patient was able to stand to void and engage in sexual intercourse at 6 months. Conclusions The prevalence of obesity is increasing and in men, the presence of a suprapubic fat bad can result in a buried penis and affect voiding and sexual function. Although weight loss should be advised in the first instance, this may often not be enough. A combination of a suprapubic fat pad excision with malleable penile implantation and spit skin graft is a treatment option that can be considered. Disclosure No

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.

The surgical outcome of buried penis surgery

Buried penis is a condition where the penis retracts. It has a significant impact on quality of life of the patient and can present with a variety of symptom. Whilst there are several causes, obesity is the most common in adults. A retrospective study on patients with buried penis operated on between 2010 and 2020. Data retrieved included presenting complaints, previous surgery, co-morbidities, surgical details and patient and surgeon satisfaction rates. A total of 141 patients were recruited with buried penis (median age 54). The presenting complaints were inability to void standing n=30, erectile dysfunction n=18, and small penis n=94. 96 patients had had previous surgery, 49 were circumcisions. The operations performed on the 141 patients were circumcision (n=40), scrotoplasty (n=35), V-Y plasty(n=11), skin grafting (n=34), suprapubic fat pad excision(n=77), abdominoplasty (n=25), penile prosthesis (n=14), and division of suspensory ligament (n=24). The post-operative length of stay was 0-52 days. There were 27 complications; infections (n=15), dehiscence (n=5), haematomas (n=2)The mean follow up was 506 days (range 0-4313 days) with a surgical satisfaction rate of 87% and patient satisfaction of 79% (p=0.021). Of note the highest dissatisfaction occurred in patients having circumcision and/or suprapubic fat pad removal. Buried penis is a complex condition with patients likely requiring a combination of surgical techniques. Circumcision alone usually does not treat the problem and may make things worse. A prolonged hospital stay with significant wound complications may occur but the majority of patients are happy with the final outcome. No conflict of interest to declare.

Expanding the Limits-Improving Penile Length With Inflatable Penile Prosthesis Implantation: A Review.

Erectile dysfunction is a multifactorial disorder that increases in prevalence as men age. When medical therapy fails or when men are unwilling to try it, surgical intervention becomes the urologist's next best tool. However, the loss of penile length is of great concern to many patients, and there have been a myriad of ways to try to combat this fear from both patients and the surgeons themselves. In this review, we evaluate the current literature of these various approaches to improve penile length in penile prosthesis surgery. To review novel techniques in penile prosthesis implantation surgery. A literature search using PubMed was conducted to identify relevant peer-reviewed studies to penile prosthesis surgery. Search terms included penile prosthesis, penile shortening, sliding technique, Peyronie's Disease, erectile dysfunction, nondegloving, penile length, and Multiple Slice Technique. Novel techniques included preoperative techniques such as use of vacuum-assisted erection device, intraoperative techniques of aggressive dilatation and maximal sizing, ventral phalloplasty and/or scrotoplasty, suprapubic fat pad excision, relaxing tunica albuginea incisions, a sliding or slicing technique, or the postoperative use of penile rehabilitation. In addition, recognizing recall bias or inconsistencies in measurement techniques is important when evaluating men with possible penile shortening after penile prosthesis surgery. Advancements in surgical techniques and managing patient expectations can be crucial in the success of penile prosthesis surgery. Panuganti S, Kannady C, Wang R, Expanding the Limits-Improving Penile Length With Inflatable Penile Prosthesis Implantation: A Review. Sex Med Rev 2021;9:498-506.

A Review of Factors Affecting Patient Satisfaction With Inflatable Penile Prosthesis.

