Observation on the therapeutic effect of a modified Devine procedure with subcutaneous sliding fixation method for concealed penis

Abstract

To evaluate the therapeutic effect of a modified Devine procedure with a subcutaneous sliding fixation method for the treatment of congenital concealed penis, we retrospectively selected 45 patients with congenital concealed penises who were admitted to General Hospital of Ningxia Medical University (Yinchuan, China) between September 2020 and November 2023. In all cases, the penis was observed to be short, and retracting the skin at the base revealed a normal penile body, which immediately returned to its original position upon release. All patients underwent the modified Devine procedure with subcutaneous sliding fixation and completed a 12-week postoperative follow-up. A statistically significant increase in penile length was observed postoperatively, with the median length increasing from 4.0 (interquartile range [IQR]: 3.5–4.8; 95% confidence interval [CI]: 3.9–4.4) cm to 8.0 (IQR: 7.8–8.0; 95% CI: 7.7–7.9) cm, with P < 0.001. The parents were satisfied with the outcomes, including increased penile length, improved hygiene, and enhanced esthetics. Except for mild foreskin edema in all cases, no complications (such as infections, skin necrosis, or penile retraction) were observed. The edema was resolved within 4 weeks after the operation. This study demonstrates that the modified Devine procedure utilizing the subcutaneous sliding fixation method yields excellent outcomes with minimal postoperative complications, reduced penile retraction, and high satisfaction rates among patients and their families.

INTRODUCTION

Congenital concealed penis is a condition characterized by the abnormal development of the penis sarcolemma, which constrains the expansion of the corpus cavernosum, resulting in the penis being obscured by suprapubic tissue.1 The primary manifestation is the short appearance of the penis.2,3 It may result in phimosis, balanitis, hygiene issues, dysuria, and psychological trauma.4 Consequently, early surgical intervention has usually been recommended by pediatric urologists as essential for affected patients.5 Currently, no single procedure is universally applicable,2,6 and medical professionals determine the most appropriate technique based on specific patient conditions. Some commonly used procedures are Brisson’s technique and Shiraki’s technique. Although both methods yield appropriate outcomes, they have major drawbacks. Brisson’s technique often results in an unsatisfactory appearance of the penis after surgery due to inadequate skin coverage on the ventral surface, which increases the likelihood of the penis retracting after the procedure.7 Shiraki’s technique requires more incisions resulting in significant edema.8 Other techniques exist in addition to these two, but they also have drawbacks, such as postoperative edema, neurovascular injury, and free flap necrosis.2,9,10,11 Modified Devine surgery is an effective procedure for patients with mild-to-moderate concealed penis, yielding favorable postoperative cosmetic results and satisfactory outcomes.12

Although current techniques effectively reduce postoperative penile retraction, they remain unavoidable in some cases.11,13,14 They may also result in additional complications by failing to provide sufficient fixation at the base of the penis, leading to inaccurate fixation points and unsatisfactory cosmetic outcomes. Consequently, our research team has improved the modified Devine surgical method by incorporating a subcutaneous sliding fixation technique, achieving greater therapeutic efficacy for patients with concealed penis.

PATIENTS AND METHODS

Study design and patients

We retrospectively reviewed 45 patients with concealed penis who were admitted to General Hospital of Ningxia Medical University (Yinchuan, China) from September 2020 to November 2023. The inclusion criterion for this study was a confirmed diagnosis of congenital concealed penis (Figure 1). The Ethics Committee of General Hospital of Ningxia Medical University approved the study (Approval No. KYLL-2024-1489). Our study excluded patients with acquired concealed penis through a manual prepubic compression test.6 Other exclusion criteria were abnormal penis development, congenital abnormalities, serious genetic disorders, and hypospadias or epispadias. The primary objective of this study was to assess the efficacy of modified divine surgery, in conjunction with a novel fixation technique, in preventing postoperative penile retraction. The secondary objective was to evaluate the surgical outcomes and compare them to preoperative measurements, such as penile length and family satisfaction scores.

Figure 1.

Preoperative appearance of the penis.

