Concealed Penis in Pediatric Age Group; A Comparison Between Three Surgical Techniques
Phase: NA
Conditions: Pediatric ALL, Surgery, Urologic Diseases
Sponsor: Egyptian Biomedical Research Network

Concealed penis in pediatric age group; A comparison between three 
surgical techniques. 
Dear editor-in-chief of the BMC Urology; 
I have the honor to submit our original research article entitled 
“Concealed penis in pediatric age group; A comparison between three 
surgical techniques” by Ahmed Elrouby aiming at your helpful review and 
hopefully your acceptance for publication in your respectable journal “BMC 
Urology”. 
We believe that this manuscript is appropriate for publication in “BMC 
Urology” because it compares three surgical techniques in the management 
of congenital concealed penis in the pediatric age group which is included in 
the aims and scope of your respectable journal. 
This manuscript has not been published and is not under consideration 
for publication elsewhere.  We have no conflicts of interest to disclose and 
our manuscript had not received any financial funds.  All of the co-authors, as 
well as the Alexandria University Scientific Committee, approved its 
publication and informed consent was signed by the parents explaining the 
study. 
Thank you for your consideration! Waiting for your respectable reply. 
Sincerely, 
 
Ahmed Elrouby* 
Corresponding Author 
Associate Professor of Pediatric Surgery, 
Faculty of Medicine, Alexandria University, Egypt 
Address: Faculty of Medicine, Alexandria University, Egypt 
Phone: +2 01223631687 
ORCID ID: https://orcid.org/0000-0002-7339-0244 
Email: elroubypaedo@yahoo.com      ahmed.elrouby@alexmed.edu.eg 
NCT number: 0305434 
Document date: September 2022 
 

Abstract 
Background: Comparison between three different surgical techniques 
in the management of concealed penis. Methods: This prospective 
interventional non-randomized study included 150 pediatric patients with 
concealed penis. They were distributed equally into three groups; group A; 
patients treated by anchoring the penile skin dermis to Buck's fascia at the 
penile base at 3 & 9 o'clock points using PDS 5/0 (phallopexy), group B; 
patients treated by complete dissection and excision of dartos fascia & group 
C; patients treated by phallopexy as in group A after complete dissection and 
excision of dartos fascia. Follow-up at the end of the 1st post-operative week 
and then monthly for 6 months as regards penile skin congestion and/or 
necrosis, wound infection, edema, and/or re-retraction was carried out. Also, 
a questionnaire of parents about the follow up points was done 
Keywords: Concealed, phallopexy, dartos excision, degloving, penile re-
retraction. 
Background 
The concealed penis is a congenital anomaly in which a normal size 
penis is hidden in the pre-pubic fat with the glans penis that does not project 
from the pubic or scrotal skin. (Figure 1) This condition is usually associated 

with poor cosmoses, difficult accessibility resulting in poor hygiene, social 
embarrassment, recurrent balanitis, difficult urination, and secondary 
phimosis. (1,2)  
The pathogenesis of this anomaly was attributed to an excessive 
development of the penile dartos fascia retracting the penis inwards, an 
insufficient attachment of the penile skin to the deep penile tissues at the 
penile base, and/or tight phimosis which is often present. Also, excessive pre-
pubic fat is usually present and worsens the appearance of the abnormality but 
does not explain the pathology by itself. (3) 
Another variety of buried penis is the congenital mega-prepuce in 
which a redundant inner preputial skin covers the glans penis in an average 
size penis in association with severe phimosis. These patients usually 
complain of voiding difficulties as the urine traps in the redundant dome-like 
mega-prepuce. This variety requires different treatment modalities (4) 
The difference in the outcome of different corrective for such 
conditions was not compared widely in the literature so this study aimed to 
compare three different surgical techniques. The aim of this study was the 
comparison three different surgical techniques used in the management of 
concealed penis in the pediatric age group. The 1st technique is in the form of 

anchoring the penile skin dermis to Buck's fascia (phallopexy) at the penile 
base, the 2nd one is in the form of complete dissection and excision of dartos 
fascia and the 3rd technique is in the form of phallopexy after complete 
dissection and excision of dartos fascia 
Methods 
This study is a prospective interventional non-randomized study. It 
included 150 uncircumcised patients in the pediatric age group who presented 
to Elshatby University Hospital with a concealed penis between June 2018 
and June 2021. The main complaint of the parents of the studied patients was 
appearing small size penis, unapparent penis, difficult cleaning, and/or un-
satisfaction. 
The inclusion criteria included patients with a buried penis at or below 
the pubic skin level with a stretched penile length for all of them within the 
normal range according to their ages as titrated in the literature. (5) 
Patients with any associated anomalies like hypospadias, torsion, 
penoscrotal web, micropenis, mega-prepuce, or chordae were excluded from 
the study.  
The included patients were distributed non-randomly into three groups. 
The procedure was chosen according to the operative findings as dartos 

