Buried Penis Repair
This is the operative companion to Adult-Acquired Buried Penis. Plan reconstruction around the patient's urinary, sexual, hygiene and skin-care problems, the tissues actually contributing to concealment, and the amount of healthy skin remaining.[1][2] AABP repair may combine several procedures.[1][2]
Plan the components
| Finding | Possible component | Planning point |
|---|---|---|
| Constricting scar or diseased penile skin | Scar release and selective skin excision | Preserve useful native skin and viable underlying tissue; determine the resulting defect |
| Contributory escutcheon | Escutcheonectomy and appropriate fixation | Distinguish suprapubic tissue from an overhanging abdominal pannus |
| Contributory abdominal pannus | Panniculectomy | Coordinate incision, perfusion, closure tension and donor-skin use |
| Diseased or redundant scrotal tissue | Scrotoplasty or selected scrotectomy | Protect the testes and spermatic cords; assess remaining coverage |
| Skin deficiency | Graft or suitable local flap | Choose by bed viability, donor quality, hair, contracture and staging needs |
| Suspected urethral disease | Urethral assessment and coordinated treatment | The type and timing of repair depend on stricture anatomy and the skin-reconstruction plan |
The PAS classification describes the penile skin and escutcheon complex (P), abdominal pannus (A) and scrotal skin (S). Its 101-patient validation cohort from ten institutions showed high agreement between two reviewers (κ = 0.95) and correlation with the operations performed. The most common subtypes were P2c (contributory escutcheon with insufficient penile skin, 27%), P2a (contributory escutcheon with sufficient penile skin, 21%), A0 or A1 (no pannus or a noncontributory pannus, 41% and 39%) and S0 (normal scrotal skin, 71%).[2] Repairs included escutcheonectomy in 59 of 101 patients, scrotoplasty in 51, split-thickness grafting in 50, penile skin excision in 47 and panniculectomy in 7.[2] Limited surgery can fail when contributory disease is left untreated, and circumferential grafting is not required when healthy shaft skin is adequate.[3][4]
Operative sequence and safety
Exposure, release and tissue assessment
Confirm markings with the patient positioned for examination and surgery, accounting for pannus descent. Release the constricting tissues sufficiently to expose the glans, meatus and shaft. Assess each tissue layer before removing it; do not routinely strip all healthy dartos or create an unnecessary circumferential skin defect. Send abnormal excised tissue for histopathology.[1][5][6] Biopsy accessible suspicious penile lesions before definitive reconstruction; NCCN calls for histologic diagnosis by punch, excisional or incisional biopsy (category 2A).[26] If concealment prevents preoperative sampling, assess and sample a suspicious lesion after release before definitive graft or flap coverage. In Daly's 180-patient cohort, five cancers could be verified only after unburying and four others were discovered on pathology without prior clinical suspicion.[6]
Daly's retrospective series included 180 patients undergoing buried-penis repair or penectomy in the setting of buried penis. LS occurred in 23% and penile cancer in 5%. The 5% penile-cancer rate applies to Daly's selected cohort of repairs and penectomies.[6] The reported 2.3-fold association concerned requiring intervention for urethral stricture (54.8% versus 23.8%).[6]
Escutcheon and pannus surgery
Remove the suprapubic tissue that contributes to burial while planning a viable, low-tension closure. Incision design and depth vary with the tissue excess and accompanying procedures. Reconstruct the penopubic angle and secure mobile tissues to suitable deep fascia when needed. Protect the penile neurovascular structures, urethra and spermatic cords; manage dead space and drainage according to the operation.[1][3] One described variation leaves an approximately quarter-inch prepubic flap after lipectomy, brings its distal end caudally, and fixes the subdermis to the superficial suspensory ligament and peripubic tissue about 2 cm proximal to the penile base; the skin is then brought up onto the shaft as a "turtleneck" collar to avoid a deep, hard-to-clean cleft and recurrent concealment, with closed suction drains placed under the flap to limit seroma. This is an attributed technical variation; flap viability, tension, tissue quality and dead-space management still govern suitability.[24]
A panniculectomy review identified only four reports with 57 patients, supplemented by an NSQIP analysis. Concurrent panniculectomy was not independently associated with more 30-day complications in that adjusted analysis, despite greater morbidity in the unadjusted group.[7] See Escutcheonectomy and Panniculectomy.
