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Congenital lymphedema of the external genitalia is a rare, disfiguring disorder. We describe here a case of a 3-year-old male with primary foreskin lymphedema persisting since birth. A compact, heterogenous swelling of the foreskin's distal third was observed, inhibiting preputial retraction (phimosis). Right lower extremity lymphedema was also observed in this case, while no further abnormalities were found. Surgery was performed, maintaining the foreskin, producing an excellent result with no recurrence at 10-month follow up., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

Congenital penile curvature (CPC) is a relatively uncommon condition, characterized by congenital angulation of the erect penis. Surgical correction of CPC is the gold standard therapy with a variety of proposed surgical techniques and modifications. This review summarizes the contemporary literature on the surgical management of CPC, trying to address the current trends, as well as the advantages and disadvantages of available methods. We performed a non-systematic narrative and interpretative literature review until December 2018. We included articles with isolated CPC in human adults. We excluded original research articles regarding the surgical treatment of Peyronie's disease (PD). In total, we identified 34 studies including 2155 patients with CPC that met our inclusion criteria. Nine studies included patients with both CPC and PD, but reported sufficient data regarding the CPC cohort. Excisional corporoplasty and incisionless plication seemed to be the preferred surgical methods (10 and 12 studies, respectively), followed by incisional corporoplasty (5) and grafting (3). Four studies reported results of more than one method. Overall, patients with CPC can expect excellent outcomes with surgical repair and minimal side effects. No definite conclusions can be made regarding which technique is superior. The widely varied outcomes highlight the need for standardized outcomes measures in future research.

Background: A defect in embryological development or closure of median raphe may lead to formation of cyst(s) anywhere in the midline from glans to anus. These cysts are referred to as median raphe cysts, an uncommonly encountered clinical condition. The cyst is generally solitary, with the penile shaft being the most common location, with average size of around 1 cm. The diagnosis is mostly clinical and confirmed histologically. We report a case of a patient with a rare histological variant of median raphe cyst and provide a focused review on presentation, histopathology, and management., Case Presentation: A 29-year-old unmarried Nepali man presented to our clinic with an asymptomatic, solitary, soft, translucent, nontender cystic lesion of about 1-cm diameter at the ventral aspect of glans penis, close to the meatus, that had been noticed at the age of 3 and was nonprogressive for the past 15 years. Ultrasonography demonstrated an isoechoic cystic lesion at the tip of the penis, separated from the urethra, and lying entirely within the mucosa without any evidence of solid component, septation, or vascularity. On the basis of clinical and ultrasonographic findings, a diagnosis of median raphe cyst of the penis was made. The cyst was excised with the patient under local anesthesia, and there was no evidence of recurrence in 2 years of follow-up. The histopathological examination with Hematoxylin and eosin staining showed the cyst wall was lined partly by ciliated pseudostratified columnar epithelium and partly by columnar epithelium with apical mucin., Conclusions: Median raphe cyst is an uncommon, mostly asymptomatic condition in young patients. The cyst may occur anywhere along the midline from glans to anus. The diagnosis is clinical with histological confirmation. Excision is the treatment of choice with minimal chance of recurrence.

Penile cysts are uncommon lesions. In general, they are asymptomatic and do not interfere with sexual function. Most of them are present since birth, but usually they are only detectable in adolescence or adulthood. We report a clinical rare case of a newborns of 4 days of birth with a 3.5 cm diameter nodule on the prepuce (dorsal face), which appeared of birth. The cyst was excised by circumcision and a histopathologic study was performed. Histopathologic examination revealed a mucoid cyst by ectopic urethral mucoid of penis skins. No recurrence was observed at a 6 months follow-up after of surgery., (Copyright: © 2019 Permanyer.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Congenital aphallia is a rare anomaly with little supporting literature and controversial management. The aim of this review is to assess the most recent literature with a focus on staged management of these cases. We performed a PubMed search of all English literature in the past 10 years using the term aphallia. Twenty-three articles were identified of which six were excluded. A further three papers meeting our criteria were found in the references to papers initially identified. We found that management can be staged in three phases: short, intermediate and long-term. We conclude that optimal short-term management centers on resuscitation and urinary diversion as necessary, intermediate-term management entails urethrorectal fistula division, urethrostomy and neophallus creation and long-term management results in successful neophalloplasty, urethroplasty, prosthetic implant and continued protection of the upper urinary tracts with a Mitrofanoff. All this within a multidisciplinary team ensuring shared decision-making with the patient and their family.

Penile curvature is a common urological disease. Tunical plication for correction of penile curvature has been much popularized being simpler, adjustable to avoid overcorrection, less bleeding, and less postoperative erectile dysfunction. This study aims to assess the results of modified 16-dot plication technique for correction of congenital and acquired penile curvature and avoidance of knot-associated complications. Eighteen patients underwent correction of their penile curvature using the modified 16-dot plication technique between January 2014 and October 2015. Patients' pre and postoperative data were analyzed. The mean age of patients is 44 years old. Of the patients 15 who were available for follow-up, 8 patients had congenital penile curvature (CPC) and 7 had Peyronie's disease (PD). The angle of deviation ranged from 30° to 90°. Erectile function (EF) was assessed preoperative by IIEF score and duplex ultrasound. Postoperative follow-up at 3 and 6 months revealed straight erect penis in all patients. Longer follow-up at 1 to 2 years, 2 patients complained from slight recurrence of curve (<20°) and 2 patients complained of worsening of their erectile function. Penile shortening was noted by 6 patients. None of our patients stated any knot complication or bothersome, nor do hematomas, numbness, or painful erections. The modified 16-dot plication technique for correction if penile curvature is a safe and effective method. This modification allowed the knots to be tucked in the plicate tunical tissue avoiding knot-associated complications. More investigation on a large scale of patients or multicenter studies is recommended.

