Efficacy analysis of modified circumcision in the treatment of pediatric concealed penis

Introduction

Concealed penis, a spectrum of conditions characterized by inadequate penile exposure, includes buried penis, webbed penis, and trapped penis (1). This anatomical anomaly may lead to numerous physical and psychological complications, including voiding difficulties, balanitis, urinary tract infections, dyspareunia, and psychosocial distress (2,3). It is worth noting that the incidence of concealed penis is higher among obese children, and the global rate of childhood obesity is increasing year by year (4). Moreover, people are increasingly aware of the male health issues and social psychological impacts caused by concealed penises (5). Therefore, a large number of patients currently urgently need effective treatment. The conservative methods for concealed penis include weight management, preputial traction, topical corticosteroids, and observation (3,6). Although conservative methods remain an important treatment option at present, their poor compliance and unsatisfactory results often lead patients to require surgical correction. Penile plastic surgery can directly address anatomical defects to improve exposure and cosmetic appearance, serving as a definitive therapeutic intervention. Notably, the primary surgical objective involves mitigating psychological sequelae and improving sexual dysfunction through enhanced penile exposure and aesthetic outcomes. Consequently, postoperative penile exposure quality and cosmetic results represent critical metrics for evaluating surgical efficacy (7).

Currently, multiple surgical techniques are employed for concealed penis treatment, but the standardized procedures remain undefined. Moreover, postoperative complications such as preputial edema, preputial redundancy, penile retraction, and unsatisfactory cosmetic outcomes have consistently been common challenges in clinical treatment (8). A major intraoperative difficulty involves achieving adequate skin coverage following circumcision and penile degloving, which necessitates meticulous preservation of the outer preputial lamina. Furthermore, excessive retention of inner preputial lamina and incomplete release of preputial constriction rings are key contributors to postoperative edema, highlighting the importance of thorough excision of inner preputial lamina and complete release of constriction ring. However, traditional approaches exhibit significant limitations in addressing these difficulties, as well as the standard circumcision. For example, the Shiraki technique, which excludes penile degloving and dartos tissue release/excision, is of little help in improving penile exposure and is not suitable for severe concealed penis (9). The Devine procedure utilizes a dorsal penile incision for degloving and constriction ring release. Still, the dorsal incision in penile skin and excessive preservation of the inner preputial lamina prepuce often compromise postoperative penile aesthetics (10). While the Borsellino technique, featuring a V-shaped incision at the penoscrotal junction to reconstruct the penoscrotal angle, demonstrates simplicity, minimal invasiveness, and favorable cosmetic results, its over-resection of the outer preputial lamina may require compensatory retention of the inner lamina, thereby increasing edema risk (11).

To address these challenges, we have developed a modified circumcision technique especially for the concealed penis for decades. Compared with traditional circumcision, our modified technique emphasizes near-complete excision of the inner preputial lamina while preserving the outer preputial lamina during circumcision, addressing both inadequate skin coverage and postoperative edema. Furthermore, the novel technique combines with penile degloving, constriction ring release, and penoscrotal angle reconstruction to improve penile exposure. Additionally, the novel technique recommends individualized operation involving the penoscrotal angle reconstruction and preservation length of the inner preputial lamina according to the penile concealment severity. Therefore, the modified circumcision may reduce surgical trauma and postoperative complications, improve the penile appearance, and be a good choice for treating concealed penis. This study aims to introduce the novel technique and test this hypothesis. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-363/rc).

Methods

Clinical data

This retrospective study analyzed clinical records of pediatric patients with concealed penis treated at The First Affiliated Hospital of Sun Yat-sen University between March 2013 and October 2023. Inclusion criteria were: (I) patients undergoing either the modified circumcision technique or the classic Devine procedure; and (II) complete clinical data and successful follow-up. Exclusion criteria included: (I) with concomitant penile abnormalities (e.g., micropenis, hypospadias, or penile curvature); and (II) treatment with alternative surgical approaches. Of 148 initially identified cases, 41 were lost to follow-up, leaving 107 patients for final analysis. Among these, 53 patients received the modified circumcision technique (study group), subdivided into subgroup 1 (n=20, mild/moderate cases treated with modified circumcision alone) and subgroup 2 (n=33, severe cases requiring additional penoscrotal angle reconstruction). The remaining 64 patients underwent the Devine procedure (control group). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Sun Yat-sen University (No. [2021]095). Written informed consent was obtained from all participants’ legal guardians before surgery.