Surgical technique

All procedures were performed by the same experienced urologist (GYL). The surgeries were done under general anesthesia, in a supine position, with routine skin preparation before the operation and careful cleaning of the perineum. After successful anesthesia, a longitudinal incision was made on the ventral surface of the prepuce 0.8 cm from the coronary sulcus, which separated the subcutaneous membrane of the foreskin up to the fascia layer. The penile skin was entirely detached to the penopubic junction, and the adherent membrane was incised to reveal the bulbocavernosus muscles on both sides (step 1; Figure 2). The superficial suspensory ligament of the penis was cut at the level of the pubic symphysis (step 1; Figure 2). Subsequently, the shaft of the penis was elongated after the dartos fascia was completely resected. For the sliding fixation method, we used nonabsorbable thread (2-0 W6977M) to suture a needle at the 10-o’clock and 2-o’clock positions on the tunica albuginea at the root of the penis without making a knot (step 2; Figure 2). After marking the fixed points on the prepubic skin surface, starting at the 10-o’clock position on the penis root, the needle was threaded through the entire layer of skin covering the pubic bone (step 3; Figure 2); this step was repeated on the other side, starting at 2-o’clock on the penis root. Once the needle exited the prepubic skin, it was subcutaneously crossed to the other side, 1 cm laterally from where it exited (step 4; Figure 2), and step 1 was repeated there. The needle was passed through the entire layer of skin covering the pubic bone until it exited, then it was returned to the 10-o’clock position of the penis root (step 5; Figure 2) and the same step was repeated on the other side, returning back to the 2-o’clock position of the penis root. We made sure that the tightness of the fixation was the same on both sides (step 6; Figure 2), and then the ends of the thread were knotted (step 7; Figure 2). Subsequently, we incised the foreskin and reconfigured it, ensuring that the penis remained asymmetrical as its length increased. We stitched the incisions using absorbable sutures (2-0 VCP751D) at regular intervals (Figure 3). A Foley catheter was inserted into the bladder, and the wound was wrapped with an elastic, self-adhesive bandage, which exerted pressure to prevent bleeding and ensure fixation.

Figure 2.

Diagram of surgical steps with corresponding intraoperative images.

Figure 3.

Ventral penile appearance after the sliding fixation technique.

Postoperative treatment and evaluation of efficacy

All patients received oral cefuroxime ester capsules administered twice a day for 3 days following surgery. For patients under 12 years of age, the standard dosage was 125 mg per capsule, administered two times daily for 3 days; and for patients over 12 years old, the dosage was 250 mg per capsule, also two times daily for 3 days. We investigated and recorded any complications that occurred during the immediate postoperative period and during follow-up consultations, including the occurrence of incision hemorrhage, infection, skin necrosis, and penile edema. Edema was classified from mild to severe. The patients’ penile foreskins exhibited mild edema, a shriveled surface, and lowered tension. We changed the dressing every 2–3 days, sanitizing with iodophor, and using sterile medical absorbent gauze and cotton balls, a disposable sterile plastic dressing change bowl, disposable sterile plastic forceps, and a sterile elastic bandage. The Foley catheter was withdrawn 1 day after surgery.

Follow-up

All patients and their families who participated in this study attended follow-up appointments at 1 week, 3 weeks, 6 weeks, and 12 weeks after surgery to assess recovery. The surgical outcomes were assessed by measuring penile length and evaluating retraction, morphological modifications, and erectile pain. For scoring, a five-point Likert scale was employed, with 1 indicating “very unsatisfactory”, 2 indicating “unsatisfactory”, 3 indicating “neither satisfactory nor unsatisfactory”, 4 indicating “satisfactory”, and 5 indicating “very satisfactory”.

Data collection

The following data were collected and analyzed. (1) Preoperative basic medical history includes age, body mass index (BMI), past medical history, penis length, penis retraction, morphology and parental satisfaction score, auxiliary examination results, and improvement of postoperative-related indexes of the patients; (2) surgical complications includes penis edema, infection, and skin necrosis; and (3) intraoperative data includes duration of operation and intraoperative blood loss.

Statistical analyses

Data were analyzed using SPSS, version 27.0 (IBM Corp., Armonk, NY, USA). The descriptive data were presented as the median and interquartile range (IQR) and normality was checked using the Shapiro–Wilk test. For nonnormally distributed data, the Friedman test was performed to compare pre- and post-operative data, with P < 0.05 considered as statistically significant.