Congenital buried penis in the child is a congenital malformation where the penis appears small in size while all the parts of the organ are normal (the urethra, the erectile tissue and the glans penis). Our study aimed to describe our experience in the surgical treatment of this abnormality. We report the case of a 18-months old infant with bilateral hydrocele initially admitted to the Emergency Department and then referred to our Department. Clinical examination showed buried penis with tight foreskin and a dilation of the preputial reservoir due to urine. Surgical procedure included several steps: Z-shaped incision, pulling back of the foreskin of the penis, release of the adhesions surrounding the corpus cavernosum and ventral penile skin coverage using bladder catheter kept for a week to protect the wound healing. Aesthetic and functional result was satisfactory after 1-year follow-up. Congenital buried penis is a very debated subject in the literature. Our technique was simple and easily reproducible. Voiding difficulties and urinary infection are the main indications of this surgical procedure.

Objective: The aim of this study is to analyze post pubertal results of pre pubertal tunica albuginea plication with non-absorbable sutures in the correction of CPC., Materials and Methods: The files of patients who underwent tunica albuginea plication without incision (dorsal/lateral) were retrospectively reviewed. Patients younger than 13 years of age at the time of operation and older than 14 years of age in November 2015 were included. Patients with a penile curvature of less than 30 degrees & more than 45 degrees and penile/urethral anomalies were excluded. All of the patients underwent surgery followed by circumcision., Results: The mean age of patients at the time of the operation was 9.7 years (range, 6-13 years). The mean degree of ventral penile curvature measured during the operation was 39 degrees while it was 41 degrees in the lateral curvatures. All of the patients were curvature-free at the end of the operation. At the time of the follow-up examination, the mean age was 16.7 years (range, 14-25 years). Six patients had a straight (0-10 degrees) penis during erection and seven patients had recurrent penile curvatures ranging from 30 to 50 degrees., Conclusion: Pre pubertal tunica albuginea plication of congenital penile curvature (30-45 degrees) with non-absorbable sutures performed without incision is a minimal invasive method especially when performed during circumcision. However, recurrence might be observed in half of the patients after puberty., Competing Interests: Conflict of interest: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Background: Circumcision has been found to be an effective strategy for lowering the transmission of HIV in Africa. The Luke Commission, a mobile hospital outreach program, has used this information to decrease the rate of HIV in Swaziland by performing voluntary male medical circumcisions throughout the country. During many of these circumcisions, genital medical conditions and penile abnormalities are simultaneously discovered and corrected., Purpose: The goal of our study was to evaluate the prevalence of penile abnormalities discovered and treated during voluntary male medical circumcisions performed by The Luke Commission (TLC) throughout rural Swaziland., Basic Procedures: We completed a retrospective analysis of all male patients who underwent voluntary male medical circumcision performed by TLC during a period from June-August, 2014. The penile abnormalities included: phimosis, paraphimosis, epispadias, hypospadias, ulcers, balanitis, torsion, and foreskin adherent to the glans., Main Findings: Of 929 total circumcisions, 771 (83%) patients had at least one pre-existing penile abnormality identified during their examinations and procedures, totaling 1110 abnormalities. Three specific abnormalities were detected - phimosis, adherent foreskin, and hypospadias. The 6-12 and 13-19 age groups had adequate sample sizes to yield precise estimates of prevalence (age group 6-12: 87% (95% confidence interval [CI]=84-90%; age group 13-19: 79% (95% CI=74-84%)., Principle Conclusions: The Luke Commission is improving the lives of children and adults with limited access to healthcare through regular preoperative evaluations during male circumcision, and the organization is setting an example for other international healthcare groups., Level of Evidence: Type of Study: Prognostic Study, Level II., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To clarify the long-term outcome of median raphe cysts (MRCs) and parameatal urethral cysts (PUCs) in males, the clinical, anatomical, and histological findings of these cysts are described, along with treatment and follow-up., Materials and Methods: Forty-six children diagnosed with PUCs and 23 children with MRCs at our institute during the past 14 years were retrospectively reviewed. The indications for surgery were symptoms or family preference. Telephone interviews of the parents or patients were conducted to ascertain the current condition of the cyst at a median age of 12.2 years. Fifty-nine children (85.5%) agreed to the telephone interview., Results: Median age at first presentation was 41 months; 81% of children were asymptomatic. The main symptoms were voiding symptoms with PUCs and pain of the ruptured cyst in MRCs. A total of 41 (59%) children underwent complete excision at a median age of 58 months. No recurrences were encountered with surgery in all children. Of 28 children managed nonoperatively, 22 agreed to an interview. All children (95.5%), except for 1, remained free of symptoms. Six cysts showed spontaneous resolution at a median age of 24 months, and 15 improved or stabilized. No one was concerned about the genital appearance and opted for surgical intervention., Conclusion: Complete excision of the cyst is a durable procedure without recurrences in childhood. In the nonoperative management, several cysts may continue to be free of symptoms during childhood, and some cysts may resolve spontaneously during the first 2 years., (Copyright © 2016 Elsevier Inc. All rights reserved.)