Surgical methods

The control group underwent the Devine procedure, while the study group received the modified circumcision surgery. Both groups underwent standardized surgical procedures: (I) release of preputial constriction rings; (II) complete penile degloving; and (III) meticulously interrupted wound closure with 5-0 polydioxanone monofilament absorbable sutures. Postoperative management was consistent across groups, with a two-layer compressive dressing (inner mesh gauze and outer standard gauze) applied to the penis and placement of a urinary catheter. Key procedural distinctions between the two methods were as follows.

Devine procedure

The surgical technique aligns with the classic Devine procedure as previously described in the literature (10). Briefly, a longitudinal dorsal incision (involving both inner and outer preputial lamina) was made to release the constriction ring and further evert the prepuce. Due to the frequent deficiency of outer preputial lamina in concealed penis cases, a dorsal V-shaped (oblique circumferential) incision extending from the dorsal to ventral aspect was employed during subsequent circumcision. This allowed the utilization of the V-shaped dorsal inner preputial lamina for penile coverage. Subsequently, penile degloving was performed at the corpus cavernosum level to the penile base, with concurrent excision of dartos tissue and suprapubic adipose tissue to alleviate penile tethering. To prevent postoperative retraction, two anchoring sutures were placed at the 2 and 10 o’clock positions of the penile base, further securing the penile base skin to Buck’s fascia. Finally, closure of the incision involved sequential steps: (I) longitudinal suturing of the dorsal prepuce; (II) oblique circumferential suturing of the coronal sulcus incision; and (III) longitudinal closure of the ventral incision. Notably, ventral closure often necessitated retention of additional inner prepuce to ensure adequate coverage.

Modified circumcision procedure

The key principles of our modified approach include: preserving the outer preputial lamina as much as possible; resecting the inner preputial lamina extensively in mild-to-moderate cases; reconstructing the penoscrotal angle while retaining a certain length of inner lamina in severe cases; and implementing preventive measures against postoperative complications such as preputial edema. The specific surgical protocol involved the following steps:

• Longitudinal incision of the inner preputial lamina: a urinary catheter was inserted, and a traction suture was placed on the glans. The prepuce was fully everted and retracted to expose the dorsal inner preputial lamina after incising the dorsal prepuce (Figure 1A-1C). Then, a longitudinal incision was made along the inner preputial lamina toward the glans, terminating 5–20 mm proximal to the coronal sulcus (Figure 1C), with care taken to avoid the outer preputial lamina. The glans and prepuce were re-sanitized following complete exposure.
• Penile degloving: a circumferential incision was created 5–20 mm proximally to the coronal sulcus (Figure 1C,1D), extending through the skin and subcutaneous tissue to the corpus cavernosum surface. In severe cases with deficient skin coverage (requiring partial inner lamina preservation), the incision was positioned 10–20 mm from the coronal sulcus, whereas mild/moderate cases (permitting maximal excision of inner lamina) employed a 5–9 mm distance. Subsequently, complete degloving to the penile base was performed at the cavernosal plane, with division of the suspensory ligament and full release of fascial tethering, while protecting the ventral urethra and dorsal neurovascular bundle (Figure 1D).
• Excision of inner preputial lamina: the distal prepuce was pulled and lifted up to expose the inner lamina. Midline dorsal and ventral incisions were made to release constriction rings of the inner preputial lamina, creating bilateral preputial flaps. Furthermore, the distal inner preputial lamina was circumferentially excised along its natural anatomical boundary with the outer lamina (Figure 1E,1F).
• Release of the preputial constriction ring: after removing the inner preputial lamina, the residual constriction ring of the outer preputial lamina was still frequently observed, primarily attributable to the fascial narrowing. To address this, longitudinal incisions were made along the dorsal and ventral fascia to release the fascial constriction ring. At the same time, excess dartos fascia and adipose tissue were also dissected from the penile skin flap. If residual constriction persisted post-fascial release, small incisions of the outer preputial lamina were performed synchronously at the 12, 3, 6, and 9 o’clock positions. Due to the relative scarcity of dorsal skin compared to the ventral abundance, priority was given to incising the ventral preputial skin for constriction relief.
• Suturing of the coronal sulcus incision: the coronal sulcus incision was closed using an equidistant interrupted suturing method (i.e., suturing the retained inner preputial lamina and outer preputial lamina; Figure 1G).
• Reconstruction of the penoscrotal angle: in patients with mild-to-moderate concealed penis and normal body weight, penile appearance improved and penoscrotal angle was restored naturally after circumcision, generally obviating the need for the reconstruction of the penoscrotal angle (Figure 1H-1J). These patients were divided into subgroup 1. The procedure of modified circumcision in the severe concealed penis was similar to that of the mild cases (Figure 2A-2I). However, patients with severe concealed penis or obesity often exhibited persistent conical penile morphology with broad and loose penile base, inconspicuous penoscrotal angle, and inadequate exposure post-circumcision, necessitating penoscrotal angle reconstruction (Figure 2H,2I). They were divided into subgroup 2. In short, if the penoscrotal angle could not be restored after circumcision, reconstruction of the penoscrotal angle was indispensable. To address this, an inverted V-shaped incision was made at the penoscrotal junction (Figure 2I,2J), followed by division of the skin and fascial layers. Subsequently, longitudinal layer-by-layer suture of the fascia and skin was performed to reconstruct the penoscrotal angle and elongate the ventral side of the penis. This technique could transform the conical shape of the penis into a cylindrical one (Figure 2K-2N), while narrowing the penile base to prevent it from retracting and enhancing the exposure of the penis.
• Wound dressing: penile wound dressing was performed using a double-layer technique. The inner layer consisted of mesh gauze followed by an outer wrapping with standard gauze (Figure 2N). Particular attention was paid to avoid excessive tightness during application of the inner mesh layer. The inner layer was generally maintained for 2 weeks postoperatively, ensuring re-establishment of adherence between the penile skin and corpus cavernosum, thereby facilitating formation of the cylindrical penile architecture.