A variety of factors that can influence patient satisfaction after inflatable penile prosthesis (IPP) surgery, including patient expectations before surgery, intraoperative complications, and perceived penile shortening and partner satisfaction after surgery. While patient satisfaction rates with IPP are high, there are several reported methods to further improve patient satisfaction with IPP. Identifying factors responsible for patient satisfaction after IPP surgery from preoperative counseling, intraoperative techniques, and postoperative care and identifying ways to improve overall patient satisfaction. A PubMed search was performed of all articles available on the database relating to penile prosthesis and patient satisfaction. The main outcome measure is patient satisfaction after IPP surgery. Patient satisfaction has been reported to be as high as 90%. Factors affecting postoperative satisfaction include preoperative counseling and expectations, patient comorbidities, partner satisfaction, and postoperative complications. One of the most common complaints is decreased penile length postoperatively. It is critical to accurately measure penile length before surgical intervention. Preoperative strategies to improve penile length with IPP include the use of penile traction therapy and vacuum erection device (VED). Several adjuvant procedures have been described and shown to safely increase penile length with concomitant IPP surgery, including ventral phalloplasty, suprapubic fat pad excision, and modified sliding technique-multiple slice technique. Postoperative penile rehabilitation program has been shown to improve penile length. The use of phosphodiesterase type 5 inhibitors in the postoperative period leads to increased glans engorgement and improved patient satisfaction. Patient satisfaction with IPP is influenced by many factors, which can be categorized into 3 distinct patient care stages: preoperative, intraoperative, and postoperative. There are several techniques described in each patient care stage to improve perceived penile length including preoperative counseling and correct penile length measuring, preoperative penile stretching, the use of adjuvant surgical procedures, and postoperative penile rehabilitation. Shah T, Wang R, A Review of Factors Affecting Patient Satisfaction With Inflatable Penile Prosthesis. Sex Med 2021;9:350-357.

Correction of retractile penis with subcutaneous soft silicone penile implant.

We report a novel solution for patients suffering from adult acquired retractile penis. Three patients complained of retractile penis (when standing) and/or prepubic recession. Physical examination confirmed the shaft of the penis was buried with only the glans visible. All three patients reported lower levels of self-confidence, self-esteem, and sexual confidence prior to their procedure. The three patients received surgical treatment with the insertion of a subcutaneous soft silicone penile implant and two of the three also received removal of the suprapubic fat pad. Over one year post operatively, the penile shaft and glans was visible and appeared natural. All patients reported an increase in self-confidence and self-esteem. The insertion of a subcutaneous soft silicone penile implant may prove to be a viable solution to reverse retractile penis and to increase patient quality of life when compared to more invasive current surgical treatments.

Subjective and objective results in surgical correction of adult acquired buried penis: A single-centre observational study.

The purpose of this study was to provide a detailed analysis of surgical and functional outcomes after correction of acquired buried penis in the adult. From 2006 to 2016, we retrospectively reviewed 47 patients undergoing surgical treatment for the correction of buried penis. Functional and surgical outcomes, as well as patients' satisfaction were the main endpoints. The most common complains at presentation were recurrent uro-genital infections, sexual dysfunction, voiding dysfunction and Lichen Sclerosus (LS). Surgical management steps included: circumcision (27.66%), scrotoplasty (19.14%), V-Y skin plasty (4.25%), split thickness skin graft (STSG) 12.76%, full thickness skin graft (FTSG) 36.17%, suprapubic fat pad excision (57.44%), abdominoplasty (25.53%), division of the suspensory ligament (36.17%). Postoperative complications were recorded in 15% of patients. Vaginal penetration and erectile function ended up being more effective in 97.87% (46/47) and 42.55% (20/47) of patients. Improvement in penile erogenous sensation was in 6.38% (3/47). Aesthetic appearance of genitalia fully satisfied 36.17% of patients (17/47). Overall patients' satisfaction rate resulted 76.59% (36/47). Management of adult acquired buried penis still remains a challenging task to achieve, however excellent cosmetic results can be obtained by surgical reconstruction.

Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis

IntroductionMany men suffering from erectile dysfunction are overweight with generous suprapubic fat pads, which often contribute to a decrease in visible exophytic phallic length. AimTo present a novel surgical concept of suprapubic fat pad excision with a concomitant placement of inflatable penile prosthesis. MethodsA transverse incision begins slightly medial to the anterior superior iliac spine, with the superior edge crossing transversely to the contralateral anterior superior iliac spine. The inferior border is incised in a curvilinear fashion, with the medial apex being approximately 1 cm above the base of the penis. Dissection is carried down to the lower abdominal anterior fascia, which leads to excision of the suprapubic fat pad. Using this same exposure, the inflatable penile prosthesis (IPP) is placed via an infrapubic approach. The wound is reapproximated in multiple layers, and 2 drains are placed, 1 subcutaneous in the area of the fat pad excision and the other in the scrotum around the pump. Main Outcome MeasuresPrimary outcomes included penile implant functionality, ability to engage in sexual activity, and cosmetic satisfaction. ResultsA total of 8 patients have undergone suprapubic fat pad excision with simultaneous placement of IPP at our institution. Average body mass index of our patient cohort was 36.6. 1 patient developed prosthetic infection after inadvertent removal of his drains in the immediate postoperative period. At last follow-up, all other patients have excellent cosmetic and functional outcomes. Clinical ImplicationsThis technique can lead to higher patient satisfaction with their penile implant, enhanced sexual performance, and improved quality of life for patients with concurrent erectile dysfunction and significant suprapubic fat pad. Strengths & LimitationsThis unique technique has never been previously described. It allows placement of IPP in the setting of fat pad excision without any additional incisions. Limitations include the small patient population and relatively short follow-up. ConclusionsSuprapubic fat pad excision is a safe and reproducible technique that can be performed simultaneously with the placement of an IPP in appropriately selected patients. Patients must be counseled appropriately on the expectations of surgeries and the theoretical increased risk of postoperative complications, such as infection.Baumgarten AS, Beilan JA, Shah BB, et al. Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis J Sex Med 2019;16:333–337.

Simultaneous Suprapubic Lipectomy and Penile Prosthesis Implantation

IntroductionA shorter penis is a frequent complaint following penile prosthesis implantation (PPI), and a large redundant suprapubic fat pad can conceal the penis and possibly compromise patient and partner satisfaction with length. AimTo evaluate feasibility and outcome of same-session, same-incision, PPI and suprapubic lipectomy (SPL). MethodsIn 22 patients, SPL was performed through an abdominal crease incision. Through the same incision, the superficial perineal pouch was opened to gain access to the base of the penis. Penile prosthesis was implanted (semirigid in 16 patients and girth-expanding 3-piece inflatable in 6). Scarpa’s fascia, subcutaneous fat, and the abdominal crease skin incision were closed. Main Outcome MeasureEvaluation was in terms of implant survival, preoperative vs postoperative patient and partner satisfaction with penile length on a 5-point rating scale, subjective opinion over penile length postoperatively, compared with recall of erect length before erectile dysfunction (ED) had set in (longer, same, or shorter), and penile length with the implant rigid, compared in the supine and standing positions postoperatively (pubic skin to tip, using a rigid ruler). ResultsNo infections or extrusions or mechanical failures were encountered. There was a 53.3% increase in patient satisfaction with length comparing preoperative (2.55 ± 0.67) to postoperative (4.77 ± 0.43) ratings, P < .0001. Partner satisfaction showed a 40.2% increase, from 1.77 ± 0.61 to 4.41 ± 0.50, P < .0001. 19 of 22 patients reported that postoperative length was longer than their recall of erect length before ED had set in, and 3 patients reported that length was the same. With the implant rigid, there was no statistically significant difference in visible length between the supine and standing positions (14.1 cm ± 2.3 and 13.9 cm ± 2.3, respectively, P = .38). Clinical ImplicationsPatients with refractory ED and a concealed penis can be counseled as to the option of simultaneous SPL and PPI (SPL-PPI), a modification that may help avoid patient and partner dissatisfaction with length. Strength & LimitationsStrengths include objective evaluation of the efficacy of the procedure by comparing supine and standing penile length. Limitations of the current study include inability to evaluate erect length preoperatively owing to refractory ED, and subjectivity of patient and partner opinion. ConclusionSame-incision SPL-PPI appears to be a safe and effective procedure, with high patient and partner satisfaction rates.Shaeer O, Shaeer K, Abdel Rahman IF. Simultaneous suprapubic lipectomy and penile prosthesis implantation. J Sex Med 2018;15:1818–1823.