A 24-year-old man presented with symptoms of difficulty in passage of urine, mixed with gas and stool from penoscrotal junction since birth. He had a history of surgery (posterior sagittal anorectoplasty) for imperforate anus in first week of his life. On physical examination, external meatus was adequate with small 5×5 mm fistulous opening noted at penoscrotal junction with normal anal tone and opening. On evaluation with retrograde urethrography, voiding cystourethrogram, cystoscopy and barium enema, he was found to have penile urethrocutaneous fistula of 0.5×0.5 cm with Y-type incomplete urethral duplication. Urethroanal fistula (Y-type urethral duplication) was of small size (<5 mm), so closed primarily through perineal route with interposition of ischiorectal fat. Penile urethrocutaneous fistula (4 mm) too was closed primarily and covered with tunica vaginalis flap in single sitting. It has been 6 months since surgery and the patient is fully continent and voiding well with no urinary or faecal leak., (2017 BMJ Publishing Group Ltd.)

Median raphe cysts are rare congenital lesions ofthe male genitalia that occur as a result of alteredembryologic development. We report two such casesof median raphe cysts in the pediatric age group. Inaddition, we review the literature.

Background: Although anorectal malformations (ARMs) are frequently encountered, rare variants difficult to classify have been reported., Methods: This study describes a patient with ARM and rectopenile fistula. The literature was reviewed systematically to assess the anatomical characteristics, clinical presentations and operations of this rare type of ARM., Results: Eight patients were reported in the six included articles. In three patients, the fistula extended from the rectum to the anterior urethra without communication with the skin. In one patient, the fistula, located deep in corpus spongiosum, opened to the ventral aspect of the penis without communication with the urethra. In the remaining four patients, the fistula extended from the rectum to the cutaneous orifice in the ventral aspect of penis, with communication or a short common channel with the urethra., Conclusions: Imperforate anus with fistula extending into the penis is a rare variant of anorectal malformation. Unawareness of this lesion resulted in a delay of correct diagnosis and appropriate management. A thorough examination, including colonourethrography and fistulography, should be performed in all patients with a fistula opening in the ventral aspect of the penis.

Congenital anterior urethrocutaneous fistula and megalourethra are both rare anomalies. These anomalies are commonly associated with other anorectal or genitourinary anomalies and evaluated with voiding cystourethrography. We examined a 34-month-old boy who presented with a fistula at the penoscrotal junction. A voiding cystourethrogram showed a jet of urine coming through the fistula and proximal saccular dilatation of the penile urethra. We present the imaging findings of the first case of an association between a congenital anterior urethrocutaneous fistula at the penoscrotal junction and a proximal penile megalourethra. We also discuss the etiology, management, and differential diagnosis of this entity, and review the literature.

Objective: Aphallia is a rare penile congenital abnormality. The aim of this systematic review was to assess all available literature on neophalloplasty in infancy with an interest in technical alternatives and clinical outcome., Materials and Methods: We performed a Pubmed search using the terms: neophalloplasty, neophallus, and phalloplasty, and selected articles that presented technical alternatives for penile construction in cases of penile dysgenesis, especially aphallia in children and/or adolescents., Results: A total of 319 articles were identified in the initial search. Among the different techniques presented in 19 papers collected, we categorized reconstructive procedures into two groups: microsurgical and non-microsurgical techniques. Among the microsurgical techniques, procedures such as the osteocutaneous fibular flap (n = 18), the myocutaneous latissimus dorsi flap (n = 24), and the radial forearm free flap (n = 293) were reported. Among the non-microsurgical techniques, we found a wider range of technical options (6 in total). Most were based on groin, abdominal, and scrotal flaps. Long-term reports on the functionability of the neophallus and psychological aspects of the patients are lacking., Conclusion: In assessing recent literature, it seems rational that neophalloplasty should be regarded as the preferred strategy for boys born with aphallia, in opposition to female gender assignment., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: Abnormalities involving the skin coverage of the penis are difficult to define, but they can significantly alter penile appearance, and be a cause of parental concern., Data Sources: The present review was based on a nonsystematic search of the English language medical literature using a combination of key words including "penile skin anomalies" and the specific names of the different conditions., Results: Conditions were addressed in the following order, those mainly affecting the prepuce (phimosis, balanitis xerotica obliterans, balanitis, paraphimosis), those which alter penile configuration (inconspicuous penis and penile torsion), and lastly focal lesions (cysts, nevi and vascular lesions). Most of these anomalies are congenital, have no or minimal influence on urinary function, and can be detected on clinical examination. Spontaneous improvement is possible. In the majority of cases undergoing surgery, the potential psychological implications of genital malformation on patient development are the main reason for treatment, and the age generally recommended for surgery is after 12 months of age., Conclusion: This review provides the pediatrician with a handy tool to identify the most common penile skin anomalies, counsel parents adequately, make sensible and evidence based choices for management, and recognize complications or untoward outcomes in patients undergoing surgery.