Figure 1 Surgical procedure for mild to moderate concealed penis. (A) Preoperative appearance of mild to moderate concealed penis. (B) Longitudinal incision of the dorsal prepuce. (C) Longitudinal incision of the inner preputial lamina after eversion and exposure. (D) Penile degloving and release of the constricted subcutaneous fascia. (E,F) Resection of the inner preputial lamina along the natural junction between inner and outer lamina. (G) Suture closure of the coronal sulcus incision. (H) Lateral view post-repair demonstrating normal penoscrotal angle and satisfactory penile exposure. (I) Dorsal view post-repair shows no longitudinal incision in dorsal penile skin. (J) Ventral view post-repair shows the penile appearance approximates the post-circumcision morphology.

Figure 2 Surgical procedure for severe concealed penis. (A) Preoperative appearance of severe concealed penis. (B) Longitudinal incision made on the dorsal prepuce. (C) Eversion and exposure of the preputial inner lamina. (D) Circumcoronal incision performed with preservation of 10–20 mm preputial inner lamina. (E,F) Degloving of the penis and release of fascial constriction ring. (G,H) Resection of preputial inner lamina along the natural junction between inner and outer prepuce lamina. (I) V-shaped incision created at the penoscrotal junction. (J) Transverse incision of the superficial and deep fascia at the penoscrotal junction. (K) Longitudinal suturing of the penoscrotal junction and the ventral view post-repair shows the cylindrical penis. (L) Lateral view of the penis after closure demonstrating normal penoscrotal angle and the cylindrical penis. (M) Dorsal view post-repair shows no longitudinal incision in dorsal penile skin. (N) Post-surgery dressing technique.

Postoperative care

The postoperative care protocols were essentially identical between the two groups. Prophylactic second-generation cephalosporins were administered for 3 days. The outer gauze dressing was removed 3 days postoperatively, followed by the removal of the inner mesh gauze at 2 weeks post-surgery. During the period of mesh gauze retention, the penis and gauze were disinfected daily with povidone-iodine solution. The urinary catheter was removed 1 week after the procedure.

