Penis Reconstruction for Trapped Penis with Chordae and Subglanular

Hypospadia : A Case Report in Sanglah General Hospital Denpasar

Maria Yustina1, Wirya Kusuma Duarsa2

1 General Surgery Resident School of Medicine Udayana University, Sanglah General Hospital Denpasar,

Bali, Indonesia
2 Department of Urology School of Medicine Udayana University, Sanglah General Hospital Denpasar,

Bali, Indonesia

Abstract
Introduction: Reconstruction for trapped penis with histories of surgical repair failures
is very challenging. It involves steps of the surgery, the outcome, patient’s psychologic
aspect, parents’ satisfaction and complication of the surgery.
Case: A 10-year-old boy complained of concealed penis. The patient was born with his
penis base below the pubic bone and scrotal bifida, the urine came out from below the
gland of the penis when urinating. He underwent first surgical repair when he was one
year old, he got repair for scrotal bifida. He underwent second surgery to restore the
base of the penis anteriorly to pubic bone and circumcised when he was three years
old. Following the second surgery, the penis has been trapped in the scrotal skin. The
patient had to retract the scrotal skin when he urinates. We evaluated the penis, it was
about 4 centimeters length and trapped under the scrotal skin. The penis’ base was
below the pubic bone, unlikely normal penis. The orifice of the urethra was below the
gland. We reconstructed the penis in 3 steps. First, we degloved the corpora, we made
circular incision 1 cm under the gland, we undermined the skin and released the penis
from inelastic tunica dartos. Then we did urethroplasty. Third, we made rotational flap of
the skin to cover the penis and made an anchor at the pubic area. We maintained the
silicone catheter for 10 days and the penis bandage for 5 days. Post operative, the
penis is prominent and the orifice of urethra at the glan penis.
Conclusion: Reconstruction of trapped penis need a high skilled surgeon, good post
operative treatment and patient’s factor

Key words: trapped penis, reconstruction, outcome

INTRODUCTION

A trapped penis is an inconspicious phallus that can be result of a circumcision or sugery

of other pathology. This condition can lead to urinary infection, balanitis, skin adhessions,
misdirection of the urinary stream, and the inability to grasp the penis during urination.
This abnormality may have psychological effects on the child and his family. Parents are
usually worried about their child’s future. Early surgical reconstruction maybe beneficial
for the patient and his parents as well. The current technique accepted are release the
Darto’s fascia and fixate the penile skin to the Buck’s fascia, then restore the penopubic
and penoscrotal angles. However, the result of the reconstruction is vary.