RESULTS

Forty-five patients with congenital concealed penis condition in our hospital underwent a modified Devine operation with subcutaneous sliding fixation. The median age of patients was 12.5 (IQR: 18–11; 95% confidence interval [CI]: 13.5–17.1) years. The median BMI of the patients was 23.5 (IQR: 26.8–20.9; 95% CI: 22.9–25.0) kg m⁻² (Table 1). The follow-up period was 12 weeks, and the other baseline data are shown in Table 1.

Table 1.

Patients’ perioperative data

Characteristic	Median (IQR)	Mean (95% CI)
Age (year)	12.5 (11–18)	15.3 (17.1–13.5)
High (cm)	165 (153–175)	162.8 (166.7–158.9)
BMI (kg m−2)	23.5 (20.9–26.8)	23.9 (22.9–25.0)
Operation time (min)	60.0 (60.0–75.5)	70.7 (63.9–77.5)
Blood loss (ml)	10.0 (8.0–12.5)	12.2 (10.2–15.7)

IQR: interquartile range; CI: confidence interval; BMI: body mass index

The length of the penis (measured from the penopubic junction to the tip of the glans in a flaccid condition) was significantly increased relative to its preoperative state from a median of 4.0 (interquartile range [IQR]: 3.5–4.8; 95% confidence interval [CI]: 3.9–4.4) cm to 8.0 (IQR: 7.8–8.0; 95% CI: 7.7–7.9) cm, with P < 0.001 (Table 2). The parents were satisfied with the increased penis length, improved morphology and hygiene, and esthetic enhancement (Table 2). No further complications (such as infections, skin necrosis, or penile retraction) were observed, except for mild foreskin edema, which subsided 4 weeks postoperation. We conducted follow-up assessments at 1 week, 3 weeks, 6 weeks, and 12 weeks after surgery and compared them to preoperative measurements. The satisfaction levels of the parents showed a significant increase (P<0.05; Table 2).

Table 2.

Penile length and satisfaction score

Variable	Pre-operation group, median (IQR)	Post-operation group, median (IQR)	12 weeks post-operation group, median (IQR)	aP	bP
Penile length (cm)	4.0 (3.5–4.8)	8.0 (7.5–8.0)	7.8 (7.5–8.0)	<0.0001*	0.275
Satisfaction score (1–5)
Morphology	1.0 (1.0–2.0)	4.0 (3.0–4.0)	4.0 (4.0–5.0)	<0.0001*	0.105
Penile length	1.0 (1.0–1.0)	5.0 (4.0–5.0)	4.0 (4.0–5.0)	<0.0001*	0.876
Hygiene	1.0 (1.0–2.0)	3.0 (3.0–4.0)	4.0 (4.0–5.0)	<0.0001*	0.018*
Voiding status	2.0 (2.0–3.0)	4.0 (3.0–4.0)	5.0 (4.0–5.0)	<0.0001*	0.013*

*P<0.05. ^aThe value of postoperation group and 12 weeks postoperation group compared to that of preoperation group. ^bThe value of postoperation group compared to that of 12 weeks postoperation group

DISCUSSION

The primary objectives of managing a concealed penis condition are to prevent penile retraction and improve family satisfaction scores, particularly concerning cosmetic appearance postsurgery. Our improved Devine surgical procedure resulted in no occurrences of penile retraction following surgery and only mild edema. The initial cause of edema may be associated with a lymphatic system reflux disorder, considering the abundance of lymphatic vessels in the distal foreskin of the penis, particularly within the inner foreskin plate. Abnormal distal lymphatic fluid reflux after surgery can cause foreskin edema, and the more the inner plate is preserved, the worse the edema.15 The vein that separates the superficial and deep layers can undergo alteration following penile detachment, and the compromised network can lead to inadequate blood return and increased venous pressure, thereby worsening tissue edema.5 Penile edema is a common complication of surgery, and we successfully managed it by leaving as few inner plates as possible (0.5 cm on the dorsal side and 1 cm on the ventral). In addition, we prolonged the duration of postoperative bandaging from 2 weeks to 1 month when necessary.