Micropenis

Micropenis refers to a normally structured penis, which is abnormally small, with a stretched length of less than 2.5 standard deviations (SD) below the mean of age or stage of sexual development. Patients with true micropenis usually have a 46,XY karyotype, associated to normally located male gonads, without any sign of other penile malformations. Penile length is measured from the point where the penis meets the pubic bone to the distal tip of the glans on maximal stretch, compressing any fat over suprapubic area. Differential diagnosis include buried penis (inability to adequately expose the penis, due to a severe phymosis associated to a decreased length of penile skin, which retain the shaft inside the preputial cavity), and obesity with excess fat pad over supra pubic area. The causes of congenital or true micropenis can be divided into three major groups: hypogonadotropic hypogonadism (pituitary/hypothalamic failure), hypergonadotropic hypogonadism (primary testicular failure) and idiopathic (associated with a functional hypothalamus–pituitary–testicular axis). Clinical treatment is based on testosterone therapy. Surgical treatment options are used after failed penile enlargement with testosterone therapy and include penile elongation, suprapubic fat pad aspiration and eventually neophaloplasty.

Surgical Management of Adult Acquired Buried Penis.

Adult acquired buried penis is a morbid condition characterized by complete entrapment of the phallus as a result of morbid obesity, post-surgical cicatrix formation, or primary genital lymphedema. Hygienic voiding is not possible and urinary dribbling is frequent with accompanying inflammation, skin breakdown, and infection from the chronic moisture. The end result is penile skin fibrosis resulting in permanent functional loss. Herein, we describe the etiology of adult acquired buried penis, advances in its surgical management, and quality of life outcomes with treatment. Adult acquired buried penis is increasing in incidence as morbid obesity becomes more prevalent. Frequently comorbid conditions affect treatment including those affecting wound healing such a diabetes mellitus. Functional and cosmetic surgical outcomes are being published in greater volume in recent years leading to more refined treatment algorithms. Patient quality of life is greatly improved by definitive surgical management. Adult acquired buried penis is a morbid condition that is increasing in incidence as obesity becomes more commonplace. Surgical management often necessitates surgical lipectomy of the suprapubic fat pad, scrotoplasty, and penile split thickness skin graft. Substantial quality of life improvements have been consistently reported after surgical treatment.

V-Neck Technique: A Novel Improvement to the Infra-Pubic Placement of an Inflatable Penile Implant

BackgroundInfra-pubic placement of an inflatable penile prosthesis (IPP) has a well-known configuration deformity from contralateral tubing that crosses the corporal bodies, resulting in tubing visibility and irritation under the penile skin. AimTo present a novel step to eliminate this tubing crossover deformity. MethodsThe V-neck technique was applied to five patients, two of whom underwent suprapubic fat pad excision with simultaneous infra-pubic IPP placement and three patients who underwent only infra-pubic IPP placement. The technique added an additional 1 minute of procedure time. The reservoir was placed on one (ipsilateral) side into the space of Retzius. OutcomesPrimary outcome measurements were esthetic appeal at follow-up, immediate postoperative complications, and difficulty of implementation of the technique. ResultsThe technique included the following steps. (i) The standard infra-pubic approach, as popularized by Perito (J Sex Med 2008;5:27–30), was used to place the reservoir and cylinders. The ipsilateral and contralateral cylinders and the reservoir were clamped and unconnected. (ii) Finger dissection was used to create a sub-phallic window and a U-shaped aortic clamp was used to pass the contralateral tubing. (iii) After passing the green tubing through the window, all connections were performed in the usual fashion. Tubing crossover was eliminated, as was passage of the right and left cylinder tubes down their respective gutters. Postoperative follow-up at 2 weeks showed no visible tubing. Clinical ImplicationsThis simple maneuver could help prevent the discomfort of tubing crossover deformity commonly seen after infra-pubic placement of an IPP. Strengths and LimitationsThis unique maneuver can be applied to all infra-pubically placed IPPs. Limitations include the small patient population and short follow-up. Whether this maneuver will make revision surgery more difficult is unclear. ConclusionThis technique is a novel step to infra-pubic IPP placement that adds minimal operative time and could eliminate visible tubing.Shah BB, Baumgarten AS, Morgan K, et al. V-Neck Technique: A Novel Improvement to the Infra-Pubic Placement of an Inflatable Penile Implant. J Sex Med 2017;14:870–875.

