Longitudinal Incision With Penoscrotal-Angle Reconstruction (Xu)
Described by Xu et al. 2015 as a component of a modified penoplasty for concealed penis (all subtypes — buried, webbed, trapped), this technique pairs complete penile degloving with a longitudinal ventral incision at the penoscrotal junction for access, drainage, and fixation, then anchors the tunica albuginea to the proximal dartos to reconstruct the penoscrotal angle and prevent retraction.[1] The authors explicitly present the longitudinal incision and a Z-plasty as interchangeable within the same operative framework, with the longitudinal incision as the simpler of the two.[1]
For the umbrella technique comparison see Penoscrotal-Web Correction; for adult buried penis repair see Buried Penis Repair (04e).
Indications
| Setting | Best for / indications |
|---|---|
| Concealed penis (any subtype) | Congenital buried penis, webbed penis, or post-circumcision trapped penis — degloving + longitudinal incision + tunica-to-dartos fixation.[1] |
| Concurrent phimosis | Circumcision integrated into the same procedure.[1] |
| Adult aesthetic webbing alone | Not studied — Thomas & Navia continues to recommend Z-plasty in this population.[8] |
Operative Protocol[1]
Step 1 — Circumcision incision and degloving
- Foreskin circumcision incision along the coronal sulcus.
- Sharp dissection in the plane immediately superficial to the tunica albuginea.
- Complete penile degloving, dividing fibrous dartos bands that tether the penile skin to deeper structures — the key maneuver that frees the shaft from its concealed position.
Step 2 — Longitudinal penoscrotal-junction incision
- Vertical incision along the ventral midline at the penoscrotal junction through skin and dartos.
- Dual purpose:
- Access for the fixation step below.
- Drainage of the degloving dead space — opening this cavity is highlighted as a benefit, reducing hematoma / seroma risk.
Step 3 — Penoscrotal-angle fixation
- Through the longitudinal incision, place fixation sutures from the tunica albuginea to the proximal tunica dartos.
- This anchors the base of the shaft in its exteriorized position and prevents proximal telescoping — addressing the fundamental pathology of concealed penis (Alter principle: hypermobility of ventral skin / dartos relative to Buck's fascia and the corpora).[4]
Step 4 — Closure
- Longitudinal and circumcision incisions closed in layers as a simple linear closure — no flap transposition.
Longitudinal Incision vs Z-plasty
The authors frame these as interchangeable alternatives for the penoscrotal-angle reconstruction step.[1]
| Consideration | Longitudinal | Z-plasty |
|---|---|---|
| Geometry | Straight midline | Triangular flap transposition |
| Operative complexity | Low | Moderate |
| Geometric lengthening | None — relies on degloving + fixation + elasticity | ~75% of central limb at 60° |
| Drainage of degloving dead space | Yes — opens cavity | No specific drainage |
| Flap-tip necrosis / trapdoor / mismatch | None | Present |
| Best fit | Concealed penis with adequate elasticity | Severe webbing where geometric lengthening is needed |
The longitudinal incision is insufficient when geometric ventral lengthening is required (severe penoscrotal webbing in inelastic tissue) — Z-plasty remains the algorithmic standard for that subset.[5][8]
Outcomes (Xu 2015, n = 41)[1]
| Variable | Result |
|---|---|
| Study period | Aug 2008 – Aug 2013 |
| Success of correction | 100% |
| Median flaccid length gain | +2.1 cm |
| Visible scarring | None |
| Erectile discomfort | None |
| Complications | None reported |
| Follow-up | 6 months – 2 years |
| Cosmetic satisfaction | Satisfactory in all patients |
The Alter Fixation Principle (Shared Across Concealed-Penis Repairs)
Alter & Ehrlich identified that surgical failure in hidden-penis repair is driven by hypermobility of ventral skin and dartos relative to Buck's fascia and the corpora — the corpora telescope proximally into the prepubic fat / scrotum because the overlying envelope is inadequately anchored. Their solution was subdermal-to-tunica-albuginea tacking sutures at the penoscrotal junction.[4] Xu applies the same principle through the longitudinal incision (tunica → proximal dartos), as do related modified penoplasty techniques:
