The dartocavernous stitch surgical technique for prevention of recurrent phimosis in obese patients presenting for circumcision

Introduction

Male circumcision dates back more than 6,000 years and is still one of the most common urologic procedures (1). It is the surgical excision of foreskin. This procedure may decrease the risk of sexually transmitted infections, such as human immunodeficiency virus (HIV), and improve penile hygiene (1,2). Circumcision can also help reduce the incidence of balanitis and penile cancer (1-3). While there are medical benefits of this procedure, there is also a unique concern about cosmetic outcomes. The most common complication of circumcision is bleeding (1). However, other skin complications can occur. If excessive skin excision occurs, there can be penile chordee or torsion. A buried or concealed penis may occur after circumcision due to cicatricial scarring (4). A buried penis can also be secondary to a congenital abnormality, obesity with excess suprapubic fat, or multifactorial (4,5). It has been hypothesized that buried penis may be secondary to insufficient excision of the inner preputial epithelium, the tendency of the penis to retract into the mons pubis, and wound contraction, forcing the penile shaft into a subcutaneous position (5). While the surgeon can control the amount of preputial epithelium removed, retraction into the mons pubis and wound contraction are patient factors that need to be considered. Obesity with excess suprapubic fat puts patients at risk for retraction into the mons as well as scarring with re-phimosis. Consequently, there is a higher risk of recurrent cicatricial scarring and buried penis in obese individuals.

With the rising obesity in adults, buried penis after circumcision is becoming a more common issue in adult male circumcisions. While there are conservative techniques requiring patient commitment to penile manipulation postoperatively to diminish the risk of postoperative scarring, it remains an ineffective maneuver. Often, surgeons may remove more penile skin than necessary to prevent this complication, or even avoid offering the procedure in these patients. In the pediatric literature, there have been various techniques employed to address circumcisions in patients with a buried penis: bucks fascia fixation, dorsal dartos flaps and a variety of fascial fixation techniques (4,6).

We propose a new technique to prevent recurrent phimosis after adult circumcision. To our knowledge, this has not been described in the literature to date. We are proposing a modification to circumcision, where a dartocavernous suture with polydioxanone (PDS) at the 3 and 9 o’clock positions at the time of circumcision (Figure 1). The goal of the proposed technique is to achieve both an aesthetically pleasing and satisfactory functional outcome. We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-24-540/rc).

Figure 1 Illustration of circumcision with dartocavernous suture fixation.

Preoperative preparations and requirements

All patients were under consideration for circumcision. The age ranged from 27 to 63 years old. Preoperatively, two patients had phimosis, one had difficulties with hygiene and painful intercourse, and one had tight foreskin and pain with intercourse. One of the patients with preoperative phimosis had a standard circumcision performed first that was complicated by re-phimosis due to a large suprapubic fat pad. The patients’ baseline body mass indexes (BMIs) were calculated. Patients with elevated BMI were considered for this technique. The average BMI was 41.45 kg/m², ranging from 34.8–50.5 kg/m². There was one patient with re-phimosis after standard circumcision due to a large suprapubic fat pad, who was also offered this technique.

This research was approved by the Institutional Review Board of Rutgers New Jersey Medical School (No. Pro2023001466). Written informed consent was obtained from the subjects to be included in research and to use their images. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Step-by-step description

The circumcisions with the dartocavernous stitch were performed as same day operations at the main university hospital by one reconstructive urologist. Each patient underwent general anesthesia by an anesthesiologist or nurse anesthetist. The patient was prepped and draped in standard sterile fashion using Betadine. A dorsal penile block by the urology team with a combination of Marcaine and Xylocaine in the operating room. Redundant foreskin was measured circumferentially for removal, and the foreskin was sharply excised. After foreskin excision and ensuring appropriate hemostasis, we placed one 2-0 PDS suture at 3 o’clock and another at 9 o’clock attaching the proximal and distal Dartos layers to the tunica albuginea of bilateral corpora cavernosa. The technique is easy to learn and does not require additional training. Afterwards the skin was re-approximated with interrupted absorbable sutures (Figure 2). The additional stitches only added a few minutes to the procedure. The procedure can still be completed in about 30–45 minutes. We then applied topical antibiotic ointment, and the patient was discharged home with instructions to apply antibiotic ointment 4 times per day for 10 days postoperatively.