V1-12 SURGICAL MANAGEMENT OF ADULT ACQUIRED BURIED PENIS (AABP)

You have accessJournal of UrologyReconstruction Lower Tract (I)1 Apr 2017V1-12 SURGICAL MANAGEMENT OF ADULT ACQUIRED BURIED PENIS (AABP) Thomas Fuller, Katherine Theisen, and Paul Rusilko Thomas FullerThomas Fuller More articles by this author , Katherine TheisenKatherine Theisen More articles by this author , and Paul RusilkoPaul Rusilko More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.244AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Adult acquired buried penis as a result of obesity is a morbid condition. Affected patients have poor sexual function, urinary dribbling, mood disturbance, and poor quality of life (QoL). Weight loss is ineffective due to chronic skin changes and suprapubic fat pad (termed the escutcheon) lymphedema. Previous efforts have described limited repairs including isolated resection of the escutcheon which unfortunately often leads to reburying. We present a surgical repair including escutcheonectomy, scrotoplasty, and penile degloving with split-thickness skin graft (STSG) to provide definitive repair and halt the progression of the disease process. METHODS A retrospective chart review was conducted of patients managed surgically for adult acquired buried penis in 2015-2016. Twelve patients were identified that underwent escutcheonectomy, scrotoplasty, penile degloving and STSG repair. All patients had morbid obesity as a sole etiology or significant contributing factor. Outcomes evaluated were surgical complications, reburying of the penis, graft take rate, and urinary symptoms. RESULTS Twelve patients underwent repair of adult acquired buried penis. All patients had good cosmetic results and durable unburying at intermediate term follow-up. Mean patient body mass index (BMI) was 45.4 ± 3.7. Fifty percent of the patients in the series were diabetics and 50% had hypertension and hyperlipidemia (Table 1). Mean operative time, length of stay (LOS), and estimated blood loss (EBL) were 312 ± 59 min, 5.3 ± 1.1 days, and 304 ± 133 cc respectively. STSG take rate was 80-100% (mean 92%) (Table 2). CONCLUSIONS Adult acquired buried penis is a challenging condition to treat. Limited surgical repairs can lead to reburying of the penis, need for further procedures, and the progression of urethral disease with voiding dysfunction. Escutcheonectomy, scrotoplasty, and STSG has encouraging intermediate term outcomes with durable unburying of the penis and good STSG take rates. Further follow-up in larger series is needed but results are thus far encouraging. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e71 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Thomas Fuller More articles by this author Katherine Theisen More articles by this author Paul Rusilko More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD2-01 BURIED PENIS IN ADULTS – PRESENTATION, SURGICAL TECHNIQUES AND OUTCOME

