A Novel Suspensory Ligament Penodermal Fixation Technique Versus Dorsal Tunica Albuginea Fixation for Pediatric Buried Penis:

Buried penis is a congenital penile anomaly in which the penile shaft is hidden beneath the surrounding skin and subcutaneous tissues, despite having a normal-sized underlying structure. It is a relatively uncommon condition in children, but it is clinically significant due to its functional, hygienic, and psychological consequences. Reported incidence varies across populations. The condition is often underrecognized or misdiagnosed, particularly in early childhood .

The etiology of buried penis is multifactorial and not yet fully understood. Several mechanisms have been proposed, including deficient or inelastic penile shaft skin, abnormal fixation of dartos fascia, and inadequate attachment between the penile skin and underlying Buck's fascia. Excess prepubic fat and abnormal ventral displacement of the penis may further contribute to its buried appearance. Additionally, fibrous tethering bands between fascial layers have been implicated in anchoring the penis within surrounding tissues .

Clinically, buried penis presents with variable severity ranging from a partially visible "stumpy" penile shaft to complete concealment beneath the suprapubic or scrotal tissue. Children often present with parental concern regarding penile size, hygiene difficulties, and functional urinary problems. These may include urine spraying, recurrent balanitis, urinary tract infections, and difficulty voiding in a standing position. In more severe or prolonged cases, psychological distress and body image concerns may develop .

Buried penis should be differentiated from other penile conditions such as micropenis, webbed penis, and trapped penis, as each has distinct anatomical and pathological features. Misclassification may lead to inappropriate management strategies and suboptimal outcomes. Accurate clinical assessment is therefore essential, often relying on physical examination and careful evaluation of penile skin deficiency, fascial attachments, and surrounding adiposity. Early diagnosis is important to prevent progressive functional and psychosocial complications .

Surgical correction remains the mainstay of treatment for buried penis, especially in symptomatic or persistent cases. The primary goals of surgery are to achieve adequate penile exposure, restore normal anatomy, and improve both functional and cosmetic outcomes. Multiple surgical techniques have been described; However, no single standardized technique has been universally accepted .

Penodermal fixation sutures utilizing suspensory ligament is a technique used as a complete penile degloving and release of abnormal dartos bands in children with buried penis occurs. Fixation sutures are placed between the penile dermis and the suspensory ligament at the penile base to maintain shaft exposure and recreate normal penopubic angles. It provides stable support, decreases postoperative retraction, and improves cosmetic appearance with low recurrence rates. Recent studies support fixation-based methods as safe and effective options in pediatric buried penis repair .

Another technique is called dorsal tunica albuginea sutures, after penile degloving and release of tethering tissues, fixation sutures are placed between the dermis or subcutaneous tissue and the dorsal tunica albuginea of the penile shaft. The tunica serves as a strong anchoring structure to maintain externalization of the penis. This approach helps secure shaft skin position and reduces recurrence of concealment. It is considered effective with good functional and cosmetic results.

The aim of the work to compare the outcomes of suspensory ligament fixation to the sub-dermis and dorsal tunica albuginea fixation in terms of success rate, need for auxiliary procedures, and complication rates in the buried penis.

• Postoperative complications [Time frame: 2 weeks, 1 month, 3 months, 6 months]