Evaluation of Z-plasty versus Heineke-Mikulicz scrotoplasty in the management of penoscrotal web in pediatric age group.

BACKGROUND: The penoscrotal web may be congenital or acquired following excessive ventral skin removal during circumcision. Several surgical techniques were described for the treatment of congenital webbed penis without a clear comparison between their outcomes. This prospective study aimed at comparing the surgical results of Z-scrotoplasty and Heineke-Mikulicz scrotoplasty in the treatment of congenital webbed penis in uncircumcised pediatric patients. METHODS: Our study included 40 uncircumcised patients who were divided randomly into two groups; Group A included 20 patients who were treated by Z-scrotoplasty and Group B included the other 20 patients who were treated by Heineke-Mikulicz scrotoplasty. All patients were circumcised at the end of the procedure. RESULTS: The surgical outcome was good without a significant difference between the two groups in 36 patients. Recurrent webbing developed in one patient of Group A and in three patients of Group B (FE p = 0.605) The only significant difference between the two groups was the operative duration which was shorter in Group B than in Group A (P < 0.001*). CONCLUSIONS: Treatment of congenital penoscrotal web in the pediatric age group could be done with either Z-scrotoplasty or Heineke-Mikulicz scrotoplasty with satisfactory results, however, without significant difference in the surgical outcomes. TRIAL REGISTRATION: • Registration Number: ClinicalTrials.gov ID: NCT05817760. • Registration release date: April 5, 2023.

Surgical treatment and outcomes of acute and chronic ulcers on the penis following injection of foreign substances.

In this paper, we present our experience with acute and chronic penile ulcers resulting from injection of an exogenous substance and their surgical treatment.

[Clinical case of penile fracture].

A clinical case of a penile fracture as a result of an unsuccessful sexual intercourse, which later required surgical treatment in the form of corporoplasty with opening and draining of the hematoma, is discussed in the article. Penile fracture is a rare urological emergency that requires immediate medical attention to avoid long-term complications, including penile curvature and erectile dysfunction.

Subcoronal Incision for Inflatable Penile Prosthesis Does Not Risk Glans Necrosis.

PURPOSE: Glans vascular compromise had previously been considered a rare but devastating complication of the subcoronal incision for inflatable penile prosthesis surgery. Here, we describe the largest series of subcoronal implants to date to assess contemporary complication rates. MATERIALS AND METHODS: A retrospective review of subcoronal prosthesis placements by a single surgeon from Seoul, South Korea, was performed. Patients were randomly assigned either Coloplast Titan or AMS 700 device per institutional practice. RESULTS: A total of 898 patients who underwent subcoronal implants from May 2015 to March 2022 were analyzed. Median follow-up was 41 months (IQR 40). Preoperative patient comorbidities included diabetes (36.6%) and Peyronie's disease (4%). The most common complication was transient distal penile edema (74.7%). Transient incisional paresthesia (20.6%) was more common in patients with diabetes (31.9% vs 13.9%, P < .01). Five cases (0.5%) of distal penile skin necrosis were reported in patients who had previously been circumcised. Of these, 3 were managed successfully with wet-to-dry dressing, 1 required skin grafting, and 1 required device explant. Device infection without incisional compromise occurred in 2 cases (0.2%). There were no instances of glans necrosis or ischemia observed in this cohort. Of the first-time implants (817, 90.9%), most (62.3%) were successfully completed under local anesthetic alone, with the remainder of surgeries completed with the addition of adjunctive conscious sedation. CONCLUSIONS: Subcoronal incision for first-time or revision penile implant surgery is not a risk factor for glans ischemia or necrosis and can be safely completed under local anesthetic with or without conscious sedation.

Repair of penile prosthesis-induced impending erosion using xenograft during simultaneous inflatable penile prosthesis replacement.