Our improved method for fixation at the penile base was responsible for averting postoperative retraction. Numerous studies have recommended attachment of the penile shaft to the skin at the base of the penis16,17,18,19,20,21 and several fixation techniques are available, including dorsal penile shaft fixation, which is moderately effective in preventing penile retraction,13,16 but risks damaging the dorsal neurovascular bundle.11,13,22,23 Because of this, clinical researchers attempted ventral penile shaft fixation, but retraction still occurred in some cases.19,21,24,25 In this study, we utilized a modified version of Devine’s operation with a new fixation method to achieve the desired results. The fixation method step started in the penis root at 10-o’clock and 2-o’clock positions, and we fixed the penile root by inserting a needle into the tunica albuginea of the proximal penis without making a knot. The needle was subsequently inserted medially through the complete dermal layer overlying the pubic bone and into the pelvic region from the needle’s exit site. The needle was then inserted subcutaneously and advanced 1 cm laterally. Subsequently, the needle was inserted medially from the same exit point into the entire dermal layer and was then retracted back to the base of the penis. Uniform tightness of the fixation was verified on both sides; after that, the ends of the thread were tied.

A novel fixation technique, known as the subcutaneous sliding fixation method, has demonstrated favorable outcomes, including expedited recovery and a reduction in postoperative complications, such as penile retraction, dermal injury, and infection at the penile attachment sites (Figure 4). In a retrospective study, Zhang et al.1 employed a dorsal fixation technique, in which the dorsal aspect of the penis and the penile tunica albuginea underwent suturing at the 2-o’clock, 10-o’clock, and 12-o’clock positions of the dorsal root. This procedural modification resulted in positive results with only five (8.9%) patients exhibiting mild retraction; but despite the positive outcomes observed, retraction continues to occur.1 Elrouby et al.26 compared the efficacy of two treatment approaches for children with a concealed penis: one-level versus two-level phallopexy. Their results showed that 2.2% of children in the one-level group experienced a recurrence of penile retraction, compared to 5.6% in the two-level group.26 In contrast, our study found no occurrences of retraction.

Figure 4.

Postoperative penile appearance 1 month after surgery.

Our surgical method diverged from Devine’s technique by preserving the subpubic fat pad in all 45 cases to mitigate trauma in the pediatric patients and minimize surgical wounds. We also did not make the Y-shaped incision at the penoscrotal angle. Based on the results of this study, we conclude that employing the sliding fixation technique in the Devine surgery procedure for patients with concealed penis disease was both effective and safe. Also, it diminished the possibility of skin necrosis, particularly at the fixation site, and minimized postoperative penile retraction. It also lessened the influence of the pubic fat pad on penile visibility and reduced penile contraction.

This study excluded patients with acquired concealed penis. Some family members of patients visited our hospital’s outpatient department with their obese children, expressing concerns regarding the diminutive size of their penile length. After diagnosing acquired concealed penis condition, we advised weight reduction as the primary intervention and scheduled a follow-up appointment to assess their progress. We informed them that management strategies tailored to the patient’s condition were not covered in this study, but future research on utilizing the sliding fixation method for patients with an acquired concealed penis could provide some benefit.

Despite the favorable outcomes of this study, there are several limitations. These limitations include the lack of long-term follow-up, the small patient cohort, and the single-arm study design. Incorporating a comparison group will enable more comprehensive evaluation of this treatment, and extended research could provide additional insights.

CONCLUSIONS

The results of our study demonstrate that a modified Devine surgery procedure utilizing the subcutaneous sliding fixation method yields excellent outcomes, with decreased postoperative complications, minimal penile retraction, improved cosmetic appearance and high satisfaction rates among patients and their families. We strongly advocate additional research and clinical application.

AUTHOR CONTRIBUTIONS

MAA contributed to the research design, data collection, and analysis and wrote the manuscript. HFT took responsibility for the integrity of the data and accuracy of the data analysis. JJF, BCH, and YST reviewed the concept and designed this study. MAUH, XHW, KMC, and JZ drafted the manuscript. GYL and RH supervised the study. All authors read and approved the final manuscript.

COMPETING INTERESTS

All authors declared no competing interests.