MATERIAL AND METHOD

A-10 year old boy complained of concealed penis. The patient was born with his penis
base below the pubic bone and scrotal bifida, the urine came out from below the gland of
the penis. He underwent first surgical repair when he was one year old for scrotal bifida.
He underwent second surgery to move the base of the penis to anterior of pubic bone
and circumcised when he was three years old. Following the second surgery, the penis
has been trapped in the scrotal skin. The patient had to retract the scrotal skin when he
urinates. The patient had no history of balanitis and other urinary tract infection. During
examination the phallus totally trapped in the scrotal skin, the external urethral orifice was
below the glan and the base of the phallus was below the pubic bone. During surgery,
patient was under general anesthesia in supine position. We inserted silicone catheter
no.10, made circular incision one centimeter below the glan and release the corpora from
inelastic Dartos fascia and preserved the skin carefully. After degloving, the length of the
phallus within normal limit, four centimeters length. We did tubularized incised
urethroplasty. Then we made rotational flap using preputial and scrotal skin to cover the
penis. We made an anchor of the skin of penis base at the symphysis pubic area. We
maintained the silicone catheter for 10 days and the penis bandage for 5 days. Post
operative, the penis is prominent and the orifice of urethra at the glan penis. The cosmetic
and function was good. The patient and the parents satisfy with the result. In 2 months
follow up there was no recurrence.
DISCUSSION
A concealed penis is an inconspicuous phallus that can be categorized into three
subgroups, according to Maizels’ classification: buried penis, webbed penis, andtrapped
penis. A trapped penis is usually the result of thoughtless circumcision of a concealed
penis. Less frequently it can be the result of surgery for other pathologic features(2).
Surgical correction of the concealed penis is a difficult challenge. Many different
procedures have been described but the results have generally been disappointing(4).
Timing of the surgical repair of urogenital anomalies with a general or local anesthetic is
important with regard to feasibility of the surgery, safety of the surgery to the patient, and
the psychological impact of the anomaly and surgery. Penile surgery and repair of
concealed penis or scrotal conditions can be scheduled at a time that is appropriate for
the infant and convenient for parents and physicians, as these conditions or anomalies
do not generally cause any functional detriment to the patient, with the exception of
megaprepuce that may cause infections or voiding difficulties if not corrected. Technically,
from the surgeon’s point of view, outpatient surgical correction with a general anesthetic
may contemplated as early as the child’s fourth to sixth month, age adjusted for
prematurity. Psychological aspects of surgery create a relative upper age time limit. The
child’s anxiety concerning hospitalization, gender identity, separation from their parents
and guardians, and subsequent sexual development generally increase with age as the
child passes the age of 1 year. If genital surgery is performed before the child is 18 months
of age, the patient will generally not remember the surgery nor associate the experience
with any abnormality of his penis or scrotum. Therefore, optimal surgical timing for these
patients is from generally best between 6 and 18 months(3). The goal of the treatment is
to achieve good cosmetic appearance of the penis and restroring adequate sexual
function(5). Many different procedures have been described, include the release of penile
shaft adhesions, degloving the penis to Buck’s fascia, dissection of the root of the penis,
division of the suspensory ligament of the penis, preputial unfurling, anchoring of the skin
to the base of the penis or even to the symphysis pubis, open lipectomy, various “Z”-
platies and skin flaps(4). Common principles of all the surgical procedures are unfurling
of the prepuce and correction of the abnormal attachment of the skin and the dartos fascia
to the corpora and also preserve the penile skin carefully(3). Borsellino in his study, took
two-stages repair for trapped penis, in which a total deficiency of penile skin precludes
adequate coverage of the shaft. The shaft was completely denuded and buried under the
scrotal wall, along the raphe with the glans emerging from the bottom of the scrotal sac.
After 6 months, a rectangular incision on the anterior surface of the scrotum with a band
of skin on either side of the shaft, allowed easy reconstruction with a median suture(2).
According to Borcellino, recurrence developed in 2 of 20 patients (10%). The final
cosmetic result was judged to be good by the parents and older patients(2). Joseph made
transverse ventral incision at the penoscrotal junction and carried out an extensive
dissection at the base of the penis and along the penile shaft. He excised the inner
preputial skin without compromising skin cover and nor anchoring suture placed(4). Alter
reported a technique which placing ventral tacking sutures from tunica albuginea to the
subdermis of the penoscrotal junction to prevent retraction to the pubic space or
scrotum(1). While the authors used those technique, we made circular incision 1
centimeter below penile glan and degloved the corpora from inelastic Dartos fascia. It
was almost similar with the technique reported by Smeulders. In this patient, there was
also subglanular hypospadia, so we did tubular incised urethroplasty and made the
external opening of urethra at the glan. We made scrotal and preputial skin flap to cover
the penis and made an anchor of the base of the penis at the pubic. The penis length is
good, the skin covered the penis well cosmetically. Post operative the silicone catheter
was maintained for 10 days and the bandage was maintained for 5 days. The patient and
the parents were satisfy with the result. Within 2 months there is no recurrency.
CONCLUSION
This technique can be applied to get a good outcome for surgical reconstruction of
trapped penis. In addition, high skilled surgeon, good post operative treatment and
patient’s factor are also important factors.

REFERENCES

1. Alter GJ, Ehrlich RM. A New Technique for Correction of The Hidden Penis in
Children and Adults. The Journal of Urology 1999, Vol: 161, 455-459
2. Borsellino A, Spagnoll A, Vallasciani S et al. Surgical Approach to Concealed
Penis : Technique Refinements and Outcome. Pediatric Urology 2007, 69 (6),
1195-1198
3. Keane TE, Graham SD et al. Glenn’s Urologic Surgery. 8th edition 2016
4. Smuelders N, Wilcox DT. Point of technique The buried penis-an anatomical
approach. BJU International 2000; 86, 523-526
5. Tolba AM, Nasr M, Abohashem A et al. Management of Post Circumcision
Trapped Penis with Galnular Amputation. Surgical Science 2014, 5, 309-313

Contact:
dr. Maria Yustina
General Surgery Resident School of Medicine Udayana University, Sanglah General
Hospital Denpasar, Bali, Indonesia
+62 8125 11 99928
maria.yustina82@yahoo.com
Pulau Adi VIII no. 3 Denpasar, Bali 80113

Supervisor:
Dr. dr. Gede Wirya Duarsa, M. Kes, Sp.U(K)
Department of Urology Division of Medicine Udayana University, Sanglah General
Hospital Denpasar, Bali, Indonesia