BACKGROUND: Penile prosthesis (PP)-induced impending erosion is a rare complication that has not been well characterized. AIM: This study evaluates the role of prosthesis sizing and of the safety of xenograft windsock repair (AlloDerm, Tutoplast, ArthroFLEX) of impending erosion. METHODS: This was a retrospective review of xenograft use during inflatable penile prosthesis (IPP) replacement. Patient demographics, prior PP characteristics, and xenograft-augmented IPP characteristics were obtained. Paired-samples t tests were used to compare the PP cylinder size, rear tip extender size, and calculated PP length between the most recent prior PP and the xenograft-augmented IPP. Complications and follow-up data were obtained. OUTCOMES: The primary outcome was comparing the corporal body and device measurements between the PP presenting with impending erosion and the implanted xenograft-augmented IPP. The secondary outcome was evaluating the incidence of subsequent explantation. RESULTS: A total of 24 patients underwent xenograft repair with simultaneous IPP replacement from 2012 to 2022. The median number of prior PP was 1 (interquartile range, 1-2.75). The median time between the most recent prior PP and xenograft-augmented IPP placement was 21 (interquartile range, 14-79) months. The prior PP was significantly longer at the time of explantation compared with the measured corporal body length in both the left (21.4 cm vs 20.1 cm; P < .01) and right (21.4 cm vs 20.1 cm; P < .01) sides. However, there was no significant difference in length between the xenograft-augmented IPP length at the time of implantation and measured corporal body length in both the left (20.1 cm vs 20.0 cm; P = .67) and right (20.2 cm vs 20.1 cm; P = .56) sides. A total of 16 (66.7%) cases required bilateral xenograft corporal body use. Only 1 (4.2%) patient had an IPP infection requiring explantation within 90 days of xenograft-augmented IPP placement. A total of 2 (8.3%) patients had device malfunction and 1 (4.2%) patient had impending erosion recurrence requiring removal/replacement of their initial xenograft-augmented IPP in a median time of 56 months from placement. CLINICAL IMPLICATIONS: PP oversizing may increase risk of PP-induced impending erosion, which is a delayed process. STRENGTHS AND LIMITATIONS: This is the largest retrospective study of xenograft use during IPP replacement for impending erosion but does not have a control cohort. This study is limited by its retrospective nature, limited follow-up, and absence of a treatment comparison. CONCLUSION: PP-induced impending erosion may be due to PP oversizing but can be successfully repaired with xenograft windsock during simultaneous IPP replacement.

Improving clinical diagnostic accuracy and management of False penile fractures characterizing typical clinical presentation: a systematic review and meta-analysis.

PURPOSE: False penile fractures (FPF) represent a rare sexual emergency characterized by blunt trauma of penis in the absence of albuginea's injury, with or without lesion of dorsal penile vein. Their presentation is often indistinguishable from true penile fractures (TPF). This overlapping of clinical presentation, and lack of knowledge about FPF, can lead surgeons often to proceed directly to surgical exploration without further examinations. The aim of this study was to define a typical presentation of false penile fractures (FPF) emergency, identifying in absence of "snap" sound, slow detumescence, penile shaft ecchymosis, and penile deviation main clinical signs. METHODS: We performed a systematic review and meta-analysis based on Medline, Scopus and Cochrane following a protocol designed a priori, to define sensitivity of "snap" sound absence, slow detumescence and penile deviation. RESULTS: Based on the literature search of 93 articles, 15 were included (73 patients). All patients referred pain, most of them during coitus (n = 57; 78%). Detumescence occurred in 37/73 (51%), and all patients described detumescence occurrence as "slow". The results show that single anamnestic item have a high-moderate sensibility in the diagnosis of FPF, and the highest sensitive item was penile deviation (sensibility = 0.86). However, when more than one item is present, overall sensitivity increases greatly, closing to 100% (95% Confidence Interval 92-100). CONCLUSION: Surgeons can consciously decide between additional exams, a conservative approach, and rapid intervention using these indicators to detect FPF. Our findings identified symptoms with excellent specificity for FPF diagnosis, giving clinicians more useful tools for making decisions.

Concealed penis in pediatric age group: a comparison between three surgical techniques.