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Penis/Testis/Urethra: Benign Disease1 Apr 2015PD2-01 BURIED PENIS IN ADULTS – PRESENTATION, SURGICAL TECHNIQUES AND OUTCOME Tet Yap, Matus Chocolaty, Raheem Amr, Giulio Garaffa, Nim Christopher, Suks Minhas, and Ralph David Tet YapTet Yap More articles by this author , Matus ChocolatyMatus Chocolaty More articles by this author , Raheem AmrRaheem Amr More articles by this author , Giulio GaraffaGiulio Garaffa More articles by this author , Nim ChristopherNim Christopher More articles by this author , Suks MinhasSuks Minhas More articles by this author , and Ralph DavidRalph David More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.184AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Buried penis in adult men is a rare, usually acquired condition in which the penis is partially or completely hidden below the surface of the prepubic skin and/or scrotum, although the corporeal length of penile shaft is normal. The aim of the study was to evaluate the presentation, treatment options and results of surgical treatment of buried penis in adults, a previously under reported entity. METHODS A total of 54 patients (mean age 55.6 ± 19.6 years) underwent surgery for buried penis between 2007 and 2013 were included in this retrospective study. The aetiology of buried penis was multifactorial, the most common factors were obesity (79.6 %) and/or previous treatment of penile cancer (16.6 %) or circumcision (31.5 %). The presentation of buried penis included voiding difficulties in 24(44.4%), sexual dysfunction in 16 (29.6 %), recurrent balanoposthitis or balanitis xerotica obliterans in 12 (22.2 %) and aesthetic concerns in 16 (29.6 %) patients. Surgical techniques included suprapubic fat pad excision, abdominoplasty, apronectomy, split/fullthickness skin graft, division of the suspensory ligament, scrotoplasty and excision of foreskin. RESULTS Mean hospital stay was 5.1 days (range 1 - 14). 46 patients (85.2 %) were satisfied with the results of the surgery. 4 patients (7.4 %) underwent further additional corrective surgery: in 2 patients the suspensory ligament division and scrotoplasty, in 1 patient scrotoplasty and in 1 patient repeated abdominoplasty. The following complications were recorded in 8 (14.8[S1] %) patients: wound infection in 4 (7.4%) patients, lost of skin graft in 2 (3.7%) patients, hematoma and deep venous thrombosis in 1 patient. CONCLUSIONS Surgical treatment of the buried penis in adults is a complex procedure with a high satisfactory rate. The overall morbidity of the procedure was low and less than 10% of patients required further surgery to achieve optimum results. However, the complexity of the procedures would mean that performing these in specialised centres is recommended. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e40 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tet Yap More articles by this author Matus Chocolaty More articles by this author Raheem Amr More articles by this author Giulio Garaffa More articles by this author Nim Christopher More articles by this author Suks Minhas More articles by this author Ralph David More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pannus Is the New Prepuce? Penile Cancer in a Buried Phallus.

Two males presented to our urology department with complaints of bleeding and malodor from buried phallus within a suprapubic fat pad. Although both men had neonatal circumcisions, advanced penile carcinoma was found in both men. Formal penectomies showed high grade, poorly differentiated squamous cell carcinoma invading the corporal bodies and urethra. Buried penis represents a difficulty in early detection of suspicious lesions but may also provide an environment susceptible to poor hygiene and subsequent chronic inflammation. Patients with buried penis may be at a higher risk for development of invasive penile cancer and may benefit from regular and thorough genital exams.

Modern Management of Adult-Acquired Buried Penis

To report our successful experience in managing acquired adult buried penis from nontraumatic origins. We describe a combination of modern techniques involving escutcheonectomy, scrotoplasty, split-thickness skin graft, and fibrin sealant application for genital reconstruction. From 2004 through 2007, 5 men with acquired adult buried penis underwent surgical repair at our medical center, by a single surgeon. A buried penis was a result of obesity in 4 of 5 patients, although other complicating factors, such as scrotal lymphedema, lichen sclerosis, and peripenile woody induration, were present in 3 of the 5 patients. All 5 patients required scrotoplasty and split-thickness skin grafts fastened with dilute fibrin glue to cover the penile skin defects. Excision of the excessive suprapubic fat pad (escutcheonectomy) was performed in the 4 obese patients. All patients achieved excellent cosmetic results, with successful and lasting unburying achieved in all cases. The operative difficulty, intraoperative blood loss, and length of hospital stay varied. No wound complications developed at the skin donor sites, and a rate of 80% to 100% graft take was observed on the penis at 2 months postoperatively. Abdominal wound complications were noted in 2 patients and resolved with daily dressing changes. Acquired adult buried penis is a correctable problem. The use of combined techniques, including surgical unburying, scrotoplasty, escutcheonectomy, and split-thickness skin grafts fixed with dilute fibrin glue, appears to be a useful approach to repair this unique condition.