Fixation against reburying
Penopubic anchoring is a described step to restore the penopubic angle and counter reburying.[28] Three approaches are described, and they anchor different tissues:
| Approach | What is anchored | Evidence |
|---|---|---|
| Penopubic anchoring sutures | Dermis at the penile root to pubic periosteum or pubic fascia, restoring the penopubic angle | Expert technical review that calls angle restoration essential to prevent recurrence; no comparative data[28] |
| Ventral penoscrotal tacking | Subdermis of the penoscrotal junction to the tunica albuginea, so the corpora cannot telescope back into the scrotum | 13 patients (6 adults, 7 children); improvement in all; the authors attribute many failures to omitting this step[29] |
| Fundiform ligament reapproximation | The fundiform ligament and suprapubic superficial fascial system, divided during escutcheonectomy, are sutured back together | Anatomic and histologic study of 3 patients (level V); lift of the genitalia observed intraoperatively; no recurrence or wound outcomes reported[27] |
Penopubic and ventral fixation address different failure directions and can be combined. Fundiform reapproximation has been described to restore fascial support and may reduce strain on the dermal closure.[27] Dehiscence and infection are reported after high-complexity buried-penis repair, but whether fundiform reapproximation reduces either complication is unknown.[20][27] No study compares these techniques, so none can be said to prevent recurrence better than another.[22] In the 204-patient cohort, hematoma was associated with recurrence and high-complexity repair with lower recurrence during a median 18-month follow-up.[22]
Select shaft coverage
| Option | Role | Limitations |
|---|---|---|
| Native skin advancement or selected Z-plasty | Enough healthy mobile skin remains | No validated universal percentage-of-circumference threshold; assess on stretch |
| STSG | Broad superficial coverage on a vascularized bed | Donor-site care, graft loss, sensory change and contracture remain possible |
| FTSG | Selected defects with a suitable recipient bed and donor skin | Careful defatting and donor assessment; no established AABP superiority over STSG |
| Ventral slit scrotal flap | Selected ventral skin deficiency with suitable scrotal tissue | Hair, rugae and disease recurrence; not suitable for every circumferential defect |
| Bilateral pedicled scrotal flaps | Unusable shaft skin with healthy scrotal skin; buried penis was 27% of indications in a 22-patient series | Dehiscence 32%, late skin retraction 27% and testicular ascent 23%; revision 9% early and 27% late[30] |
| Staged reconstruction | Uncertain tissue viability, extensive inflammation or complex combined reconstruction | More procedures and longer treatment course |
STSG from the thigh and STSG or FTSG from suitable excised suprapubic tissue are described options. Reusing appropriate escutcheon or pannus skin can avoid another donor wound; it is not automatically the donor of choice when the skin is diseased, hair-bearing in an unsuitable pattern or otherwise poor quality.[8][9][5]
The small retrospective Gül comparison included 39 patients overall but only 22 graft recipients: nine FTSG and 13 STSG. In Jeng's 32-patient LS/FTSG series, one patient had complete and two partial graft loss; all three had diabetes, but the reported association was not statistically significant. Neither study establishes diabetes as the dominant independent cause of FTSG loss.[10][11]
In the ventral slit scrotal flap, a ventral slit is made in the phimotic ring to expose the penis, and a ventral midline scrotal incision with horizontal relaxing incisions creates local flaps that are rotated to resurface the ventral shaft. The original report involved 15 consecutive patients with a trapped penis from lichen sclerosus (13 of 15) or phimosis, with mean BMI 42.6 kg/m². Mean operative time was 83 minutes, mean blood loss was 57 mL and all were discharged the same day. Eleven were satisfied without further intervention, and three had recurrent concealment from lichen sclerosus, pannus migration or edematous groin tissue.[12] See Penile Skin Grafting, Ventral Slit Scrotal Flap and Scrotal Flaps.