Observation and follow-up

Preoperative measurements included penile length above baseline skin level (BPL) (measured from the pubic skin to the glans tip without traction) and the degree of concealed penis [classified per the Chinese Andrology Society criteria: mild (partial penile body type), where part of the penile shaft and glans are visible within a conical skin mound; moderate (glans type), with a protruding conical skin mound, barely visible glans beneath the mound, and palpable coronal sulcus at the abdominal plane; severe (skin mound type), presenting only a conical skin mound without palpable glans or palpable only at the distal end of glans]. Intraoperative blood loss and operative duration were also recorded. Postoperative BPL and early complications (e.g., bleeding, incisional infection, skin flap necrosis) were assessed before discharge. At 1-year postoperatively, telephone follow-up or outpatient review will be conducted to evaluate complications including preputial edema, preputial redundancy, penile retraction [the improvement of exposure during the operation was significant, but the retraction was obvious after surgery; determined by no change or even a deterioration in BPL (evaluated objectively by follow-up physician)], and penile constriction (due to scar contracture limiting erectile exposure). BPL was also measured. Additionally, patient satisfaction with penile appearance was scored [to minimize anticipation error, pediatric penile perception score (PPPS) ≥8 defined as satisfied, <8 as unsatisfied] to calculate satisfaction rates.

Notably, this study referenced the PPPS (12), a postoperative evaluation tool for penile appearance in hypospadias patients, to develop a novel assessment scale for postoperative penile appearance satisfaction in this study. The scale comprises four parameters: penile skin condition, penile exposure, penile axis, and overall penile appearance. Each parameter was scored as 0 (very dissatisfied), 1 (dissatisfied), 2 (satisfied), or 3 (very satisfied), with total scores ranging from 0 to 12. The first three parameters were objectively assessed by follow-up physician, while the overall appearance was subjectively evaluated by patients or their parents (Table S1).

Statistical analysis

Data were recorded using Excel and analyzed with GraphPad Prism 8.0 software (San Diego, CA, USA). Measurement data were expressed as [mean ± standard deviation (SD)]. Categorical data were compared using the Chi-squared test, while the Student’s t-test was applied for continuous variables with normal distribution. A two-tailed (P<0.05) was considered statistically significant.

Results

Baseline characteristics

No statistically significant differences were observed between the control and study groups in terms of age, overweight status, BPL, or severity of concealed penis (all P>0.05), indicating comparable baseline characteristics between the two groups (Table 1).

Postoperative outcomes and complications in control and study groups

There were no intraoperative complications, such as bleeding, in either the control or study groups. No statistically significant differences were observed in blood loss between the control and study groups. However, the study group exhibited significantly shorter operation time compared to the control group (66.7±11.0 vs. 86.9±9.10 min, P<0.001). There was no significant intergroup difference in the measured BPL immediately after wound closure. Similarly, the incidence of postoperative wound infection and bleeding did not differ significantly between the two groups (P>0.05). These results indicate that the modified circumcision technique does not increase surgical trauma but significantly reduces operative time (Table 2).

Postoperative complications, including preputial edema, preputial redundancy, and penile retraction, occurred in both study and control groups, however, with significantly lower incidence in study group than that in control group (P<0.05). At the 1-year follow-up, the study group exhibited greater total BPL (3.17±0.89 cm) and increase in BPL (1.65±0.57 cm) than the control group (2.55±0.80 and 1.00±0.50 cm, P<0.001). Additionally, the study group achieved higher PPPS scores (9.55±1.41 vs. 7.92±1.92, P<0.001) and greater satisfaction rate with penile appearance (96.2% vs. 64.1%, P<0.001) (Table 2). It is worth noting that the study group also demonstrated excellent postoperative cosmetic effects. The key feature is that the penile appearance approximates the post-circumcision morphology, with no midline dorsal incision on the penile shaft, and the prepuce is evenly distributed without redundancy (Figure 3A-3H). Three patients in control group underwent reoperation due to severe complications. In contrast, the penile appearance in the control group was relatively poor, and the probabilities of persistent preputial edema, preputial redundancy, asymmetry of the prepuce and deviation of the penile axis were also more common (Figure 4A-4F).

Figure 3 Postoperative recovery in the study group. (A-D) Case 1: mild to moderate type. (A) Preoperative penile appearance. (B) Immediate postoperative penile appearance. (C) Postoperative appearance at 1 month. (D) Postoperative appearance at 1 year. (E-H) Case 2: severe type. (E) Preoperative penile appearance. (F) Immediate postoperative penile appearance. (G) Postoperative appearance at 1 month. (H) Postoperative appearance at 1 year.