dissection and excision were recommended in patients with a thick abnormal 
dartos alone, phallopexy was recommended in case of absence of normal 
penile fixation alone and a combination of both techniques was recommended 
when the two pathologies were found.  Group A included patients who were 
treated by anchoring the penile skin dermis to Buck's fascia (phallopexy) at 
the penile base without excision of dartos fascia, group B included patients 
who were treated by complete dissection and excision of dartos fascia only 
and group C included patients who were treated by phallopexy as in patients 
of group A but after complete dissection and excision of dartos fascia. The 
choice of the procedure was random among the studied patients  
All of the studied patients had routine pre-operative laboratory 
investigations including CBC, CT, BT, PT, PTT, and INR. Informed consent 
was signed by the parents or caregivers after a complete explanation of the 
study design, its publication as well as any possible complications. 
All of the studied patients were operated on under general anesthesia 
with skin preparation using povidone-iodine. The prepuce was also retracted 
backward and cleaned completely from any smegma with povidone-iodine.  
The procedure was started by the application of two forceps mosquitos 
at the preputial mucocutaneous junction with formal circumcision leaving 

about 5 mm of the mucosal collar from the sub-coronal level. (Figure 2; A & 
B). This is followed by the application of two curved mosquito forceps at the 
sub-coronal level at three and nine o'clock points retracting the penis outwards 
during the whole procedure taking care of non-rotating the penis along with 
the operation by keeping retraction in the mid-line continuously. (Figure 2; 
C).  
Complete penile degloving in the sub-dartos plane was then started with 
meticulous dissection of the skin and dartos fascia out of Buck's fascia down 
to the level of penoscrotal junction ventrally and penopubic angle dorsally 
taking care of both neurovascular bundle and skin vascularity. On the dorsal 
aspect; the fundiform ligament - which is usually attached to the distal or mid-
penile shaft - was identified and dissected to increase the penile length. The 
dissection was completed circumferentially releasing all of the abnormal 
bands anchoring dartos fascia to Buck's fascia. (Figure 2; D)   
To avoid penile re-retraction; one of the following techniques was done. 
(Figure 2; B). In patients of the group, A phallopexy was done in the form of 
anchoring the penile Buck's fascia to the penile skin dermis at the penile base 
at three & nine o'clock points without excision of dartos fascia. This was done 
using PDS 5/0 taking care of non-rotating the penis while taking the stitches 
by keeping retraction just in the midline. Patients of group B were managed 

by complete circumferential dissection and excision of dartos fascia only. This 
was done in a meticulous fashion taking care of skin vascularity. Lastly, 
patients of group C were managed by phallopexy as in patients of group A but 
after complete dissection and excision of dartos fascia. (Figure 2; E&F) 
After removal of the retracting forceps; the skin was repositioned over 
the degloved penis and was sutured distally to the mucosal collar in a sub-
cuticular fashion using Vicryl 6/0. (Figure 2; G, H & I). A compression 
dressing was applied over the wound after the application of local antibiotic 
cream. 
Removal of the dressing was done on the 1st postoperative day with 
repeated application of local antibiotic cream three times daily for one week 
in addition to oral anti-inflammatory (NSAIDs) and anti-edematous for five 
days. 
Follow-up of the appearance of the penile skin (congestion, necrosis), 
wound infection, edema, and or re-retraction at the end of the 1st post-
operative week and then monthly for six months was done. Comparing the 
follow-up results between the three studied groups was carried out using the 
appropriate statistical method 
Also, a questionnaire of parents about the follow up points was done 

Statistical Analysis 
Data were coded, reviewed, and analyzed using the SPSS version 25.0 
(Armonk, NY: IBM Corp). The Kolmogorov-Smirnov (KS) test was used to 
test the normal distribution of the data. Quantitative data were expressed as 
median and range. Qualitative data were expressed as frequency and 
percentage. Kruskal-Wallis test was used to detect any statistically significant 
differences between three or more independent non-normally distributed 
groups. A pairwise comparison was conducted among significant groups. The 
Chi-square test was used to test the association between two categorical 
variables or to detect the difference between two or more proportions and 
whenever χ2 was not valid, Monte Carlo exact probability was used for RxC 
tables. The statistical analysis was carried out in the Community Department, 
Faculty of Medicine, Alexandria University