BACKGROUND: Comparison between three different surgical techniques in the management of concealed penis. METHODS: This prospective interventional non-randomized study included 150 pediatric patients with a concealed penis. They were distributed equally into three groups; group A; patients treated by anchoring the penile skin dermis to Buck's fascia at the penile base at 3 and 9 o'clock points using PDS 5/0 (phallopexy), group B; patients treated by complete dissection and excision of dartos fascia and group C; patients treated by phallopexy as in group A after complete dissection and excision of dartos fascia. Follow-up at the end of the 1st post-operative week and then monthly for 6 months as regards penile skin congestion and/or necrosis, wound infection, edema, and/or re-retraction was carried out. RESULTS: Penile edema and re-retraction have a statistically significant difference among the studied groups (p < 0.001 and p = 0.002 respectively). Penile re-retraction was noticed to be lowest in patients of group C, however penile edema was observed to be highest in patients of group B. CONCLUSIONS: Phallopexy after complete dissection and excision of dartos fascia have better results than doing either phallopexy or dartos excision alone in the treatment of concealed penis. CLINICAL TRIAL REGISTRATION: The manuscript was registered in ClinicalTrials.gov Protocol Registration and Results System. CLINICALTRIALS: gov Identifier: NCT05565040. Our manuscript was registered on 4/10/2022.

Smile Incision-Modified Technique for Better Scrotal Outcome in Surgical Management of Penile Paraffinoma.

INTRODUCTION: Penile augmentation with foreign material injection is used to increase penile length, girth, or both. Most of these individuals develop complications due to an abnormal mass formation known as penile paraffinoma. Multiple surgical techniques for restoring penile function and correcting near-normal penile shape have been developed, but prior techniques have some post-operative complications. METHODS: We explained the smile incision-modified technique for penile paraffinoma reconstruction using illustrations to describe step-by-step procedures. This study aimed to describe our modified surgical technique for reconstruction to correct complications due to disastrous consequences of failed penile augmentation. RESULTS: A total of 16 patients aged 28-66 years (mean: 44.25 ± 2.63) were operated with a smile incision-modified technique from January 2017 until December 2020 in Semarang Dr. Kariadi tertiary hospital. There were no intraoperative complications observed. We found hematoma in 3 patients in a 1-week follow-up. After 2 weeks of post-operative surgery, all patients had no skin dehiscence or necrosis. Cosmetic appearance and functional improvement after reconstruction were acceptable by all patients. CONCLUSION: Penile paraffinoma reconstruction using the smile incision-modified technique was a feasible and effective technique to manage penile paraffinoma patients with good esthetic results and minor complications.

Unaided visual assessment of ventral curvature during hypospadias repair is inferior to objective measurement using app goniometry.

OBJECTIVE: Failure to perform artificial erection or objectively assess ventral curvature (VC) during primary hypospadias repair is an important reason for residual/ recurrent chordee. The present study compares the accuracy of unaided visual inspection (UVI) with objective VC assessment using smartphone application (app) goniometry. METHODS: All patients who underwent primary hypospadias repair between January 2021 and September 2022 were included. Assistant surgeons were asked to grade the degree of VC on UVI (after degloving and an artificial erection test) into: none, mild (<30 degree), severe(>30 degree). Lateral profile photograph was taken and angle measurement was performed on an android mobile application (Angulus). Correlation was performed with both methods of assessment. RESULTS: During this period a total of 210 patients were analyzed; VC was noted in 40/138 (29%) cases of distal and in 62/72 (86%) cases of proximal hypospadias. Erroneous visual inspection was noted in 41/210 (20%; 95% CI 14-25%) on UVI (15 erroneously marked none while 26 marked mild). Among those found to have chordee, UVI assessed 39/82 (47%) as severe while app goniometry assessed 65/97 (67%) as severe. There was significant relative risk of labelling severe chordee as a mild one by UVI: 1.4 (95%CI 1-1.8; p=0.01). CONCLUSIONS: UVI was erroneous in 20% of cases. UVI was less accurate in differentiating severe chordee from mild one. In 60% patients UVI alone could have led to erroneous VC assessment and thus wrong selection of technique. Further studies are required to validate our findings and standardize VC measurement using an app goniometry.

A new treatment of concealed penis: symmetrical pterygoid flap surgery.

