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New Surgical Technique for the Treatment of Buried Penis: Results and
Comparison with a Traditional Technique in 75 Patients

Article  in  Urologia Internationalis · July 2013

DOI: 10.1159/000351944 · Source: PubMed

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 Surgical Technique
Urologia Urol Int 2013;91:134–139
Internationalis DOI: 10.1159/000351944
New Surgical Technique for the Treatment
of Buried Penis: Results and Comparison with
a Traditional Technique in 75 Patients
Anne-Françoise Spinoit Stefanie De Prycker Luitzen-Albert Groen
Erik van Laecke Piet Hoebeke
Department of Urology, Ghent University Hospital, Ghent, Belgium
Key Words
Buried penis · Urogenital anomalies · Reconstructive
surgery of the penis
Abstract
Introduction: Buried penis is a pathology for which several
reconstructive techniques are described. We report our
technique and its outcome. Patients and Methods: 75 pa-
tients underwent repair of buried penis by one surgeon (P.H.)
between 1997 and 2011. The first 17 patients (mean age 2.6
years) underwent skin-sparing circumcision. The next 58 pa-
tients (47 children, mean age 4.4 years; 11 adults, mean age
38 years) underwent our new technique. Its key point con-
sists in releasing dartos tissue and in anchoring the corpora
cavernosa to dartos bundles at the penile base. Outcome was
evaluated by reoperation rate, complications and satisfac-
tion according to surgeon/patients/parents. Results: The re-
sults of skin-sparing circumcision performed in 17 children at
1 year were reported as good by the surgeon in 62.5% (n =
10) and in 82.4% (n = 14) by patients. Reoperation for recur-
rence occurred in 29.4% (n = 5) patients. Complications treat-
ed conservatively were reported in 35.3% (n = 6) of the chil-
dren. The new technique was performed in 58 patients (47
children, 11 adults). The results were reported as good by the
surgeon in 96.6% (n = 56) and in 91.4% (n = 53) by patients.
© 2013 S. Karger AG, Basel
0042–1138/13/0912–0134$38.00/0
E-Mail karger@karger.com
www.karger.com/uin
Received: February 19, 2013
Accepted after revision: April 23, 2013
Published online: July 4, 2013
Reoperation occurred in 4 patients (6.9%). Conclusions: The
outcome of the new technique is superior to skin-sparing cir-
cumcision regarding complication/reoperation rate and cos-
mesis according to patients/parents/surgeon.
© 2013 S. Karger AG, Basel
Introduction
Buried penis is a poorly known pathology that affects
children as well as adults. It can be congenital or acquired.
In children it is mostly a congenital condition where the
penile shaft appears entrapped in the subcutaneous fatty
tissues [1]. The penis is normally developed but seems
completely or partially hidden by preputial skin. It has to
be distinguished from webbed penis, trapped penis and
micropenis [2]. Webbed penis is a condition in which the
scrotal skin extends onto de ventral side of the penile
shaft. Trapped penis is acquired after circumcision: the
penis becomes entrapped in the suprapubic fatty tissue by
a circumferential scar at the level of the circumcision. Mi-
cropenis is a normally built penis that is at least 2.5 SD
below the mean size [3]. The condition of buried or con-
cealed penis in children seems to be related to a lack of
elasticity of the dartos tissue, as can also be observed in
hypospadias. The normal dartos tissue allows penile skin
193.191.170.2 - 7/31/2014 3:14:55 PM
Dr. Anne-Françoise Spinoit
Biomedische Bibliotheek
Ghent University Hospital
De Pintelaan 185
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BE–9000 Ghent (Belgium)
E-Mail afspinoit @ hotmail.com
 1 2
Incision
line
Fig. 1. Circumcision incision prolonged
ventrally.
Fig. 2. Penile deglovement until the penis is
freed to its base.
to slide freely on the deeper layers and allows the penis to
stretch easily in erection. In buried penis, this tissue lacks
elasticity and retracts the penis into the depths, since the
penile skin is not anchored to the deep fascia of Buck [3].
In adults, the condition of buried penis is mostly acquired
due to a loss of elasticity of the dartos tissues with age and
to a progressive accumulation of suprapubic fat.
The condition of buried penis can be symptomatic
both in children and adults. Cosmetics are the most fre-