Surgical Techniques: Surgery to Correct Hidden Penis

Many men suffering from erectile dysfunction are overweight with generous suprapubic fat pads, which often contribute to a decrease in visible exophytic phallic length.To present a novel surgical concept of suprapubic fat pad excision with a concomitant placement of inflatable penile prosthesis.A transverse incision begins slightly medial to the anterior superior iliac spine, with the superior edge crossing transversely to the contralateral anterior superior iliac spine. The inferior border is incised in a curvilinear fashion, with the medial apex being approximately 1 cm above the base of the penis. Dissection is carried down to the lower abdominal anterior fascia, which leads to excision of the suprapubic fat pad. Using this same exposure, the inflatable penile prosthesis (IPP) is placed via an infrapubic approach. The wound is reapproximated in multiple layers, and 2 drains are placed, 1 subcutaneous in the area of the fat pad excision and the other in the scrotum around the pump.Primary outcomes included penile implant functionality, ability to engage in sexual activity, and cosmetic satisfaction.A total of 8 patients have undergone suprapubic fat pad excision with simultaneous placement of IPP at our institution. Average body mass index of our patient cohort was 36.6. 1 patient developed prosthetic infection after inadvertent removal of his drains in the immediate postoperative period. At last follow-up, all other patients have excellent cosmetic and functional outcomes.This technique can lead to higher patient satisfaction with their penile implant, enhanced sexual performance, and improved quality of life for patients with concurrent erectile dysfunction and significant suprapubic fat pad.This unique technique has never been previously described. It allows placement of IPP in the setting of fat pad excision without any additional incisions. Limitations include the small patient population and relatively short follow-up.Suprapubic fat pad excision is a safe and reproducible technique that can be performed simultaneously with the placement of an IPP in appropriately selected patients. Patients must be counseled appropriately on the expectations of surgeries and the theoretical increased risk of postoperative complications, such as infection.Baumgarten AS, Beilan JA, Shah BB, et al. Suprapubic Fat Pad Excision with Simultaneous Placement of Inflatable Penile Prosthesis J Sex Med 2019;16:333–337.

INTRAOPERATIVE PHARMACOLOGICAL ERECTION AS AN AID TO PEDIATRIC HYPOSPADIAS REPAIR

The intraoperative evaluation of erection is a major advance in hypospadias surgery. We determined the advantages of erections induced pharmacologically over those induced by intracorporeal saline injection for evaluating chordee during hypospadias surgery. During the repair of hypospadias or chordee without hypospadias 56 boys 6 months to 13 years old underwent pharmacological erection induced by 14 microg. alprostadil administered intracavernously. Phenylephrine (40 microg. ) was given for detumescence. We monitored the adequacy of erection and detumescence, changes in blood pressure and pulse, and in 3 cases intracorporeal pressure. Intraoperative artificial erection was also induced in 30 patients. Erection occurred within 1 minute of injection. It was judged to be excellent in 47 cases and adequate in 6, while it failed in 3 probably due to injection outside of the corpora. Erection involved the whole penis, in contrast to artificial erection when tourniquet placement altered the erection and left the penile base flaccid. The degree of chordee remained stable during evaluation compared to artificial erection when curvature varied with the force of the saline injection. Erection persisted during chordee repair as long as the corpora were not opened. Detumescence occurred within seconds in all cases in which phenylephrine was given. There were no cases of priapism, and systemic blood pressure and pulse did not change. Intracorporeal pressure during pharmacological erection was 47 to 70 mm. Hg, whereas during artificial erection pressure was 50 to 250 mm. Hg depending on how much saline was injected and how rapidly fluid drained through the tourniquet. Chordee was induced by over injection. Pharmacological erection in hypospadias repair is effective and reliable with no significant complications. It is especially valuable in severe hypospadias and in patients with a large suprapubic fat pad. Artificial erection with saline injection should be performed with only moderate force since over filling is unphysiological and may falsely induce chordee.