- Casale 1999 — penile-skin fixation at penoscrotal and penopubic angles (12/18 type-1 and 10/18 type-2 patients).[2]
- Yang 2013 — penoscrotal-angle reconstruction as Step 3 of a modified penoplasty (n = 201).[7]
- Borsellino 2007 — penopubic and penoscrotal angle reconstruction via the scrotal raphe (n = 87).[3]
Comparison Across Concealed-Penis / Webbing Techniques
| Feature | Xu longitudinal | Z-plasty | Borsellino raphe | V-I (Bagnara) | Alter ventral tacking |
|---|---|---|---|---|---|
| Primary indication | Concealed penis (all types) | Webbed penis / penoscrotal webbing | Concealed penis (all types) | Congenital webbed penis | Hidden penis |
| Incision | Vertical at penoscrotal junction | Oblique Z | Along scrotal raphe | V → I closure | Penoscrotal junction |
| Flap transposition | None | Required | None | None | None |
| Geometric lengthening | No | Yes (up to ~75%) | No | No | No |
| Fixation | Tunica → dartos | None (tissue rearrangement) | Penopubic / penoscrotal angle fixation | Release + linear closure | Subdermis → tunica albuginea |
| Drainage of dead space | Yes | No | Via raphe | Not described | Not described |
| Series size | 41 | 100 | 87 (11 webbed) | 21 | 13 |
| Complication rate | 0% | 2% | 5.3% buried / 0% webbed | 0% | Minor wound issues |
Advantages and Limitations
Advantages. Straightforward technique; longitudinal incision serves a dual access-plus-drainage role; no flap geometry required; versatile across concealed-penis subtypes; integrates phimosis correction in the same operation; 0% complication rate in the index series.[1]
Limitations.
- Single-center, single-series evidence (n = 41); no replication or comparative trial.
- Authors do not report which patients received longitudinal incision vs Z-plasty, so the "interchangeable" claim is not outcome-stratified.
- No validated patient-reported outcomes or standardized cosmetic scoring.
- Follow-up capped at 2 years — durability through puberty and erection-cycle is unknown.
- Lacks the geometric lengthening capacity of Z-plasty; theoretically insufficient for severe penoscrotal webbing in inelastic tissue.[5]
- Validated in a concealed-penis cohort, not in adult aesthetic webbing — Thomas & Navia continues to recommend Z-plasty for adult aesthetic indications.[8]
See Also
- Penoscrotal-Web Correction (umbrella)
- V-I Penoscrotal Reconfiguration (Bagnara)
- Reduction Scrotoplasty
- Buried Penis Repair (04e)
- Male Cosmetic Genital Surgery
References
1. Xu JG, Lv C, Wang YC, Zhu J, Xue CY. Management of concealed penis with modified penoplasty. Urology. 2015;85(3):698–702. doi:10.1016/j.urology.2014.06.044
2. Casale AJ, Beck SD, Cain MP, Adams MC, Rink RC. Concealed penis in childhood: a spectrum of etiology and treatment. J Urol. 1999;162(3 Pt 2):1165–1168. doi:10.1016/S0022-5347(01)68114-X
3. Borsellino A, Spagnoli A, Vallasciani S, Martini L, Ferro F. Surgical approach to concealed penis: technical refinements and outcome. Urology. 2007;69(6):1195–1198. doi:10.1016/j.urology.2007.01.065
4. Alter GJ, Ehrlich RM. A new technique for correction of the hidden penis in children and adults. J Urol. 1999;161(2):455–459.
5. Álvarez Vega DR, Mendelson JL, Gitlin JS, Joshi P, Hanna MK. Optimizing pediatric genital reconstruction: the role of Z-plasty in enhancing aesthetic and functional outcomes. Urology. 2025. doi:10.1016/j.urology.2025.06.011
6. Bagnara V, Donà A, Berrettini A, et al. The "V-I penoscrotal reconfiguration": a simple technique for the surgical treatment of congenital webbed penis. Int J Urol. 2024;31(8):886–890. doi:10.1111/iju.15476
7. Yang T, Zhang L, Su C, Li Z, Wen Y. Modified penoplasty for concealed penis in children. Urology. 2013;82(3):697–700. doi:10.1016/j.urology.2013.03.046
8. Thomas C, Navia A. Aesthetic scrotoplasty: systematic review and a proposed treatment algorithm for the management of bothersome scrotum in adults. Aesthet Plast Surg. 2021;45(2):769–776. doi:10.1007/s00266-020-01998-3