quent motive of complaint. Recurring balanitis or void-
ing difficulties, urine spraying and dribbling can be asso-
ciated with this condition [4, 5]. In infants, parents often
report ballooning of phimotic penis if uncircumcised,
and paediatricians who are unfamiliar with this condition
often call it micropenis. On clinical evaluation in adults
as well as in children, the penis appears to have a normal
length when applying pressure on both sides of the penile
shaft base.
Several techniques to correct penile concealment have
been described in small series [1, 4, 6–18]. We describe a
new technique and compare the results of this new tech-
nique with a classical approach we used for several years.
Patients and Methods
Patients
75 patients underwent surgical repair of buried penis between
1997 and 2011 in the hands of one single surgeon (P.H.). The first
17 patients (mean age 2.6 years) underwent a classical repair con-
sisting of skin-sparing circumcision, until 2003. The surgical ap-
proach was changed in 2004 and the next 58 patients underwent a
new surgical technique in which anchoring of the penis to dartos
bundles at the penoscrotal angle is the key point (47 children, mean
age 4.4 years; 11 adults, mean age 38 years).
Methods
The outcome of both techniques was evaluated by patients’/
parents’ satisfaction with surgery, by the surgeon’s satisfaction
New Surgical Technique for the
Treatment of Buried Penis
Color version available online
Color version available online
Skin and
dartos layer
with surgery and by complication rate/need for redo surgery. The
first subjective evaluation criterion was the satisfaction of patients/
parents at the first postoperative consultation 6 weeks after surgery
and at the last follow-up 1 year after surgery. The second subjective
evaluation criterion was the surgeon’s satisfaction with surgery re-
sults at 6 weeks and 1 year. Good outcome according to patients/
parents was defined by satisfactory aesthetical appearance and
meeting of expectations. Good outcome according to the surgeon
was defined by healing without complication and if the expected
outcome of the operation was reached. Bad outcome was reported
if the above-mentioned criteria were not met and/or buried penis
reoccurred.
The outcome of both procedures was also objectively assessed
by complication rate and need for reoperation. Reoperation rate,
type of reoperation, results of the reoperation and time between
initial procedure and reoperation were also reported. Statistical
analysis was performed using Fisher’s exact test comparing two
groups. The local ethics committee approved this retrospective
study.
Surgical Technique
The initial technique used consisted of a skin-sparing circumci-
sion as described by Boemers and De Jong [8]. The new surgical
technique developed and used is done as follows: The patient un-
der general anaesthesia is placed in the supine position and pro-
phylactic antibiotics are given. The operative field is disinfected, a
polypropylene traction suture is placed in the glans, and a bladder
catheter is inserted. A circumcision incision is performed, further
extending longitudinally on the ventral side of the penile shaft
from the circumcision incision to the cranial part of the scrotum
(fig. 1). Careful deglovement of the penis is done with release of all
tethering fibrotic dartos tissue bands, until the penis is freed to its
base (fig. 2, 3). A dartos tissue flap is taken dorsally, as classically
described in hypospadias surgery (fig. 4, 5) [19]. This flap is split
into two equal parts and brought ventrally (fig. 6). The base of the
stretched penis is anchored bilaterally at the level of the corpus
cavernosum with the ventrally brought dartos flap with one gly-
colic copolymer suture, which is also used for haemostasis of this
dartos bundle (fig.  7). The excessive dartos tissue is removed
(fig. 8). Careful haemostasis is done before closing the skin. Exces-
sive skin is removed and the penile skin is sutured to the subcoro-
nal mucosa. A circumcision is often needed due to the lack of skin
with a stretched penis (fig. 9, 10).
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Urol Int 2013;91:134–139 135
Biomedische Bibliotheek
DOI: 10.1159/000351944
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 Color version available online