Figure 4 Postoperative recovery in the control group. (A-C) Case 1: mild to moderate type. (A) Preoperative penile appearance. (B) One-month postoperative penile appearance (“→” indicates poor appearance, deviation of penile axis, irregular preputial incision). (C) One-year postoperative penile appearance (“→” indicates poor appearance, redundant prepuce, and persistent deviation of penile axis). (D-F) Case 2: severe type. (D) Preoperative penile appearance. (E) 1-month postoperative penile appearance (“→” indicates poor appearance, preputial edema, asymmetric prepuce, and deviation of penile axis). (F) One-year postoperative penile appearance (“→” indicates poor appearance, persistent preputial redundancy and deviation of penile axis).

Comparison between subgroup 1 and subgroup 2

A further subgroup analysis was conducted on the study group to evaluate the clinical value of individualized treatment. Subgroup 1 consisted of patients with mild to moderate concealed penis and most of them were of normal weight, while subgroup 2 included patients with severe concealed penis and most of them were overweight. There was no difference in age between the two groups. However, the preoperative BPL of subgroup 1 was significantly longer than that of subgroup 2 (P<0.001), suggesting that more complex surgical approaches might be needed for patients with severe conditions (Table 3). Furthermore, the operation time was shorter in subgroup 1 (55.0±5.13 min) compared to subgroup 2 (73.8±6.62 min, P<0.001), while blood loss and postoperative BPL after wound closure showed no significant intergroup differences (P>0.05). At 1-year follow-up, no statistical disparities were observed in postoperative complications (preputial edema, preputial redundancy, penile retraction), PPPS scores, and satisfaction rate with penile appearance (P>0.05). Moreover, the total length of the penis in subgroup 1 was greater (3.52±0.84 vs. 2.96±0.86 cm, P=0.02), while the increase in the length of the penis in subgroup 2 was even greater (1.84±0.61 vs. 1.34±0.31 cm, P=0.003). This might be attributed to the better preoperative exposure of the penis in subgroup 1 (Table 3). Finally, both subgroup 1 and subgroup 2 showed favorable postoperative appearance, presenting typical characteristics of post-penile circumcision (Figure 3A-3D vs. Figure 3E-3H). These results indicate that for mild to moderate cases, only performing modified circumcision is sufficient. However, for severe concealed penises, measures such as reconstructing the penile scrotal angle may be necessary to optimize the postoperative level of penile exposure (Table 4).

Discussion

This study introduces a novel modified circumcision technique for concealed penis repair based on critical anatomical findings. Although circumcision has historically been used to address phimosis and preputial redundancy (13), it proved insufficient as a standalone treatment for concealed penis (14). Severe phimosis are critical anatomical abnormalities in concealed penis (15). Additionally, circumcision is also an essential step of concealed penis surgery. Therefore, our surgical team proposes the application of circumcision to treat concealed penis. However, concealed penis typically presents with other anatomical anomalies, including insufficient fixation between penile skin and corpora cavernosa, abnormal development of superficial penile fascia, poor anchoring of the penile base, and effacement of the penoscrotal and penopubic angles (16). Conventional circumcision fails to address all these abnormalities and may even aggravate the concealment of the penis due to excessive excision of the prepuce (17,18). Based on these anatomical characteristics, our surgical team modified the conventional circumcision techniques by incorporating circumcision, penile degloving, superficial fascia resection/incision, and penoscrotal angle reconstruction. The key technical modifications include: (I) simultaneously incise the narrow ring of prepuce from both the dorsal and ventral sides, being careful to avoid excessive incision of the dorsal outer preputial lamina, thereby preventing penile curvature or skin asymmetry; (II) preserves 5–20 mm vascularized distal inner lamina without sublamina dissection through coronary sulcus-circumferential incision (5–20 mm proximal); (III) complete release of preputial constrictive rings; (IV) systematic fascial ring release with selective fibrotic fascia excision; and (V) severe cases require penoscrotal angle reconstruction for penile elongation and anatomical base fixation. Notably, conventional procedures have shortcomings such as complex incisions, the need for flap transfer, and lack of standardization regarding penoscrotal angle reconstruction (10,19-21). However, our modified method is similar to circumcision and successfully overcomes these shortcomings. Therefore, the modified circumcision technique is simple and easy to learn and promote.