Introduction: By definition, congenital concealed penis presents at birth. Children are usually referred to physicians because of parental anxiety caused by their child's penile size., Objective: Several surgical procedures have been described to treat this condition, but its correction is still technically challenging. The present study reports a simple surgical approach, which allows preservation of the prepuce., Patients and Methods: During the last 6 years, 18 children with concealed penis (according to the classification by Maizels et al.) have been treated in the present department (mean age 4.5 years, range 3-12 years). Patients with other conditions that caused buried penis were excluded from the study. The operation was performed through a longitudinal midline ventral incision, which was extended hemi-circumferentially at the penile base. The dysgenetic dartos was identified and its distal part was resected. Dissection of the corpora cavernosa was carried down to the suspensory ligament, which was sectioned. Buck's fascia was fixed to Scarpa's fascia and shaft skin was approximated in the midline. Penoscrotal angle was fashioned by Z-plasty or V-Y plasty., Results: The median follow-up was 24 months (range 8-36). The postoperative edema was mild and resolved within a week. All children had good to excellent outcomes. The median pre-operative to postoperative difference in penile length in the flaccid state was 2.6 cm (range 2.0-3.5). No serious complications or recurrent penile retraction were noted., Discussion: Recent literature mostly suggests that concealed penis is due to deficient proximal attachments of dysgenetic dartos. Consequences of this include: difficulties in maintaining proper hygiene, balanitis, voiding difficulties with prepuce ballooning and urine spraying, and embarrassment among peers. Surgical treatment for congenital concealed penis is warranted in children aged 3 years or older. The basis of the technique is the perception that in boys with congenital concealed penis, the penile integuments are normal but they have abnormal attachments, and that incision of the skin and dartos will allow the shaft to extend. Furthermore, incisions of the fundiform and suspensory ligaments facilitate this maneuver. With this technique, the blood supply of the penile skin is not interrupted and postoperative lymphedema, a difficult complication to deal with, is prevented. One major advantage is the preservation of the prepuce, giving a normal penile appearance and an excellent cosmetic result., Conclusion: The method proposed here is simple and has no serious complications. It is suggested that this condition be treated in pre-school-aged children in order to prevent psychological impairment., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To evaluate the correction of different degrees of penile torsion following a ladder step so that simpler steps are used whenever possible. This can avoid the morbidity and complications of complex procedures., Patients and Methods: Cases of congenital and acquired penile torsion were repaired on a ladder step basis irrespective of the degree of torsion, starting with degloving and skin realignment, then a dorsal dartos flap and finally corporopexy. The torsion is checked with artificial erection after each step, and if corrected completely then the next step(s) is omitted., Results: Twenty-five cases of penile torsion (30-180°) were repaired over a 4-year period. Three cases were corrected by degloving only, 12 by degloving and skin realignment, five by a dartos flap and four required a corporopexy. Postoperative complications included five cases of penile edema, one case of hematoma and one case of dorsal skin gangrene. Residual torsion of <15° occurred in three cases. No cases required redo surgery., Conclusion: A ladder step approach is a good option for penile torsion repair, starting with simpler techniques until complete correction is achieved. There is no need to plan a complex procedure in advance., (Copyright © 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

We describe three cases of split median raphe of the penis (SMR) from our hospital newborn records from 2004 to 2013. One case was associated with median raphe cyst, one with skin hypochromia, and one with a scar-like aspect of the region of interest. SMR is thought to be the result of defective fusion of ectodermal tissue in the urethra and scrotum area or of defective growth of the perineal mesoderm around the urethra during gestation. Although SMR associated with other major penile congenital defects (epispadias, hypospadias, penile torsion, bifid scrotum, chordee) is common, isolated SMR is probably an underdiagnosed (although not rare) malformative condition. Recognizing SMR in a newborn may be of educational value to neonatologists because it leads to the search for and exclusion of the above-mentioned pathologic conditions., (© 2014 Wiley Periodicals, Inc.)

The objective of this study was to compare the outcomes of the modified Nesbit procedure using different techniques for dissecting the neurovascular bundle (NVB) to correct ventral congenital penile curvatures (CPCs). The bundle was mobilized using the medial and lateral dissection technique in 21 (Group 1) and 13 (Group 2) patients, respectively. In the medial technique, Buck's fascia is opened at the dorsal side of the penis, the deep dorsal vein is removed at the most prominent site of the curvature and a diamond-shaped tunica albuginea (TA) is excised from the midline of the penis. In the lateral technique, the bundle is mobilized using a longitudinal lateral incision of the Buck's fascia above the urethra at the 5 and 7 o'clock positions via a bilateral approach. The localization and degree of curvature was evaluated using the combined intracavernous injection stimulation test or from the patients' photographs. The mean patient age and degree of curvature were similar between groups. The mean operation time was longer for Group 2 (P = 0.01). In Group 1, nine patients (42.8%) required one diamond excision, 10 (47.6%) required two diamond excisions and two (9.5%) required more than two excisions; in Group 2, six patients (46.2%) required two diamond excisions and seven patients (53.8%) required more than two diamond excisions (P = 0.019). The differences in penile shortening, penile straightening and numbness of the glans penis were not statistically significant. Medial dissection of the bundle for the modified Nesbit procedure reduces the number of diamond-shaped removals of TA and thus shortens operation time in comparison with its lateral counterpart.

