Association Between Buried Penis and Peyronie ’ s Disease : One Stage Surgical Correction Using Porcine Dermal Collagen Graft ( Permacol TM )

Buried penis is a condition one might encounter in patients complaining of a small penile size, and in adulthood can be acquired because of obesity, genital lymphedema, diabetes mellitus, or genital skin loss. Peyronie’s disease is a pathology whose unknown etiology, characterized by an excessive accumulation of fibrotic tissue in the tunica albuginea. A 61years old man, previously undergone twice Peyronie’s disease correction, presented with association between an acquired buried penis and recurrence of Peyronie’s disease.We report our experience in managing associated acquired buried penis and Peyronie’s disease, using porcine collagen graft (PermacolTM Surgical Implant, Covidien Europe) and anchoring the stretched penis at its base, conserving the erectile function and the penis lengthin one stage procedure.


Introduction
Buried penis is a condition that can be observed in patients complaining of a small penile size.This pathology is however characterized by a normal penile length, with a shaft hidden below preputial skin in the prepubic fat [1].This condition has to be distinguished from the webbed penis, caused by obliteration of the pen scrotal angle andtrapped penis, which is acquired after circumcision [1,2].These forms of inconspicuous penis must not be confused with micropenis which size is 2.5 Standard Deviations below normal.There are no data in the literature reporting the incidence of inconspicuous penis, but Williams et al. [3] reported 9% of this disorder as a complication after circumcision.Buried penis in adulthood can be acquired because of obesity, genital lymphedema, diabetes mellitus, or genital skin loss caused by infection, trauma or iatrogenic [2].Still unknown the etiology of Peyronie'sdisease that has first described by Francois Gigot de la Peyronie's in 1743, as an excessive accumulation of fibrotic tissue in the tunica albuginea [4].The prevalence rate for Peyronie's disease reported in the literature in the general population range 3%-9% [5].This disease is commonly associated with presence of penile plaques, penile curvature and shortening, leading to psychological distress.This pathology can even in severe cases hamper intromission because of marked curvature, and can moreover be associated with erectile dysfunction.Peyronie'sdiseaseis commonly associated with dia-betes mellitus, ischemic cardiopathy, smoking, hypertension, lipid abnormalities and excessive alcohol consumption.Moreover, Dupuytren's disease is frequently associated with this disease, affecting 9%-39% of patients [4].There are no data in the literature supporting the association between buried penis and Peyronie's disease.

Case report
A 61 years old man with no co morbidity consulted for penile curvature and buried penis.He had previously undergone an unspecified surgical procedure for correction of curvature in another center one year before and a lengthening procedure (V-Y plasty) 15 years before.After surgery, the patient observed a worsening of penile curvature and an important reduction of the penile length causing important psychological distress.Interestingly, the patient mentioned his sister was affected by Dupuytren's disease.The patient had no voiding problems and refers good rigidity, but due to the curvature, he mentioned difficulties with coitus and reported occasional episode of pain during intercourse with unsatisfying sexual intercourse and IIEF score 18. Physical examination revealed a normal penile shaft, hidden within the scrotal skin with a palpable plaque on the dorsal aspect of the penis.Diagnosis of buried penis associated with recurrent Peyronie's disease was made and surgical correction was proposed.As the patient's main concerns were related to his penile length and to the curvature pre-venting intercourse, the aims of the proposed surgery were, preservation of the length while correcting curvature avoid erectile dysfunction and improve quality of life.
Correction of buried penis was done using a locally developed surgical technique for treatment of buried penis published by Spinoit et al. [6].An artificial erection test was done using the classical tourniquet technique published by Gittes and McLaughlin [7].A 19-gauge needle is tuck into the body of one of the corpora cavernosa and saline solution is injected.This maneuver showed an important ventral curvature of more than 90° caused by one Peyronie's plaque in the dorsal side.Compared with the original Nesbit technique in which an elliptical excision of the tunica albuginea on the contralateral side of maximal curvature is performed, resulting on a shortening of the longer side of the phallus, we performed a lengthening procedure with dissection of the plaque and creation of a partial rectangular tunical defect removing the scarred tissue and the fibrotic tissue of the prior interventions [8].After measuring, a 4 cm porcine dermal collagen graft Permacol ™ Surgical Implant, Covidien Europe), was sutured to the defect using a running 4/0 monofilament polyglyconate suture to the tunica albiginea.Artificial erection control proved the repair to be waterproof and showed no more curvature.A Zplasty was performed at the penoscrotal junction to redefine the penoscrotal angle.Excessive skin was removed and suction drain was left in the scrotum.A non-compressive dressing was applied.Tadalafil 5 mg oral therapy was started one week after surgery to help corpora cavernosa rehabilitation.The postoperative course was uneventful and Tadalafil 5 mg was suspended 3 months after surgery.After 4 months of follow-up the patient reported a good tumescence of the penis with good erectile function and successful intercourse to his satisfaction.He report also improvement of the psychological relationship problem and better quality of life.

Discussion
Peyronie's disease is an idiopathic condition characterized by loss of elasticity of the tunica albiginea due to formation of fibrotic tissue resulting in various penile deformities.For the surgical management of patients with Peyronie's disease and buried penis several techniques are described in literature [2,6,9] (Table 1).Higher risk of infections and revision procedure

Risk of sensory deficit
Surgery for Peyronie's disease is recommended in stable disease.In the literature there is however no consensus on the precise concept of stable disease.For some authors no change of deformity, absence of pain and no new plaque formation for at least 3 months mark the chronic and stable phase of the disease and those patients should be candidates to surgery.Others define stable disease, 6 months or 1 year without progression [4,9].
Different types of graft materials have been used in the current clinical practice (Table 1), but none of them is now considered the gold standard.There is no high level of evidence-based data to identify which is the best [5,9,10].The porcine dermal collagen as an extracellular matrix graft is strong, has low immunogenicity and promotes the surrounding cell ingrowth.In literature the porcine dermal collagen has been used in 5 patients with Peyronie's disease showing good results even if only preliminary [10].In our experience this graft was easy to use, readily available and helpful to avoid penile shortening.The most important advantage of using grafts in Peyronie'sdisease is that they are not associated with penile shortening but they theoretically have a high risk for erectile dysfunction (ED) due to venoclusive dysfunctions.A good preoperative erectile status is the only variable that may be predictive for occurrence of postoperative ED and consequently success rate and patient satisfaction [9].In our case, to avoid this important complication, the plaque was carefully resected from the tunica avoiding damage to the underlying spongious tissue, to minimize the venoclusive dysfunction.The neurovascular bundle was identified and preserved.The use of a xenograft allows for shorter operative time and especially lower morbidity rate compared to the autologous graft, due to the necessity of another incision for harvesting the autologous graft [5,9,10].
Buried penis in adults can be secondary to obesity, lymphedema,post circumcision correctionand penile trauma.However being a congenital condition buried penis in adults can also be a primary disease.Similar to Peyronie's disease, different surgical techniques have been described in literature, however, without any correction being considered gold standard [4,9].The key point of the technique we have described before is the anchoring of the stretched penis at its base to the released dartos tissue avoiding any retraction after release.

Table:
Surgical treatment for peyronie's disease.
In a previous study this technique showed good results in terms of peri-operative morbidity, patient and surgeon satisfaction [6].This is to our knowledge the first description of the association between Peyronie's disease and buried penis we can conclude that correcting this combined penile deformity asks for surgical experience in penile reconstruction and insight in pathology of penile deformities.