The modified Devine procedure for penile reconstruction: A retrospective study of 80 cases

Abstract

Objective

Concealed penis is a common congenital genital abnormality. This study aimed to introduce a penile reconstruction method for concealed penis, namely the modified Devine procedure, and evaluate its safety and efficacy.

Methods

We retrospectively reviewed 80 consecutive patients with concealed penis, who underwent surgical correction between May 2019 and May 2023 in our department. All patients underwent a modified Devine procedure. Data on the patients’ age, body mass index, operative time, blood loss, preoperative and postoperative penile lengths, and postoperative complications were collected and analyzed.

Results

All operations were successful. Patients had a mean age of 10.30 (standard deviation [SD] 1.07) years and a mean body mass index of 20.26 (SD 2.26) kg/m². The mean operative time was 56.35 (SD 8.62) min, and the mean volume of blood loss was 6.58 (SD 1.34) mL. The mean follow-up time was 15.97 (SD 2.92, range 12–24) months. Penile length increased significantly at 1 month and 12 months postoperatively, with continued growth over time. No major complications occurred. Mild lymphedema was the most common minor complication but resolved spontaneously within 6 weeks. No other adverse events were observed.

Conclusion

The modified Devine procedure for concealed penis achieved clinically safe and effective penile reconstruction outcomes, as well as satisfactory cosmetic appearance. Given its favorable results and minimal complications, this surgical approach appears to be a promising surgical option for selected patients with concealed penis.

1. Introduction

Concealed penis (CP), which is a congenital genital abnormality, often necessitates surgical correction [1], as it can lead to conditions such as phimosis, balanitis, difficulties in urination, erectile dysfunction, and psychological distress [2]. Although various surgical techniques have been employed to correct this abnormality, no single method is universally accepted for all CP repairs [2,3]. The Devine operation, as an effective technique for CP, is highly favored by many urologists due to its advantages of simplicity and minimal trauma [4]. However, the traditional surgery has some limitations, such as poor release of the dartos fascia, chances of flap necrosis, poor esthetic results, and a lack of fixation at the penile base [5]. In response to the limitations of the traditional techniques, we aimed to introduce a modified Devine procedure and evaluate its efficacy and safety in this study.

2. Patients and methods

2.1. Patients

From May 2019 to May 2023, we evaluated 80 cases of CP that were surgically treated using the modified Devine procedure. The inclusion criteria were as follows: (1) patients aged 9–12 years; (2) all cases conformed to the clinical characteristics of CP [6], including the penile shaft being entrapped within the subcutaneous tissue, resulting in the penis appearing small. When pressure was applied to the penile base, the normal penile shaft was revealed and once the pressure was released, the exposed penile shaft retracted. The exclusion criteria were as follows: (1) webbed penis; (2) trapped penis; (3) hidden penis; (4) micropenis; (5) concurrent genital anomalies, such as hypospadias or chordee. Before surgery, the guardians of all patients signed informed consent forms after being fully informed of potential risks associated with the procedure, and agreed to the use of relevant data for publication. This study was approved by the Ethics Committee of the Seventh Affiliated Hospital, Sun Yat-Sen University (ethics number: 2019SYSUSH-022).

2.2. Surgical techniques

All 80 operations were performed by the same senior urologist (Liao G). Patients underwent general endotracheal anesthesia and were positioned supine on the surgical table. The surgical steps for penile reconstruction, as shown in Supplementary Video 1, were elaborated in detail below.

Supplementary video related to this article can be found at https://doi.org/10.1016/j.ajur.2025.01.003

The following is/are the supplementary data related to this article:

Supplementary Video 1

The modified Devine procedure: a reconstruction technique for genital abnormality.

The foreskin was evaginated and a circumferential incision was made around the coronal sulcus, leaving a 0.5 cm mucosal collar proximal to the coronal sulcus (Fig. 1A and B). The penile shaft was completely degloved along the surface of the Buck's fascia to the base, dorsally to the pubic surface, and ventrally to the penoscrotal junction. During degloving, fibrous bands constraining the penis were thoroughly excised to allow full exposure of the penile structure (Fig. 1C). The dorsal skin at the penile base was marked at approximately the 2- and 10-o'clock positions (Fig. 1D). Two 2-0 silk sutures, with one end tied into 6–8 simple knots as traction sutures, were vertically passed through the marked points, leaving the suture knots outside the skin (Fig. 1E). When the traction sutures were pulled to evert the penile skin, the dermis was clearly exposed. Centered around the traction sutures, the dermis was sutured in a circular pattern with 2-0 silk sutures (Fig. 1F). The penis was fully extended and the length from the base to the coronal sulcus was measured. After complete exposure of the penile shaft, this length was used as a reference to determine the fixation points at the 10 o'clock and 2 o'clock positions on the shaft, measured from the coronal sulcus (Fig. 1G and H). The marked penile tunica albuginea was penetrated by silk threads at the corresponding penile dermis. Then the silk sutures were knotted respectively, anchoring dermis to tunica albuginea firmly (Fig. 1I). After trimming the foreskin, the circumferential incision was closed using 5-0 absorbable sutures. A catheter was routinely placed, and the penis was appropriately compressed with oil gauze, sterile gauze, and an elastic bandage for dressing.