Purpose: Male patients with bladder and cloacal exstrophy are born with demure genitalia and often desire phalloplasty during late adolescence or early adulthood. Radial forearm free flap phalloplasty was used successfully for congenital aphallia in a few small series. We present a series of patients treated with phalloplasty using a radial forearm free flap after the repair of bladder and cloacal exstrophy., Materials and Methods: We reviewed the records of 10 patients who underwent radial forearm free flap phalloplasty between 2007 and 2012. Indications for phalloplasty were classic bladder exstrophy in 8 cases and cloacal exstrophy in 2. Nine patients underwent prior urinary diversion and 1 underwent urethroplasty at phalloplasty. In each case we reviewed the details of prior exstrophy repair, flap size, donor and recipient vessels, complications, need for subsequent surgeries and self-reported sensation., Results: The graft survived in all 10 patients. Short-term complications requiring surgical intervention developed in 2 patients. Five patients subsequently underwent placement of a penile prosthesis and 2 devices were removed secondary to erosion. All 10 patients reported protective sensation and erogenous sensation with ability to achieve orgasm at last followup., Conclusions: Radial forearm free flap phalloplasty results in a sensate, cosmetic neophallus. No patient had long-term complications related to phalloplasty but complications related to penile prostheses continue to be a challenging aspect of phalloplasty. The long-term results of the forearm free flap are encouraging in this series of patients with bladder and cloacal exstrophy who desired phalloplasty., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the results of dorsal dartos flap rotation versus suturing tunica albuginea to the pubic periosteum for correction of congenital penile torsion., Patients and Methods: Seventeen patients with congenital penile torsion were evaluated and managed from 2006 to 2010. On a random basis, 9 patients underwent surgical repair using a dorsal dartos flap rotation technique (group 1), and 8 patients by suturing tunica albuginea to the pubic periosteum (group 2). All were followed up every 6 months., Results: The mean age in group 1 was 52.3 ± 24.8 months, while in group 2 it was 53.4 ± 33.6 months. Mean follow up was 22.3 ± 10.2 and 21.5 ± 7.2 months in group 1 and group 2 respectively. Torsion was corrected in 6 (66.7%) patients of group 1; 3 (33.3%) had residual torsion < 10°. In group 2, correction was achieved in 6 (75.0%) patients and 2 (25.0%) had residual torsion < 10°. The mean operative time was significantly less for group 1 than for group 2: 45.3 ± 7.1 and 74.5 ± 5.3 min, respectively (P < 0.0001)., Conclusions: In short-term prepubertal follow up, both dorsal dartos flap rotation and suturing tunica albuginea to the pubic periosteum are effective for correction of congenital penile torsion. The former technique is easier to perform as it requires much less dissection., (Copyright © 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To investigate the effectiveness of the penile ventral scrotum cohesion place wedge cutting and improved Brisson technique for congenital buried penis., Methods: Between March 2010 and June 2012, 68 boys with congenital buried penis were treated by the penile ventral scrotum cohesion place wedge cutting and improved Brisson technique, with a median age of 4 years and 10 months (range, 3 months-13 years). Of 68 cases, 14 were classified as phimosis type, 14 as rope belt type, 20 as moderate type, and 20 as severe type. The body of penis developed well and had no deformity. After operation, complications were observed, and the effectiveness was evaluated by the designed questionnaire., Results: Early postoperative complications occurred in 11 cases, including obvious adhesion of the outside wrapping mouth in 4 cases, scrotal skin bloat in 5 cases, and distal foreskin necrosis in 2 cases; long-term complications occurred in 9 cases, including abdominal incision scar formation in 4 cases, wrapping mouth scar stricture in 3 cases, and short penis in 2 cases. Primary healing of incision was obtained in the other boys. Fifty-four cases were followed up 6-12 months (mean, 8 months). According to the designed questionnaire, satisfaction rate with the overall view in parents was 77.78% (42/54); the clinical improvement rate was 85.19% (46/54); exposure of the penis was satisfactory in parents of 50 cases; and the parents had no psychological burden of penis exposure in 46 cases, which were significantly improved when compared with preoperative ones (P < 0.05). The boys had no psychological burden of penis exposure in 29 cases (53.70%) after operation, showing no significant difference when compared with preoperative one (18 cases, 33.33%) (chi2 = 1.22, P = 0.31)., Conclusion: Application of the penile ventral scrotum cohesion place wedge cutting and improved Brisson technique can effectively correct congenital buried penis.

Unlabelled: Study Type--Therapy (practise pattern survey) Level of Evidence 3b. What's known on the subject? and What does the study add? Congenital penile deviation has become a relatively frequent finding due to a greater awareness of the problem among patients and physicians. Since the first surgical correction for congenital penile curvature was performed, many modifications have been implemented to overcome the disadvantages of the standard procedure and to improve functional results. Among the possible side effects of the original technique are postoperative erectile dysfunction, the development of painful nodules at the suture sites ('dog ears'), alteration of cutaneous sensibility and significant penile shortening. This study presents a novel approach for the correction of congenital penile curvature. We modified the conventional Nesbit technique by applying superficial tunica albuginea excisions, according to the geometric principles of the Egydio technique., Objective: • To report our experience with a new technique for the correction of congenital penile curvature based on geometric principles., Patients and Methods: • Between January 2006 and March 2011, 211 men with congenital penile curvature underwent our modified Nesbit technique. • The technique consists of an objectivation of the degree of curvature and distribution of the bending force by multiple, small, superficial, elliptical excisions of the tunica albuginea., Results: • The overall success rate was 99.1%. • A residual curvature of less than 20° was reported in 5% (n = 11) of the cases; none of these patients opted for further surgical correction. • Residual curvature of up to 30° was observed in 0.9% (n = 2); these patients underwent a reoperation. • Acquiring or regaining the ability to perform sexual intercourse brought major relief and high rates of satisfaction and self-esteem. • No recurrence of a ventral curvature occurred., Conclusions: • Our modified Nesbit technique, consisting of superficial tunica albuginea excision according to the geometric principles of the Egydio technique, leads to rapid and excellent results due to an objectivation of the curvature. • It is a safe and valid alternative for the treatment of congenital ventral or ventro-lateral penile deviation., (© 2012 THE AUTHORS. BJU INTERNATIONAL © 2012 BJU INTERNATIONAL.)

Congenital penile curvature results from disproportionate development of the tunica albuginea of the corporal bodies and is not associated with urethral malformation. Patients usually present after reaching puberty as the curvature becomes more apparent with erections, and severe curvature can make intercourse difficult or impossible, at which point surgical repair is recommended. Excellent outcomes can be expected with surgical intervention. The three most commonly used repair techniques are the original Nesbit procedure, modified Nesbit procedure, and plication. Nesbit and modified Nesbit techniques require that an incision is made in the tunica albuginea while plication techniques utilize plicating sutures without an incision. While Nesbit and modified Nesbit techniques are more complex operations, these generally result in less recurrences and more satisfactory outcomes as opposed to the quicker and simpler plication technique.