PURPOSE: Considerable controversy exists regarding the surgery for concealed penis. We describe a new technique for repairing concealed penis by symmetrical pterygoid flap surgery. METHODS: From January 2016 to July 2022, we evaluated 181 cases of concealed penis that were surgically treated using the symmetrical pterygoid flap surgery. We measured the penile size preoperative and 2, 4, 12 weeks, and 1 year postoperative to confirm the improvement. A questionnaire was administered to the patients and parents to assess satisfaction regarding penile size, morphology, and hygiene. RESULT: The perpendicular penile length was1.59±0.32cm preoperative and 3.82±1.02 cm after the procedure (p < 0.05), and 4.21±1.91cm after one year of postoperative (p < 0.05). The overall satisfaction of patients was 97.89%, while the overall satisfaction of older children patients (age>7) was 75.24%. Parents focus more on the penile exposure size, while patients focus more on the penile morphology. Almost every patient had postoperative penile foreskin edema. However, this symptom had spontaneously resolved by 4-6 weeks. The complications such as skin necrosis, tissue contracture, or wound infection were 4.42%. CONCLUSION: The symmetrical pterygoid flap surgery is an effective surgical technique for the management of concealed penis in children producing predictable results and excellent satisfaction of the parents and patients.

[A Case of Penile Calciphylaxis in a Hemodialysis Patient].

In the present case of a 56-year-old male, hemodialysis was introduced from December 20XX-2 due to chronic renal failure caused by diabetic nephropathy. In February 20XX, a glans penis ulcer was observed. It gradually expanded. Angiography conducted in April revealed complete occlusion of the left internal pudendal artery and poor visualization of the bilateral penile arteries. Given the high risk of obstruction, endovascular treatment was not conducted. The glans penis ulcer continued to expand, and maintenance dialysis became difficult due to intractable pain. Opioids were introduced, but the pain could not be controlled. In May 20XX, the patient was referred to our department for surgical treatment, and partial penile resection was performed. The patient was diagnosed with penile calciphylaxis based on clinical findings and pathological diagnosis. After the surgery, the pain subsided considerably, and the patient is being followed on an out-patient basis.

The Lived Experience of Patients with Adult Acquired Buried Penis.

PURPOSE: We describe the lived experience of adults with acquired buried penis (AABP) through thematic analysis of patient interviews. We examine the challenges that patients face and the impacts of surgery. MATERIALS AND METHODS: This mixed-methods study utilized validated instruments and semi-structured interviews to capture pre- and postsurgical outcomes. Semi-structured interviews were conducted with open-ended questions to elicit the impact of AABP on a patient's quality of life in several domains including urinary function, sexual function, interpersonal relationships and mental health. Recruitment was completed once we achieved thematic saturation. RESULTS: Twenty patients participated in the study; 11 underwent surgical treatment for AABP. Semi-structured interviewee responses were coded into 12 different themes and 39 subthemes. The most common themes were problems with urinary (19/20, 95%) and sexual function (19/20, 95%). Most participants (16/20, 80%) reported negative impacts of AABP on social life. Interviewees struggled with relationships (8/20, 40%) and mental health (11/20, 55%), often avoiding romantic relationships and reporting fear of rejection with concomitant depression and/or anxiety. The majority (70%, 14/20) experienced difficulties accessing care. Among patients who underwent surgery, the majority discussed improvement in urinary and sexual function (82% [9/11] and 73% [8/11], respectively). Though weight gain was a precipitating factor, weight loss did not result in symptom improvement. Rather, in 4/20 (20%), weight loss made their condition worse. CONCLUSIONS: Patients living with AABP experience profound negative impacts on quality of life including their urinary and sexual function, social life and mental health. Many patients face issues with access to care.

Aesthetic Penile Augmentation Procedures: A Comprehensive and Current Perspective.

PURPOSE OF REVIEW: Some men experience small penis syndrome (SPS), a body dysmorphic disorder in which a patient believes their penis to be small even when it is clinically average. As cosmetic surgery becomes more widely accepted, management of SPS may present a challenge for urologists. We aim to provide an updated review of aesthetic penile augmentation procedures. RECENT FINDINGS: Augmentation procedures range from invasive to noninvasive. Surgical solutions include grafts and flaps, suspensory ligament release, and suprapubic lipectomy. Minimally invasive solutions include injections of fillers (hyaluronic acid, polylactic acid, and polymethyl methacrylate). Noninvasive solutions include external devices such as vacuum pumps and traction devices. In the current climate, aesthetic penile augmentation is becoming a desirable option for many patients but remains clinically controversial. Our review summarizes recent and relevant studies and demonstrates the need for further research and consensus on penile augmentation procedures.

Milroy disease with predominant preputial involvement.

