Surgery Spotlight: Buried Penis-Surgery Spotlight: Buried Penis

Surgery Spotlight: Buried Penis

Video Transcription

Hello, I'm Bill Kuzan from the University of Michigan, and today we're going to go to the operating room and do a reconstruction for a gentleman with a diagnosis of hidden  penis or buried penis that is actually a spectrum of causes for ending up with a similar anatomy  This particular gentleman had a phimosis, had a circumcision elsewhere about three years ago and ended up with a very tight scar band and a completely submerged penile shaft  This is a 53-year-old gentleman who had phimosis, underwent a circumcision at another institution  about three years ago and developed this recurrent cicatrix that causes significant difficulties  with urination hygiene and with sexual functioning. These operations are obviously individualized  for each patient and their specific deformity, but our general approach has been to deglove the penile shaft, retrieve the corpora and in combination with a suprapubic lipectomy  anchor the corpora in a projected position with deep dermal sutures right to the corpus cavernosum and then that often requires skin grafting of the penile shaft because there's  not enough skin. So, first step of the operation is to expose and deglove the penile shaft  The skin of the distal penile shaft and the transition to the glands is scarred and atrophic  and if we were to try to just release that, it would certainly recur, so Dr. Ohl is now marking  the planned resection of skin, trying to save what's normal. So you can see the area of skin to be resected is from the good skin at the base of the penis up to the coronal sulcus.  Obviously on the dorsal aspect of the penis is the neurovascular bundle and on the ventral aspect is the spongiosum with the urethra.  So we'll probably be a somewhat delicate dissection to avoid injuring those structures. So they're elevating at the level of Buck's fascia.  Obviously don't want to get into the corpora, don't want to get into the neurovascular bundle. When it's scarred like this it's a little more difficult.  So the tissue deep to the skin actually looks relatively normal. So that's good.  The scar's been released and the corpora have been freed and retrieved. What we'd like to do is anchor the corpora with sutures to the dermis like this.  We have found over time that it's very beneficial to combine this procedure with a small suprapubic lipectomy that eliminates this big bulge and helps with penile projection.  He's got a previous scar here is where we're going to start, start in the midline. The limit of this for the most part is the pannus crease and I think one important point  is it's very important to keep this resection oriented completely vertically so that the incision is vertically.  If you make a transverse incision anywhere in this suprapubic area you run the risk of setting off a cycle of significant scrotal edema.  There's not a whole lot very scientific about this. We pinch this, we figure about how much we can get out. Do you have a ruler?  And obviously we want it to be symmetrical. That's probably a little generous. That would be a little difficult to close. Let's try about three and a half.  That will obviously easily close. So this is to both, this little resection is both to help, I'm actually going to be  a little more aggressive than that, is to both help with penile projection and as you'll see in a minute, provide access for Dr. Ohl to get the rest of the penile shaft degloved  and access to the corpora so that we can provide maximal corporal projection. So scalpel for Dr. Kelly please. Again learn from experience.  Do not make transverse incisions in this area in patients with this degree of obesity and with this problem of penile projection already.  This scrotal edema is unpredictable but when it happens it's very difficult to manage. So they're going to finish retrieving the corporal shaft.  Obviously we've saved some of the penile skin tube here that we can use. This scar at the base is not ideal but we may divide a little bit of that. We'll see what we end up with.  So it's finished completely freeing the corporal shaft. Generally do not need to or I don't know if it's advisable to release the suspensory ligament.  Maybe in extreme cases but in general I don't think that that's a useful maneuver. I think it produces a weird deformity with the way the phallus comes off. I'm going to forceps.  Okay. So then let's see. That'll be much better. That'll be much better. We've been generally very satisfied with the outcomes of these procedures.  We've retrieved the penile shaft from a buried position.  We've greatly improved the patient's hygiene and allowed them to have some capacity for sexual functioning.  The penile edema that is seen postoperatively can sometimes be problematic. It resolves over time but it can take some period of time.  Other complications that are common are the everyday things, minor wound healing issues, and those are usually resolved with local wound care.  So now the next step of the procedure you'll see Dr. Ohl will choose a point on the dermis  anchored directly to the corpora cavernosum and that maintains the penis in a projected position. Prevents the corpora from retracting proximally.  Sometimes this deformity involves a lot of scrotal edema or scrotal obesity and requires the vertical excision to extend right into the scrotum.  And often there's no residual penile shaft skin at all. The entire thing gets skin grafted. This is actually a little atypical today.  So we're going to take a dermal stitch, anchor it directly to corpus cavernosum, which has to be obviously done on the lateral aspects of the circumference  so you don't get into the dorsal neurovascular bundle or into the urethra.  Just making a little window on the dermis there.  So you can see now dermis is anchored to corpora there, dermis is anchored to corpora there.  We have some residual skin tube for the base of the penis, which is actually very helpful when you have to run the graft right down to the base, you get that difficult healing.  And then we'll skin graft all this. So now let's close this vertical incision.  I don't think there's any reason not to put a drain in this, so let's put a short blake. And then the only, I think a ratus or debakes or something.  The only thing about closing this is we're going to close scarpas to scarpas and then take a bite deep on the fascia. So we're going to do that, right, up as far as we can.  So we'll take some more threomycopops.  Threomycopops for deepness. And then threomonococcus.  So now we're going to harvest a piece of skin to resurface the penile shaft. As I mentioned earlier, this is a large volume, or a large surface area,  so it's going to be a large volume. As I mentioned earlier, this is a large volume, or a large surface area, so it's approximately a 10 by 10 centimeter piece of skin that we need.  We harvest it moderately thick, with a 14th or 15 thousandths of an inch thick with as little as possible secondary contraction.  We want to put the seam, obviously, on the ventral surface. Bite of that, bite of the...  Great. Okay, so let me stand there. So...  There you go.  So about there. Okay.  Another one to hold it.  Now go distally.  Postoperatively, the patients are placed into a  bolster dressing. We use a Reston bolster  attached both at the base and at the glans penis, and that stays in place for a full week while the skin graft matures.  During that time we maintain a urinary catheter.  After a week, usually as an outpatient in the clinic, we take down the bolster and then simple protective nonstick dressings for a while until the skin graft matures.  He'll stay in the hospital for the next couple of days to make sure that he's okay pain-wise and he's  emotionally compensated, and then  assuming both of those things are true, then we'll let him go home where you just have to take care of the catheter  and keep this clean.