Introduction: Penile drop is a condition where the erect penis is pointing downward. It can either be congenital or posttraumatic. Congenital cases can be attributed to either a defective penile suspensory ligament (PSL) or severe congenital curvature, with the point of maximum curvature proximal, at the base of the penis, concealed within the pubic fat (proximal penile curvature [PPC]). It is important to diagnose the underlying abnormality and choose the surgical approach accordingly, considering that surgical correction of PSL defects results in shortening that can be avoided in PPC cases., Aim: This work describes a method for discriminating PSL defects from PPC and their surgical management., Main Outcome Measures: Accuracy of preoperative diagnosis and results of surgery in terms of erection angle and penile length., Methods: This is a retrospective study of the management of 12 male patients with congenital penile drop. Diagnostic measures were the pubic gap sign: palpation of a gap between the pubis and the penis, the straightening sign: patients with PSL defects can correct the angle of erection while contrary to PPC cases, Sexual Health Inventory for Men (SHIM), and intraoperative trial rotation of the corpora cavernosa that will correct PPC cases and point them out. Accordingly, PSL cases were managed by anchoring the base of the penis to the pubis, while PPC cases were managed by corporal rotation., Results: Penile drop was fully corrected with shortening in PSL group and without in the PPC group. The straightening sign, SHIM, and trial rotation were in agreement contrary to the pubic gap sign., Conclusion: Discriminating PSL defects from PPC is possible by the combination between "straightening sign" and SHIM results. PSL cases should be managed by anchoring sutures despite the inevitable shortening. PPC cases can be spared the shortening by corporal rotation., (© 2011 International Society for Sexual Medicine.)

Purpose: Using statewide data, we evaluated whether the changing incidence of penile anomalies and hypospadias is reflected in the diverse California population of newborn males over the past 20 years., Methods: Discharge data from all California hospitals, prepared by the OSHPD (Sacramento, CA) was reviewed for the years 1985-2006 for male infant births with an ICD-9 code (752.6) for hypospadias, epispadias or other penile anomalies. Trends were examined by Generalized Estimation Equations for Poisson regression., Results: From 1985 to 2006, the birth incidence of newborn penile anomalies increased in California from 47 to 57 cases per 10,000 newborn discharges, yet the trend for hypospadias alone appears stable from 1997. The rates for penile anomalies in newborns increased 1.4% annually (p < 0.001). All racial/ethnic groups analyzed showed this increase (p < 0.001 for each). During the study period there was a 2% increase per year in plural births (p < 0.001). Interestingly, the rate of change in penile anomaly incidence was greater in males of plural births compared to their singleton cohorts (2% vs 1% annually) (p < 0.001). The birth incidence of cleft palate, another congenital anomaly known to be stable over time, remained unchanged over this period., Conclusions: From 1985 to 2006 in California the incidence of penile anomalies increased in a statistically significant manner, but the incidence of hypospadias appears stable for the last decade. Our data support the notion that different racial/ethnic groups have distinct incidences of penile anomaly formation and that an association with plural births appears to be present., (Copyright © 2011 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

A 2-month-old boy was referred to our department for evaluation of a double mass on the ventral aspect of the penile shaft. There were no associated signs or symptoms of urologic dysfunction. The patient underwent circumcision with complete resection of the masses under general anesthesia.

Introduction: Penile duplication is a rare anomaly with an incidence of 1 in 5,500,000. It is normally associated with other malformations, such as double bladder, presence of the cloaca, imperforate anus, duplication of the rectosigmoid and vertebral deformities. Presented here is the surgical technique used to resolve a rare case of complete penile duplication in a 5-year-old child, without any other malformation., Patient and Methods: A male Caucasian patient presented with a rare diagnosis of complete penile duplication, without any associated systemic malformation. At 5 years of age, he was successfully submitted to surgical treatment. The procedure included the following steps: penile dissection up to the point of ischial-pubic insertion; dissection of the hypoplastic urethra; amputation of the less developed penis; termino-lateral urethral anastomosis and phalloplasty., Results: Three years after surgery, penile morphology was normal, with a normal urinary flow according to age., Conclusions: Treatment should always be individualized. The malformations that are potentially life-threatening should be solved first. Fortunately, this patient had only penile duplication, successfully corrected after surgical treatment., (Copyright (c) 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study is to report a simple and minimally invasive surgical technique for congenital concealed penis repair., Methods: Described technique includes two approaches based on common principle, which could be selected according to the degree of penis buried. Through the minimally invasive incision at the base of penis, the repair is performed combination of tacking penile base to prepubic fascia and anchoring subcutaneous penile skin to base of penile shaft. The outcome of the operation is evaluated by improvement of penile length and satisfaction of penile appearance., Results: A statistically significant difference of the penile length between preoperative and postoperative was 2.6 cm for procedure I, and 2.7 cm for procedure II (P < 0.001). There were 58 parents (93.5%) satisfied with the result. No serious intraoperative or perioperative complications. Edema and swelling on the penis are common, but improves with time. All patients are followed for at least 5 months, no retractions occur in any case., Conclusions: The described technique is simple and minimally invasive. Excellent cosmetic results are achieved with low complication rate and high parent satisfaction. In our experience, there were no additional procedures required to perform deglove or reorganization of the penile skin.