Figure 2 Example of circumcision with dartocavernous suture fixation. (A) Preoperative: uncircumcised prior to start of procedure. (B) Retracted penis after foreskin removed. (C) Placement of first dartocavernous suture. (D) Dartos exposed after first fixating suture placed. (E) Placement of second dartocavernous suture. (F) After dartocavernous suture fixation prior to skin closure. (G) Circumcision with dartocavernous suture fixation completed with penile skin closed.

Postoperative considerations and tasks

The patients were not instructed to manipulate the foreskin. They were told the same postoperative instructions as standard circumcisions in normal BMI patients. They were only instructed to apply antibiotic ointment 4 times per day for 10 days and to follow-up for postoperative visit. The average follow-up for the patients was 1 month at their postoperative visit in office. One patient continued to follow up with an additional appointment 8 months after surgery.

All patients had excellent postoperative outcomes both functionally and cosmetically at a minimum of 1 month follow up. Figure 3 shows the postoperative outcomes with no recurrence of buried penis or re-phimosis, while maintaining adequate penile shaft skin. Figure 4 presents a patient at 8 months postoperatively. None of the patients had post-op complications, including bleeding or infection.

Figure 3 Three different patients who had circumcision with dartocavernous suture fixation at 1-month postoperative office visit.

Figure 4 One patient who had circumcision with dartocavernous suture fixation 8 months after the procedure.

Tips and pearls

The dartocavernous stitch prevents retraction of the penis due to suprapubic fat pad. The stitches should be placed laterally to avoid damage to urethra or dorsal neurovascular bundle. If the stitch prevents retraction in the operating room, it will remain that way. Once there is a satisfactory outcome intraoperatively, the penile skin can be closed.

Discussion

Acquired buried penis is a disease process that can be a consequence of a scar formation following circumcision in obese patients (7). Patients with a buried penis can have difficulties with maintaining adequate penile hygiene, sexual activity, and voiding. This then continues to worsen as a buried penis can also lead to balanitis, phimosis, and scar formation, further promoting hygienic difficulties (1,2). There are some urologists who defer performing circumcisions in obese patients with a buried penis, given poor surgical cosmetic outcomes, surgical site infections, possibility of penile shortening, and postoperative persistence of buried penis. Penile shortening can be prevented with de-gloving at the time of circumcision or liposuction of the suprapubic fat (8). Liposuction or panniculectomy is often a larger procedure done separately from circumcision. While de-gloving also only adds minimal time to circumcision and can be used in conjunction with our technique, the dartocavernous stitch prevents retraction of the penile shaft, giving a more aesthetic and functional outcome.

With rising rates of obesity, there is increased concern for buried penis after circumcision due to excess suprapubic fat. By adopting this surgical technique, we improved penile concealment intraoperatively and prevented recurrent phimosis postoperatively. Additionally, we eliminated the need for any patient-driven intervention or daily retraction of the suprapubic fat pad in the postoperative period. We had no postoperative complications during our follow-up period. However, we acknowledge that the majority of our patients had a follow-up period of 1 month. It may be difficult to observe long-term complications or late formation of re-phimosis in this time period. We plan to continue to grow this cohort and will plan to have more long-term follow-up.

The main limitation of this study is the low sample size and retrospective nature of the review article. In addition, there are limitations to the reproducibility of the results due to the performance of the surgery by a single surgeon at a single center. However, this technique is easy to learn with negligible additional cost and time added to a circumcision. Given that this is a new technique adopted in the adult population with excellent postoperative outcomes, we aimed to share our early results. Moving forward, we will present more data as we accrue more patients.

Conclusions

The dartocavernous stitch is a safe and effective technique with satisfactory functional and cosmetic outcomes in patients undergoing circumcision that are at substantial risk of developing postoperative buried penis. This stitch can be performed in standard circumcision or in dorsal slit. While this technique is new with a small cohort of adult patients, it shows good potential with high success thus far.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-24-540/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-540/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-24-540/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This research was approved by the Institutional Review Board of Rutgers New Jersey Medical School (No. Pro2023001466). Written informed consent was obtained from the subjects to be included in research and to use their images. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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