Figure 1.

Operative steps. (A) Incision design 5 mm from the coronal sulcus; (B) Preservation of a sufficiently long frenulum; (C) Complete degloving of the penile shaft along the surface of Buck's fascia to the base; (D) Marking of skin folds at the 2- and 10-o'clock positions on the penile base; (E) Placement of two traction sutures (with 6–8 simple knots at one end) vertically through the marked penile skin points; (F) Circular suturing of the dermis centered around the traction sutures with 2-0/4-0 silk sutures; (G) Measurement of the length from the base to the coronal sulcus after straightening the penis; (H) Accurate marking of the 2- and 10-o'clock positions on the penile tunica albuginea near the base starting from the coronal sulcus based on the previously measured length; (I) Anchoring the dermis to the tunica albuginea firmly.

2.3. Postoperative treatment

Two days postoperatively, the dressing and catheter were removed. The local skin was maintained dry and clean until the wound was completely healed. Prophylactic antibiotics were administered for 3 days.

2.4. Data collection

Patients were scheduled for regular follow-up visits at our outpatient department for at least 12 months postoperatively. Data on the patients’ age, body mass index, operative time, blood loss, preoperative and postoperative penile lengths, which were measured from the penile base to the penile tip in a non-erect state, and postoperative complications were collected and analyzed.

2.5. Statistical analysis

Statistical analyses were performed using SPSS for Windows 26.0 software (IBM, Armonk, NY, USA). The Shapiro-Wilk test was used to examine the normality of data. All continuous data were expressed as mean ± standard deviation (SD). The paired t-test was employed for group comparisons. A p-value <0.05 indicated statistical difference.

3. Results

All 80 children successfully underwent the operation. The patients' mean age was 10.30 (SD 1.07) years, and their mean body mass index was 20.26 (SD 2.26) kg/m². The mean operative time was 56.35 (SD 8.62) min, and the mean volume of blood loss was 6.58 (SD 1.34) mL. The mean follow-up period was 15.97 (SD 2.92, ranging 12–24) months. Compared to the preoperative measurements, the mean penile length significantly increased at both 1 month (4.04 [SD 0.29] cm vs. 1.47 [SD 0.29] cm, t=54.265, p<0.001) and 12 months (4.29 [SD 0.50] cm vs. 1.47 [SD 0.29] cm, t=55.394, p<0.001) postoperatively, with a further significant increase observed at 12 months compared to 1 month (4.29 [SD 0.50] cm vs. 4.04 [SD 0.29] cm, t=9.840, p<0.001) postoperatively. No Clavien–Dindo grade ≥II complications were found during postoperative follow-up [7]. Most patients experienced postoperative mild penile lymphedema, which resolved in 6 weeks. No complications such as skin necrosis, penile retraction, wound infection, urination problems, erectile issues, abnormal glans sensation, or suture knot reactions were observed. The postoperative appearance of the penis was considered aesthetically satisfactory (Fig. 2A–D).

Figure 2.

The appearance before and after surgery. (A) Typical appearance of a concealed penis before surgery; (B) Appearance immediately after surgery; (C) Appearance 1 month postoperatively; (D) Appearance 12 months postoperatively.

4. Discussion

CP, also known as buried penis [8], refers to a condition in which the normally developed penile shaft is hidden beneath the subcutaneous tissue, resulting in a small apparent penis [6]. This condition differs from trapped penis, webbed penis, and hidden penis, which involve other anatomical or surgical factors [9,10]. It is important to distinguish these conditions for an accurate diagnosis and treatment. Our study primarily addresses CP and proposes the modified Devine procedure as a safe and effective solution.