Objective: To assess the feasibility of correction of torsion by mobilization of the urethral plate with the corpus spongiosum and the proximal urethra., Patients and Methods: Of 27 cases of congenital penile torsion, 18 had hypospadias, seven were chordee without hypospadias, and two were isolated penile torsion. Age of patients varied from 2 to 26 years (mean 6 years, 8 months). Correction of torsion was performed: (1) penile skin de-gloving; (2) mobilization of the urethral plate with the corpus spongiosum up to the corona; (3) mobilization of the proximal urethra up to the perineum; and (4) mobilization of the hypoplastic urethra/urethral plate into the glans. Tubularized incised plate urethroplasty with spongioplasty was done in cases of hypospadias, as compared to spongioplasty alone in cases of chordee without hypospadias., Results: Degree of torsion varied from 45 to 180 degrees (mean 68.70); 74% of the patients had left and 26% had right penile torsion. Correction of torsion was possible by penile de-gloving (4%), mobilization of urethral plate and spongiosum (26%), mobilization of proximal urethra (22%), and mobilization of urethral plate/hypoplastic urethra with spongiosum into glans (48%)., Conclusions: Extended urethral mobilization corrected penile torsion in almost all cases. The technique is simple, safe, reproducible and effective for correction of both torsion and chordee.

This study tested the hypothesis that the estrogen receptor (ESR) pathway, androgen receptor (AR) pathway, or both mediate estrogen-induced developmental penile disorders. Rat pups received diethylstilbestrol (DES), with or without the ESR antagonist ICI 182,780 (ICI) or the AR agonist dihydrotestosterone (DHT) or testosterone (T), from Postnatal Days 1 to 6. Testicular T concentration, penile morphology and morphometry, and/or fertility was determined at age 7, 28, or 150 days. DES treatment alone caused 90% reduction in the neonatal intratesticular T surge; this reduction was prevented by ICI coadministration, but not by DHT or T coadministration. Unlike the T surge, coadministration of ICI and coadministration of DHT or T mitigated penile deformities and loss of fertility. Generally, ICI, DHT, or T treatment alone did not alter penile morphology; however, fertility was 20% that of controls in ICI-treated rats vs. 70%-90% in DHT- or T-treated rats. The lower fertility in the rats treated with ICI alone could be due to altered sexual behavior, as these males did not deposit vaginal plugs. In conclusion, observations that both an ESR antagonist and AR agonists prevent penile deformities and infertility suggest that both pathways are involved in estrogen-induced penile disorders. Observations that coadministration of ICI, but not DHT or T, prevents the DES-induced reduction in the neonatal T surge suggest that, although ICI exerts its mitigating effect both at the level of Leydig cells and penile stromal cells, DHT and T do so only at the level of stromal cells.

Purpose: Penile torsion is a congenital malformation that results in a rotational defect of the penile shaft. Various techniques have been described for correcting penile torsion, although there is no consensus on the best repair. We describe our experience using a dorsal dartos flap to correct penile torsion., Materials and Methods: We retrospectively reviewed the records of all 25 patients who underwent repair of significant penile torsion using a dorsal dartos flap at our institution between 2004 and 2007. A total of 17 repairs were performed in association with chordee repair, 7 with hypospadias and 1 with bilateral inguinal hernias. Patient age at the time of repair ranged from 6 to 19 months (mean 9). Of the patients 15 had torsion of at least 90 degrees, 8 had torsion of 60 to 90 degrees and 2 had torsion that was not recorded in degrees., Results: Mean followup was 4 months (range 1.5 to 19). Of the cases 16 demonstrated complete resolution of penile torsion, 7 had residual torsion less than 10 degrees and 2 had documented improvement that was not reported in degrees. No patient has undergone further repair for torsion., Conclusions: Penile torsion is a challenging congenital anomaly. The dorsal dartos flap is familiar to pediatric urologists and can be varied for use in repair of penile torsion. The procedure results in successful repair of the torsion, has few complications and can easily be performed concurrently in the setting of other operative repairs. This approach provides excellent short-term results.

Introduction: Correction of penile curvature by corporal rotation enabled the correction of 90 degrees ventral curvature with neither shortening nor erectile dysfunction. However, some limitations were described, and only one case was reported upon., Aim: This work described a 3-year experience with corporeal rotation, the modifications addressing and eliminating its drawbacks and limitations, as well as the long-term follow-up of 22 patients., Methods: Modified corporeal rotation was performed in 22 patients with various degrees of curvature. Degree of deviation, erect penile length, symmetry, and erectile function were evaluated and compared pre- and postoperatively., Main Outcome Measures: Correction of curvature, resultant sexual function, penile length, and girth., Results: Full correction of curvature was achieved in 20 out of 22 patients, with no shortening, asymmetry, or erectile dysfunction. Residual curvature in two patients was no more than 10 degrees., Conclusions: Corporal rotation can restore straightness to the penis with no loss in phallic length, asymmetry, or erectile dysfunction. While a variety of surgical techniques are feasible for the correction of milder degrees of curvature, we believe that severe degrees should be spared the shortening and corrected by corporeal rotation.

This retrospective study was designed to evaluate the surgical outcome of correction of congenital penile curvature, via multiple vertical incisions in the tunica albuginea using two different types of suture material, simple inverted 2-0 PDS sutures versus Proline 2-0 suture followed by closure with 3-0 vicryl. The study included 45 men with congenital penile curvature and surgeries were performed in four general hospitals. Patients were divided into two groups; Group A (n=24) included patients undergoing penile curvature correction using 2-0 PDS sutures; and Group B (n=21) patients undergoing the same procedure by placing an inverted Proline 2-0 suture in the middle of the suture line and completing the closure of the incision line with 3-0 vicryl. The procedures straightened the penile shaft in all cases but a degree of curvature recurred in three cases (all Group A). No operative or postoperative complications occurred and no reoperations were needed. Four patients complained of penile shortening (all Group A). No recurrence was observed in the proline group (difference not statistically significant). Horizontal plication after vertical corporal incisions is safe and effective in the treatment for congenital penile curvature without hypospadias. We advise avoiding overcorrection to prevent penile shortening.