This study proposes individualized treatment based on the severity of concealed penis. The anatomical abnormalities differ between mild-moderate and severe cases (16,22), necessitating distinct therapeutic approaches (14). While most surgeons still employ a single surgical method for varying degrees of concealed penis, there is growing advocacy for individualized treatment (23). Mild-moderate concealed penis cases possess a relative abundance of preputial skin, extensive excision of inner preputial lamina to prevent preputial edema and redundancy is feasible. Additionally, for mild to moderate cases, circumcision effectively restores the penoscrotal angle and significantly improves penile exposure. Consequently, the modified circumcision procedure alone can solve all abnormities of mild to moderate concealed penis. However, severe concealed penis commonly presents with a conical penile morphology due to the abnormally broad and loose penile base. This anatomical configuration leads to: (I) inadequate fixation at the penile base; (II) insufficient adhesion between the penile skin and corpus cavernosum; and (III) obliteration of the penoscrotal angles (Figures 2,3). The circumcision alone fails to achieve spontaneous restoration of the penoscrotal angle in severe cases. Severe concealed penis cases, particularly in obese patients, have historically demonstrated suboptimal outcomes after surgery, including an increased risk of penile contraction and a decrease in postoperative appearance satisfaction. Consequently, an additional procedure to reconstruct the penoscrotal angle is an indispensable step. Traditional management protocols usually mandated preoperative weight loss as a prerequisite for surgical intervention (3). Notably, the Devine procedure prevents penile retraction through penile base fixation via strategic suture anchorage to Buck’s fascia (10). Additionally, narrowing the penile base is another strategy to restore anatomical structure, strengthen dermal-cavernosal adhesion, and reconstruct penoscrotal angle. Based on the above situation, in this study, mild-moderate cases only underwent modified circumcision with less preserved inner preputial lamina (5–9 mm), while severe cases received modified circumcision combined with penoscrotal angle reconstruction and more preserved inner preputial lamina (10–20 mm). We made a V-shaped incision and longitudinal suture at the penoscrotal junction, to narrow the penile base, reconstruct the penoscrotal angle, and elongate the ventral side of the penis (Figure 2). As a result, individualized treatment not only reduced surgical trauma and shortened the operation time in patients with mild-moderate concealed penis, but also improved the penile exposure and appearance of severe concealed penis, while reducing the incidence of postoperative complications such as preputial edema and penile retraction (Table 3, Figure 3). Furthermore, this study also promoted the reattachment between penile skin and the corpora cavernosa by prolonging the time of pressure bandaging with gauze after the operation, thereby preventing penile retraction. In conclusion, individualized treatment based on the degree of concealment is worthy of further clinical promotion.

Currently, standardized scoring systems for evaluating penile appearance following concealed penis surgery remain scarce. This study proposes a novel PPPS system to assess postoperative penile morphology in concealed penis repair, developed by adapting existing scoring systems for hypospadias surgery outcomes (12). Our PPPS system includes four parameters: penile skin condition, penile exposure, penile axis, and overall penile appearance. To mitigate parental emotional bias and physician subjectivity, our scoring system integrates evaluations from both medical professionals (assessing the first three parameters) and patient families (assessing the final parameter). Additionally, the system provides explicit scoring criteria for each parameter (see Table S1). Consequently, this newly developed evaluation system is highly objective and user-friendly, potentially serving as a future standard for postoperative concealed penis appearance assessment.

The concealed penis surgery is regarded as a type of plastic surgery, and its aesthetic outcomes serve as the primary criterion for evaluating the surgical success (7). Suboptimal penile appearance not only diminishes patient satisfaction but may also negatively impact physical and psychological well-being. Key factors contributing to unfavorable postoperative aesthetics include preputial edema, redundant prepuce, incision scarring, penile torsion, inadequate penile exposure, and retraction. Traditional Devine surgery, which employs a dorsal midline penile incision and uses the transferred flap from the inner preputial lamina to cover the penis, often results in persistent midline scarring and preputial redundancy (10). These will damage the aesthetic appearance of the penis after surgery. In this study, the control group receiving Devine surgery demonstrated higher complication rates (Table 2) alongside suboptimal aesthetic results and reduced patient satisfaction (Figure 4). The Shiraki technique, involving interwoven suturing of inner and outer prepuce, may also compromise penile aesthetics and increase the ischemic necrosis risk in the interposed flaps (9). Similar to the Borsellino procedure (11), our modified circumcision technique also excises the prepuce through circumcision and reconstructs the penoscrotal angle through V-shaped incision in penoscrotal junction. However, unlike the Borsellino procedure, we extensively remove the redundant inner preputial lamina but completely preserve the outer lamina. These modifications effectively prevent preputial edema, preputial redundance, and penile retraction (Table 2). Actually, the study group acquired excellent penile aesthetics approximating the post-circumcision morphology, even in those severe cases (Figure 3). Thus, our optimized approach enhances both cosmetic outcomes and therapeutic efficacy of the surgery.