Surgical intervention is the main treatment for CP, although the optimal timing for surgery remains controversial. Some urologists advocate for immediate surgery upon diagnosis [11,12], while others advocate waiting until after puberty [13]. In our practice, we prefer performing the modified Devine procedure on children aged 9–12 years because this age group offers several advantages: easier postoperative care, lower risk of penile erection pain, and minimal psychological impact.

Various surgical methods for CP have been described, including the Devine operation [14], “two-corner” surgical technique [1], Shaeer's technique [15], and Brisson's technique [10]. However, no universally accepted procedure exists for all cases. The traditional Devine operation, which involves vertical incisions on the inner and outer dorsal prepuce, preputial degloving, fibrous tissue excision, pubic fat removal, and penile root fixation [5], has several limitations, such as poor release of the dartos fascia, inadequate fixation at the penile base, and possible complications like flap necrosis and poor cosmetic results [2,5]. To overcome these limitations, we introduced several technical modifications to improve outcomes and minimize complications.

Key improvements in our modified Devine procedure included the following four aspects. The first improvement involved complete penile degloving and improved release of fibrous bands. We performed a circumferential incision around the coronal sulcus and fully degloved the penile shaft down to the base, excising fibrous bands between the tunica dartos and tunica albuginea. This step eliminated the tethering effect of preputial tissues, ensuring adequate penile exposure and reducing the risk of postoperative complications [5]. Most cases achieved satisfactory penile shaft coverage and spontaneous restoration of the penoscrotal angle after degloving, eliminating the need for further reconstruction. The second improvement focused on traction sutures for enhanced surgical exposure. We placed traction sutures at the 2- and 10-o'clock positions at the penile base. These sutures expanded the surgical workspace, aiding in the precise exposure of the dermis and allowing for better fixation of the dermis to the tunica albuginea. This technique not only improved visibility but also facilitated a stable and symmetrical fixation at the penile base, minimizing curvature and optimizing cosmetic outcomes. The third improvement entailed fixation of dermis to tunica albuginea. After degloving, we secured the penile dermis to the tunica albuginea using silk sutures, which provided a “point-to-surface” fixation. This method prevented the suture knots from loosening and helped prevent penile retraction. The fourth improvement centered on minimizing the use of the inner foreskin. We retained as much of the outer foreskin as possible while minimizing the use of the inner foreskin plate. This technique reduced postoperative foreskin tags and minimized the risk of postoperative lymphedema.

In this study, the mean follow-up was 15.97 (SD 2.92) months and the postoperative penile length significantly increased at both 1 month and 12 months compared to preoperative measurements (p<0.001), with further growth observed at the 12-month follow-up. This outcome suggested that the modified procedure not only provides immediate aesthetic improvement but also promotes further penile development. The results were comparable to those reported in other studies using different surgical techniques for CP [16,17].

Most patients experienced mild lymphedema postoperatively, likely due to lymphatic vessel damage during complete penile degloving along Buck's fascia, which resolved spontaneously within 6 weeks. No Clavien–Dindo grade ≥II complications were observed. With careful protection of the penile skin blood supply and prophylactic antibiotic use, no skin necrosis or wound infections occurred. Routine urinary catheter placement did not result in urinary tract infection or difficulty urinating. Non-absorbable sutures were commonly used in the surgical treatment of CP [18,19], and in this group of patients, silk sutures were used to anchor penile skin to the tunica albuginea, with no suture rejection observed. No penile retraction was found during postoperative follow-up, which may be related to the firm fixation at the penile base. Following the method described by Zhang et al. [4] and Su et al. [20], we fixed the dermis and tunica albuginea at the 2- and 10-o'clock positions, which prevented dorsal penile nerve injury. No erectile dysfunction or glans sensory abnormalities were observed postoperatively.

Several limitations existed in this study. For instance, as it was a single-center retrospective analysis and the duration of the follow-up for patients was still not long enough, these findings need to be confirmed in further studies.

5. Conclusion

Our modified Devine penile reconstruction technique, which addressed some limitations of the traditional procedure, was technically feasible and safe, and achieved favorable postoperative outcomes. The postoperative penile appearance was considered cosmetically pleasing. We believe that this surgical approach is superior to the conventional method for selected CP patients, as it has demonstrated successful outcomes with minimal complications in our study.

Author contributions

Study concept and design: Guolong Liao.

Data acquisition: Xianju Chen.

Data analysis: Guolong Liao.

Drafting of the manuscript: Guolong Liao.

Critical revision of the manuscript: Jun Pang.

Conflicts of interest

The authors declare no conflict of interest.