Milroy disease is a form of congenital primary lymphedema that usually affects the lower limbs. Predominant genital lymphedema in Milroy disease is uncommon and disabling. When conservative management is ineffective, surgical treatment becomes necessary. Here, we present a rare case of congenital primary penile lymphedema in a 4-year-old child.

Significance and Surgical Options for Nontranssexual Phalloplasty: A Retrospective Single-Center Analysis of 166 Patients.

OBJECTIVE: This study aimed to evaluate the long-term outcomes of phalloplasty and explore the clinical significance and selection of methods for penile reconstruction. METHODS: The same surgical team performed primary phalloplasty in 166 nontranssexual patients using different surgical approaches between September 2000 and September 2020. All patients had at least 6 months of follow-up. Surgical techniques, complications, and outcomes were retrospectively recorded. RESULTS: A total of 166 patients with indications such as penile trauma (n = 68 [41%]), amputation injury (n = 15 [9%]), iatrogenic (n = 13 [8%]), penile aplasia (n = 54 [32%]), genital ambiguity (n = 15 [9%]), and Peyronie disease (n = 1 [0.6%]) underwent different techniques of phalloplasty. Four patients (2.4%) had total flap necrosis, and 17 (10%) had partial flap necrosis. The total urethral complications rate was 32.5% (54 of 166); however, all the patients were able to void while standing after successful corrective surgery. CONCLUSIONS: Individualized selection of appropriate penile reconstruction methods tailored to the cause of penile defect, patients' personal needs, thickness of donor site, and the blood supply of the flap are conducive to achieving satisfactory treatment results, reducing complications, and improving patient satisfaction. We believe that a scapular flap has certain advantages in nontranssexual patients, whereas other flaps also have their own indications.

Penile Ultrasound: An Essential Tool in an Emergency Setting (Traumatic and Non-Traumatic Diseases).

Penile conditions requiring urgent care are uncommon and result from trauma and a variety of non-traumatic causes. Some cases could rapidly evolve into an emergency situation and require prompt treatment to prevent severe complications. Therefore, correct and rapid diagnosis is fundamental. Although clinical history and physical examination are essential, diagnostic imaging is usually required to confirm the clinical diagnosis. In this setting, the sonologist in the emergency department has to be familiar with the basic US penile anatomy and with the most common US findings in urgent penile care. US is the key imaging method because it is readily available, safe, cost-effective, and well-tolerated by the patient. US can differentiate intracavernosal from extracavernosal hematomas and detect rupture of the tunica albuginea, consistent with penile fracture, that requires early surgical exploration. Color Doppler evaluation and spectral analysis are necessary to depict vascular abnormalities.

The Management of Penile Fracture: a Review of the Literature with Special Consideration for Patients Undergoing Collagenase Clostridium Histolyticum Injection Therapy.

PURPOSE OF REVIEW: To review the current literature on acute management of traumatic penile fracture, with a specific discussion of those injuries following collagenase clostridium histolyticum (CCH) injections for the treatment of Peyronie's disease. RECENT FINDINGS: The immediate repair of traumatic penile fracture injury is associated with significantly better prognosis for long-term sexual health. Corporal disruption following CCH administration has several distinct features, and the trend is to manage these patients conservatively in the absence of urethral injury. Traumatic penile fracture repair continues to have excellent results when performed immediately following injury. The post-CCH treatment setting portends increased difficulty during surgical management and can be successfully managed in most cases by conservative measures.

Surgical results in penile fracture: Our single center experience.