Color version available online

Skin
Dartos

Color version available online

Fig. 4. Dartos flap taken dorsally. Fig. 5. Development of dartos flap.

Color version available online

Color version available online

Dartos

Fig. 3. Release of all tethering fibrotic dar- Fig. 6. Dartos flap split dorsally. Fig. 8. Removal of excessive dartos tissue.
tos tissue.
Color version available online

Fig. 7. The base of the stretched penis is

anchored bilaterally at the level of the cor-
pus cavernosum with the ventrally brought
dartos flap.
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136 Urol Int 2013;91:134–139 Spinoit/De Prycker/Groen/van Laecke/

Biomedische Bibliotheek

DOI: 10.1159/000351944 Hoebeke

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 9 10

Color version available online

Color version available online

Fig. 9. Removal of excessive skin.
Fig. 10. Circumcision is often needed due
to skin shortage.

Table 1. Evaluation 1 year after surgery according to the surgeon Results

(p = 0.000267)
Classical Repair
Good Bad Total
Skin-sparing circumcision, further called classical re-
Skin-sparing circumcision 10 7 17 pair, was done in 17 children between 1997 and 2003.
New technique 56 2 58 Results 6 weeks after surgery were reported as good ac-
cording to the surgeon in 16 of the cases (94.1%). Bad
outcome according to the surgeon at 6 weeks was report-
Table 2. Evaluation 1 year after surgery according to patients/par- ed in 1 case (5.9%). Results 1 year after surgery were re-
ents (p = 0.37) ported as good by the surgeon in 62.5% (n = 10) and in
82.4% (n = 14) by patients/parents. Bad outcome 1 year
Good Bad Total after surgery was reported by the surgeon in 37.5% (n =
7) (table 1) and by patients/parents in 17.6% (n = 3) (ta-
Skin-sparing circumcision 14 3 17
New technique 53 5 58 ble 2). Reoperation was performed in 29.4% (n = 5) of
patients for recurrent buried penis (table 3). Complica-
tions needing no further intervention (haematoma, in-
fection, oedema, hypertrophic scar) were reported in
Table 3. Report of patients who underwent reoperation (p = 0.02) 35.3% (n = 6) of the children.
Yes No Total New Technique
Skin-sparing circumcision 5 12 17 The new technique was performed in 58 patients (47
New technique 4 54 58 children, 11 adults). The results were reported as good by
the surgeon at 6 weeks in 98.3% (n = 57) and as bad in
1.7% (n = 1). The same outcome was reported by patients/
parents at 6 weeks. The results at 1 year were reported as
Table 4. Report of results 1 year after surgery, according to pa-
tients/parents, considering the need for reoperation as a bad out-
good by the surgeon in 96.6% (n = 56) (table 1) and in
come (p = 0.041) 91.4% (n = 53) by patients/parents (table 2). Reoperation
was performed in 4 patients (6.9%) for recurrent buried
Good Bad Total penis in 2 cases, for fistula in 1 case, and an additional
aesthetical procedure in 1 case (table 3). The fistula was
Skin-sparing circumcision 14→12 3→5 17 observed in an adult who had been initially operated for
New technique 53 5 58
mid-shaft hypospadias in childhood. If we consider the
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New Surgical Technique for the Urol Int 2013;91:134–139 137

Biomedische Bibliotheek

Treatment of Buried Penis DOI: 10.1159/000351944

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need for reoperation as a bad outcome, then statistical
significance is reached (table 4).
All patients who underwent a second surgery were sat-
isfied with the results. Pathology reports are only avail-
able in 8/75 patients and therefore the results are not giv-
en.
Discussion
Many surgical techniques in small series report satis-
factory results in buried penis repair [4, 7, 9–11, 13, 14,
16–18, 20]. None of those previously described tech-
niques has reached the status of gold standard, highlight-
ing the fact that none of them is quite satisfactory enough
to spread it. As long as we do not understand the em-
bryological origin and the pathological development of
buried penis, our efforts in repairing this anomaly are
more or less successful, depending on the applied tech-
nique. The published techniques are based on a few prin-
ciples: redistribution of the abnormal preputial skin [8,
10, 11, 13, 20], division of the deep fascia anchoring the
penis in the depths [18], release of the dartos tethering
cords [4, 5, 11, 18], and eventually anchoring of the pe-
nile skin at the penoscrotal junction to the deep fascia
[18]. Some authors describe a skin release technique as-
sociated with pubis liposuction [15]. Our technique is
based on the idea that buried penis is caused by a lack of
elasticity of the dartos tissue, and eventually by abnormal
adherences between dartos and Buck’s fascia [3]. The re-
lease of all tethering cords of dartos, essential in our tech-
nique, allows the penis to regain its elasticity. The key
point of our technique, being the anchoring of the
stretched penis at its base to the released dartos tissue,
avoids any further retraction after release. Further re-
search is needed to prove that buried penis is based on
abnormal dartos tissue.
Our series, although small, shows obviously good re-
sults according to parents/patient and according to sur-
geon. If we consider that parents asking for reoperation
judged the outcome as bad, we even reach statistical sig-
nificance in favour of our technique. The small number
of patients in our control series – the skin-sparing cir-
cumcision series – can be explained by the fact that we
spontaneously stopped performing that technique as we
considered the results insufficient, which can be consid-
ered a bias in the surgeon’s judgement of outcomes.
A weakness of our study is the lack of penile measure-
ments. Our study being retrospective, the data could not
be retrieved from the files as penile measurement is not
138 Urol Int 2013;91:134–139
DOI: 10.1159/000351944
common practice. To overcome this flaw, a prospective
study is actually started on our new technique alone, sys-
tematically measuring penile length and with systematic
pathology of the resected dartos tissue.
The lack of pathology reports in most studies and also
in this study could be interpreted as a sign of ‘normality’.
In classical circumcision, the prepuce is only sent to the
pathology lab when obvious macroscopic lesions are ob-
served.
Some authors consider surgical correction of buried
penis in infancy useless. They believe that with puberty
and the raise in testosterone, the prepubic fat will de-
crease, which combined with penile growth will resolve
the problem [15]. However, Lardellier-Reynaud et al., in
their series, showed that testosterone is no solution, since
some of the children in their series preoperatively re-
ceived testosterone [5]. There was no improvement after
testosterone injection and the children were finally re-
ferred for surgical correction. The existence of this condi-
tion in adults is another argument against this theory.
Furthermore, in adults liposuction alone is not consid-
ered a satisfactory treatment for buried penis, supporting
the idea that excessive prepubic fat is not the simple cause
of this buried penis condition, and maybe encouraging
further research in dartos pathology that might result in
penile anomalies.
Conclusion
Buried penis remains a difficult and not so well-known
condition. The described technique is easy to perform,
reproducible, safe with good results and high parent/pa-
tient satisfaction. Further research is needed to under-
stand its pathophysiology.
Disclosure Statement
The authors declare no conflict of interest.
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