Video Summary

The video discusses a surgical procedure for a patient with a buried penis due to a previous circumcision that resulted in a tight scar. The 53-year-old patient experiences difficulties with urination, hygiene, and sexual function. The surgery aims to expose and deglove the penile shaft, retrieve and anchor the corpora to prevent retraction, and skin graft the shaft. A suprapubic lipectomy helps with penile projection. Surgeons take great care to preserve sensitive anatomical structures during dissection. A vertical incision minimizes scrotal edema. Postoperative care involves a bolster dressing, a urinary catheter, and hospitalization to manage pain and ensure recovery. The procedure improves the patient’s functionality and hygiene significantly.

Asset Caption

In this video, William Kuzon, MD, demonstrates an approach for treating a condition known as “Buried” or “Hidden Penis.” In this instance, a 53-year-old patient had previously had difficulty with phimosis, had undergone a circumcision at a different institution and subsequently developed recurrent cicatrix difficulties with urination, hygiene and sexual function. Dr. Kuzon notes that while each patient’s treatment is personalized depending on the extent of the deformity, his general approach, demonstrated in this video, is to deglove the penile shaft, retrieve the corpora, and in combination with a superpubic lipectomy, anchor the corpora in a projected position with deep dermal sutures to the corpus cavernosum. This often requires skin grafting to the penile shaft.

Surgeon William Kuzon, MD

Disclosure Dr. Kuzon has nothing to disclose. This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Reconstructive

Microsurgery

William Kuzon MD; Memben

buried penis surgery

suprapubic lipectomy

skin graft

postoperative care

urination difficulty