Preputial edema represents a common yet clinically significant complication following concealed penis repair. Severe or persistent edema may progress to preputial redundancy, substantially compromising penile aesthetics and potentially necessitating reoperation. The pathophysiological mechanisms involve two primary factors: (I) excessive retention of inner preputial lamina during surgery; and (II) impaired venous/lymphatic drainage due to constriction from both cutaneous and fascial layers. Conventional techniques (Shiraki, Devine, Sugita, and Brisson) typically preserve substantial inner preputial lamina for penile coverage, thereby increasing postoperative edema risk (9,20,24-26). Anatomically, the outer preputial lamina exhibits lower edema susceptibility. Similarly, the distal inner preputial lamina near the coronary sulcus, which retains an intact vascular supply and lacks a constrictive ring, demonstrates reduced edema propensity. Conversely, the proximal inner preputial lamina adjacent to coronal incisions becomes edema-prone due to compromised microcirculation. Therefore, our modified technique incorporates four anatomical considerations for edema prevention: (I) selective lamina preservation: complete retention of outer preputial lamina and non-constricted distal inner lamina, combined with aggressive resection of proximal inner lamina near coronal incisions to balance skin coverage and edema mitigation; (II) pathology-adapted resection: extensive inner lamina excision in mild-moderate cases (preserved lamina: 5–9 mm) vs. strategic distal lamina preservation in severe cases (preserved lamina: 10–20 mm); (III) fascial release: complete and thorough incision of fascial constriction rings; and (IV) targeted decompression: make radial incisions at the 12, 3, 6, and 9 o’clock positions on the outer preputial lamina to alleviate preputial stenosis and reduce the occurrence of preputial incarceration. Compared with Devine procedure controls, our modified technique demonstrates significantly reduced incidence of postoperative edema and preputial redundancy (Table 2), confirming its clinical superiority in preventing edema.

However, there are several limitations in this study. First, as a single-center retrospective investigation, the findings may be subject to surgeon-dependent variability, underscoring the need for multicenter prospective trials to validate the clinical efficacy of this modified technique. Second, the control group exclusively utilized the conventional Devine procedure, lacking comparative analyses with other established surgical methods. Third, the limited follow-up duration precluded assessment of pubertal and adult outcomes, rendering long-term efficacy inconclusive. Fourth, the extended enrollment period and modest sample size may introduce temporal and statistical biases. Fifth, our PPPS system for concealed penis has not been validated and requires future study. Notwithstanding these constraints, this study provides pioneering technical details for a modified circumcision approach in concealed penis repair. By proposing a severity-stratified treatment protocol and demonstrating its efficacy in reducing complications (e.g., edema, redundancy) while enhancing aesthetic outcomes, this work establishes both methodological novelty and translational clinical value.

Conclusions

In brief, the modified circumcision technique presented in this study demonstrates effectiveness in concealed penis repair, characterized by simplified technical procedures, minimal invasiveness, reduced complication risks, and improved penile aesthetic outcomes. Furthermore, its individualized therapeutic protocol tailored to the degree of penile concealment suggests significant clinical applicability.

Acknowledgments

We are especially grateful to Chunhua Deng, and Cheng Su from The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China for their generous help with surgical guidance.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-363/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-363/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-363/prf

Funding: This research was supported by funding from the Medical Research Funding of Guangdong (No. A2022499), the National Natural Science Foundation of China (No. 82301796), and the Natural Science Foundation of Guangdong Province (No. 2025A1515012486).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-363/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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Sun Yat-sen University (No. [2021]095). Written informed consent was obtained from all participants’ legal guardians before surgery.

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/.

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