Broken-line closures and the W-plasty
A straight scar across the penoscrotal or penopubic junction can contract and tether the penis again. Z-plasty and W-plasty break a closure into interdigitating triangular flaps, which redistributes tension and reorients the scar. Both are general reconstructive techniques that have also been adapted to perineal and vulvar surgery.[31] Xu's 41-patient concealed-penis series (ages 8–35 years; mean 15.2) combined degloving with fixation of the tunica albuginea to proximal dartos through a longitudinal or Z-plasty penoscrotal incision.[32] The authors reported initial correction in all patients, a median flaccid-length gain of 2.1 cm at 6–24 months, and drainage through the incision.[32] Pediatric concealed-penis series use dorsal dartos flaps and ventral V-Y plasty for skin deficiency.[33][34]
The W-plasty described by Klein, Rusilko and colleagues applies the broken-line principle to the scrotal and abdominal flaps of a combined AABP repair. Their video case was a post-bariatric patient with Wisconsin stage IV disease. The repair comprised degloving and excision of diseased penile skin, removal of the suprapubic fat pad, panniculectomy with an abdominal advancement flap, and scrotoplasty with the lateral scrotal and superior advancement flaps reassembled in a "W" configuration, followed by penile skin grafting under a bolster. The authors report that the W reduces tension over the suprapenile part of the reconstruction compared with the traditional keystone configuration, with better scrotal cosmesis and less urogenital lymphedema.[35] A 2025 report, with Rusilko as coauthor, describes its first use in the Philippines.[36] The evidence is technique reports. No study compares the W-plasty with keystone, V-Y or Z-plasty closure, so the choice still follows the skin, pannus and scrotal anatomy of the individual patient. Rusilko reviews a W-plasty case on BackTable Urology Episode 319 (see Videos).
The term has other meanings. A "spatial W-plasty" full-thickness graft is a neovaginal technique (four patients).[37] In penile-lengthening surgery, a W-flap is one of the flaps described for advancing penopubic skin after suspensory ligament division, alongside the inverted V-Y flap and lower-abdominal Z-plasty.[38] Neither is an AABP repair.
Harvest, fixation and dressing
For STSG, choose the donor, thickness and meshing pattern for the actual defect and functional goals. Sheet grafts and unexpanded 1:1 meshing have both been used on the shaft. Black's nine-patient prospective report used 0.012- or 0.016-inch grafts meshed 1:1 without expansion, with transverse slits and a ventral zigzag junction, and all nine grafts took fully.[13] Figler's outpatient technique harvested an unmeshed graft from the pannus in 2-inch sections at 0.018 inch, through a modified trapezoid incision that left the superior attachments intact for graft harvest.[14]
For FTSG, retain epidermis and dermis while removing adherent fat carefully. Maintain graft contact with a hemostatic, viable recipient bed, prevent fluid collection and minimize shear. Fit and secure the graft with the penis extended to avoid preventable tethering, without applying a constricting dressing.[9][5]
Bolster materials, NPWT, catheter use and removal timing depend on the repair and local protocol. Figler's 19-patient outpatient technique used a bolster for 5–7 days and reported graft take of at least 95% in all patients.[14] The 21-patient Rook series used a bolster of bacitracin on a nonadherent dressing, a saline-moistened silver dressing, gauze and eggcrate foam with the spikes toward the wound, applied with the penis extended to length and stapled in place, and removed it at a median of four days. Rook's 100% early graft take was a median.[15] Routine fibrin sealant, erection suppression or a particular dressing is not established by these uncontrolled series.[14][15][16] A small preliminary series describes using diluted fibrin sealant to secure penile split-thickness grafts in complex genital reconstruction; some authors consider it their routine practice.[25]
Coordinate urethral reconstruction
Assess voiding symptoms, the meatus and suspected stricture disease before finalizing the skin operation. When exposure prevents adequate preoperative evaluation, consent and plan for intraoperative assessment and, if necessary, temporary suprapubic drainage. Avoid forcing an instrument through a narrowing simply to complete evaluation.[1]
Fuller's retrospective cohort found strictures in 13 of 42 patients; eight of those 13 had strictures at least 6 cm long and underwent Kulkarni urethroplasty before AABP repair. Stricture was universally anterior, and clinically diagnosed lichen sclerosus was associated with stricture (p = 0.00019).[17] Kulkarni urethroplasty before AABP repair is a useful option for selected long anterior strictures: it is a single-stage repair with meatal voiding, and the dorsal graft allows safe degloving at the later repair. Other expert operative experience describes selected simultaneous dorsal oral-mucosal graft urethroplasty. Plan staging with a reconstructive urologist, considering recipient-bed perfusion and the difficulty of later mobilizing grafted shaft skin.[17][1]