Introduction: Torsion of the penis is a condition where the penis rotates around its longitudinal axis, whether congenital or acquired. Extreme degrees may provoke a cosmetic complaint., Aim: We describe surgical correction of congenital torsion of the penis in adults, and its prevalence among a special patient group., Main Outcome Measures: Success and ease of surgical repair., Methods: Sixteen cases with congenital torsion were operated upon, by counter-rotation, using a dartos flap in eight cases, and skin realignment in the other eight. The prevalence of congenital torsion was examined in 12,307 patients attending two andrology clinics., Results: Full correction was achieved in all cases. Skin realignment was easier and faster than dartos flap, and was equally effective. Congenital torsion was present in 11.993% of the epidemiologic study group, mild in 80%, moderate in 15%, and severe in 5%. Only 2.2% was bothered by the condition., Conclusion: Torsion of the penis is not uncommon but rarely provokes a complaint. Surgical repair by degloving and skin realignment is effective and easy. Dartos flap technique may be utilized if the former is inadequate.

The authors developed a preputial skin flap technique to correct the buried penis which was simple and practical. This simple procedure can be applied to most boys with buried penis. In the last 3 years, we have seen 12 boys with buried penis and have been treated by using preputial flaps. The mean age is about 5.1 (from 3 to 12). By making a longitudinal incision on the ventral side of penis, the tightness of the foreskin is released and leave a diamond-shaped skin defect. It allows the penile shaft to extend out. A circumferential incision is made about 5 mm proximal to the coronal sulcus. Pedicled preputial flaps are obtained leaving optimal penile skin on the dorsal side. The preputial skin flaps are rotated onto the ventral side and tailored to cover the defect. All patients are followed for at least 3 months. Edema and swelling on the flaps are common, but improves with time. None of our patients need a second operation. The preputial flaps technique is a simple technique which allows surgeons to deal with most cases of buried penis by tailoring the flaps providing good cosmetic and functional results.

Preputium is the extended part of the foreskin of the penis and covers the glans penis. Several congenital anomalies of the preputium such as disproportionate preputial growth, epidermoid cyst, and phimosis have been reported previously. Although lack of the ventral part of preputium is associated with hypospadias, there are no articles about complete agenesis of the preputium. Here, we report a case with the diagnosis of "complete preputial agenesis." This case is the first in our knowledge.

Objectives: Although plication of the tunica albuginea with nonabsorbable sutures is an effective method in correcting congenital penile curvature (CPC), suture-related complications may happen. We investigated the long-term outcome and patient satisfaction of a modified tunical plication technique using absorbable sutures., Materials and Methods: From January 1999 to July 2005, 114 consecutive patients with CPC treated with a modified tunical plication technique by a single surgeon were retrospectively reviewed. With the modified corporeal plication technique, two, interrupted, U-shaped sutures with 2-zero polyglactin were applied to create bumps on the tunica albuginea. The long-term outcome and patient satisfaction were assessed by a post hoc questionnaire interview., Results: Among the 114 patients, complete straightness of the penis was achieved in 65 (57%) patients, and 33 (29%) patients reported a 15-degree or less residual or recurrent curvature at 6 mo postoperatively. Although 32 (28%) patients experienced suture failure (median time: 38.5 d), only half of them had a residual or recurrent curvature greater than 15 degrees. Younger patients (<24 yr) had a higher chance of suture failure than elder patients (p=0.03). Among the 103 patients completing the questionnaire, no palpable suture knots, suture granuloma, erectile discomfort, or erectile dysfunction was reported (median follow-up time: 41.5 mo). Eighty-three (81.5%) patients were either very or moderately satisfied with the surgical outcome., Conclusions: The modified technique using double, interrupted, U-shaped sutures and absorbable suture material is a simple and effective method for treating CPC. Suture-related complications rarely happen. The long-term outcome is satisfactory, and most patients are pleased with the procedure.

Objectives: To present the results of repairing congenital or acquired penile torsion by means of a simple surgical procedure that does not involve resection of corporeal tissue., Methods: Forty-six circumcised patients (mean age 27 months, range 6 to 119) presented with isolated penile torsion of a greater than 30 degree rotation. The surgical technique involved degloving the penile skin to the penoscrotal junction. Residual torsion was corrected using 5-6/0 polyglactin absorbable suture applied to the desired 12-o'clock position of the penile skin adjacent to the glans and to a location counter to the direction of the torsion in the degloved penile skin sleeve. A wedge of loose ventral penile skin was usually resected. The resultant tightening of the skin allowed for proper alignment of the penis and better cosmesis. The rest of the circumferential incision was closed using the same suture material. The success of the procedure was evaluated according to physician and parental satisfaction with the final outcome., Results: Thirty-seven patients were available for follow-up (mean 31 months, range 8 to 68). Satisfactory results were achieved in 35 (95%) of the 37 patients; the other 2 had residual torsion. Complications were minor and consisted of postoperative fever and a subcutaneous hematoma in 1 patient that resolved with conservative treatment., Conclusions: The degloving and realignment procedure is a simple technique that may be applied safely and successfully in most cases of penile torsion.