INTRODUCTION: Penile fracture arises as a result of a unilateral or bilateral rupture of the tunica albuginea of the corpus cavernosum. It is a rare condition that requires urgent surgical intervention. In this study, we aimed to determine the effectiveness of surgical treatment in penile fracture and its effect on complications. METHODS: The data of 21 patients who were admitted to the emergency department of our clinic between 2012 and 2019 and underwent emergency surgical repair with the diagnosis of penile fracture were collected retrospectively. The diagnosis of penile fracture was established by anamnesis and physical examination. Age, etiology, duration from trauma to surgery, physical examination findings,length and localization of the tunica albuginea defect, length of hospital stay, and postoperative first-, third- and sixth-month follow-up results were analyzed. Erectile function was evaluated using the International Index of Erectile Function (IIEF-5). Complications such as penile curvature, penile nodule and painful erection were evaluated. RESULTS: The mean age of the patients was 36.8 ± 8.3 years. The most common reason of penile fracture was manually bending the penis for detumescence. All patients underwent surgery. The mean duration from trauma to surgery was 7.6 ± 3.1 h. The mean length of the tunica albuginea defect was 11 ± 2.5 mm. The mean length of hospital stay was 2.5 ± 0.5 days. The mean IIEF-5 scores in the postoperative first, third and sixth months were 20.5 ± 2.6, 22 ± 2.2, 22.1 ± 1.7, respectively. CONCLUSION: Penile fracture is a urological emergency, and timely surgery is an effective treatment method for preventing postoperative complications.

Increase apparent penile length by cryolipolysis in the reduction of male suprapubic fat.

The buried or hidden penis in adults is troublesome in males, whereas the length of the penile shaft is buried under the skin surface of the suprapubic fat to a degree that reveals the concept of a little penis. We aimed to assess a new modality of treatment to increase the apparent penile length by using the cryolipolysis in the reduction of male suprapubic fat as a noninvasive procedure. This prospective study was performed on 46 male patients complaining of buried short apparent small size penis. All patients were subjected to full medical history, body mass index and examination of penile (length, size and abnormalities). The measures of the apparent penile length from the skin to the tip of the glans penis and suprapubic skin fold thickness using (adipometer) were recorded before the three consecutive suprapubic cryolipolysis sessions. The mean apparent stretched penile length at session 1, 2 and 3 were 12.1 ± 0.5 cm, 12.66 ± 0.48 and 12.88 ± 0.72, respectively, with a statistically significant increase between three sessions (p < .001), whereas the mean skin fold suprapubic fat at session 1, 2 and 3 was 2.99 ± 0.49 cm, 2.37 ± 0.48 and 2 ± 0.37, respectively, with a statistically significant decrease (p < .001). The cryolipolysis of suprapubic fat is a safe, effective, noninvasive and applicable procedure that successfully decreases the suprapubic fat in males and increases the apparent length of the buried penises.

Uncovering the Hidden Penis: A Nomenclature and Classification System.

INTRODUCTION: A hidden penis can interfere with normal hygiene, prevent effective voiding, restrict sexual activity, and cause great embarrassment to the patient. The terms "hidden," "buried," and "trapped" penis are used interchangeably. To date, there is no classification system that adequately characterizes the spectrum of this condition. In this study, we propose a simplified nomenclature and classification system for adult-acquired hidden penis. METHODS: We performed a retrospective review of all adult patients treated surgically for hidden penis by the senior author from 2009 to 2019. Patients were classified into either "buried" or "trapped" categories. A "buried" penis was defined as a hidden penis concealed by suprapubic fat without fibrous tethering. These patients were managed with panniculectomy, monsplasty, or both. In contrast, those with a "trapped" penis presented with scarred or fibrous tissue, which required surgical lysis, phalloplasty, and penile skin resurfacing. RESULTS: Thirteen patients met the inclusion criteria. The cohort was aged 53 ± 15.7 years with a mean body mass index of 37.4 ± 4.3 kg/m2. Two patients required repeat operations, yielding a total of 15 operative encounters. Six were defined as buried, and 9 as trapped. Inability to achieve erection was the most common preoperative complaint in those with buried penis (67%), whereas difficulties in voiding were most common with trapped penis (78%). Patients with trapped penises had a significantly larger body habitus than those with a buried penis (39.8 vs 34.2 kg/m2, P = 0.0088). Operative duration and length of hospital stay were comparable between the trapped and buried penis groups (206 vs 161 minutes, P = 0.3664) (5 vs 1 day, P = 0.0836). One third experienced wound complications, but this was not significantly different between buried and trapped penises (17% vs 44%, P = 0.5804). Postoperatively, 5 patients experienced spontaneous erections, and 7 were able to void while standing. CONCLUSIONS: Patients with a trapped penis present with a different preoperative symptom profile and body type than those with a buried penis. Our nomenclature and classification system offer a simple and clear algorithm for the management of hidden penis. Large cohort studies are warranted to assess differences in clinical outcomes between trapped and buried penises.