Recovery and risk counseling
The 2026 EAU guideline strongly recommends that AABP surgery be performed in high-volume centers.[40] Individualize outpatient versus inpatient care to the repair, comorbidity, mobility, support and access to wound care. Erpelding's selected 16-patient series discharged ten on the operative day and six the following day; all recorded 30- and 90-day complications were Clavien II.[18] Figler's separate 19-patient series reported five cellulitis and three minor-dehiscence events.[14]
Optimize weight-related risk, diabetes, smoking, nutrition and functional status, and arrange appropriate perioperative thromboprophylaxis and wound support. Chestnut's 76-patient retrospective cohort associated BMI with recurrence and complications; its data-derived BMI 38 and 40 thresholds and large odds ratios are not externally validated eligibility cutoffs or individual risk estimates. Frailty was independently associated with complications in Staniorski's 103-patient high-complexity cohort.[19][20]
Counsel specifically about wound breakdown, infection, hematoma, graft loss, genital lymphedema, recurrent concealment and possible revision. In one 32-patient series using escutcheon full-thickness grafts for buried penis with lichen sclerosus, two patients required reoperation for lymphedema at a median eight-month follow-up.[11] Minor wound problems may respond to local care, whereas progressive infection, significant ischemia, hematoma or graft failure requires reassessment.[20][11]
Outcomes: keep populations and endpoints separate
| Study | Population and endpoint | Interpretation |
|---|---|---|
| Pariser 2018 | 64 repairs; 58 achieved an unburied penis without further unburying surgery; median follow-up 209 days | 91%[21] |
| Staniorski 2023 | 103 high-complexity repairs; 50% had complications, with 41% Clavien I–II; 3.9% revision for poor outcome, median follow-up 11 months [20] | — |
| Plamadeala 2026 | 204 first-time repairs; 91 received grafts; median follow-up 18 months; 55 patients had complications and 26 had recurrences | Mixed procedures and retrospective selection[22] |
| Chestnut 2025 | 76 consecutive repairs, single center; recurrence (reburying for which repeat repair was offered) in 17 (22%) at a mean 436 days; complications in 23 (30%), most often cellulitis | Retrospective; recurrences may be undercounted through loss to follow-up [19] |
| Falcone 2023 | 28 repairs, single center, median follow-up 27.5 months; complications 32.1% (Clavien ≥3 in 7.1%); 1-year recurrence-free survival 88.7%; IPSS and IIEF-15 improved | Small retrospective cohort spanning circumcision to grafting and abdominoplasty [39] |
Sources: Pariser,[21] Staniorski,[20] Plamadeala,[22] Chestnut[19] and Falcone.[39] In the 204-patient cohort, recurrence-free survival was estimated at 91.5% at 12 months and 83.7% at 24 months.[22] Complications occurred in 27.0% overall and were more frequent after high-complexity repair (32.6% vs 13.3%).[22] Recurrence occurred in 12.7%.[22] On multivariable Cox analysis, postoperative hematoma predicted recurrence (aHR 6.64, 95% CI 2.5–18.0) and high-complexity repair was associated with less recurrence (aHR 0.35, 95% CI 0.1–0.8).[22] In the Cox model, BMI ≥30 kg/m² was nonsignificant both before and after adjustment; prior circumcision and prior bariatric surgery lost significance after adjustment. In separate logistic regression, each BMI unit was associated with 6% higher odds of recurrence and prior circumcision with threefold higher odds (OR 3.00).[22] The authors suggest that postoperative complications or impaired wound healing could explain why obesity-related variables lost significance in the adjusted recurrence model.[22] Complexity partly reflects baseline severity. The protective association does support matching the extent of repair to the disease, careful hemostasis and drainage, and follow-up through the first 2 years. The reported 3-cm stretched-length gain was a median, and patient-reported outcomes were available for only 68 patients.[22]
Follow-up should assess healing, urinary function, erection-related tethering, recurrent inflammatory disease, recurrent concealment and patient goals. Pediatric congenital concealed penis requires a separate pediatric assessment; adult excision and grafting algorithms should not be applied automatically.[1][23]
See Also
- Adult-Acquired Buried Penis
- Penile Reconstruction
- Scrotal Reconstruction
- Kulkarni One-Stage Panurethral Urethroplasty
Podcasts
Videos
References
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