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Preputioplasty as a surgical alternative in treatment of phimosis

✉
Daniar Osmonov 1 , Claudius Hamann1, Ahmed Eraky 1
, Almut Kalz1, Diethild Melchior1, Robert Bergholz2 and
Javier Romero-Otero 3

© The Author(s) 2021

Preputioplasty denotes various surgical techniques directed at resolving phimosis without the need for radical or partial
circumcision. This narrative review summarizes the best-known surgical techniques of preputioplasty. A MEDLINE and EMBASE-
based literature search of original manuscripts and case reports published in English has been carried out using the following key
words: “circumcision”, “partial circumcision”, “phimosis”, “paraphimosis”, and “preputioplasty”. Six different procedures are explored
in more detail and illustrated. The complication rates of all surgical procedures presented here are reported to be low. In cases of
medical (rather than cultural and religious) indications, foreskin-preserving procedures present useful alternatives to circumcision in
the routine clinical practice of urologists and pediatric surgeons.

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INTRODUCTION of preputioplasty, such as triple incision plasty, preputial plasty,

Surgical treatment of phimosis is a very common procedure ventral “V”-plasty (“VVP”), “Y”-“V” plasty, trident plasty, and “Z”-
worldwide. Radical or partial foreskin removal is one of the oldest plasty, exploring the success rates and complications of the
surgical procedures in the history of mankind. The foreskin was known procedures.
called “prepuce” in Roman time and means as it protrudes before
(pre) the tip of penis (putos) [1]. The inventor and first person to
perform a circumcision is unknown. The actual indication for MATERIALS AND METHODS
circumcision was not a medical condition but was based mostly Literature search and study eligibility
on religious and cultural beliefs [2, 3]. A MEDLINE and EMBASE-based literature search of original
Testify to the known historical sources, circumcision was first manuscripts and case reports published in English has been
performed in old Egypt probably inspired by the mythology of carried out using the following key words: “circumcision”, “partial
Osiris. From those old times till now circumcision is an important circumcision”, “phimosis”, “paraphimosis”, and “preputioplasty”.
part of the Jewish and Muslim cultures [3]. Based on the historical
documents of the 19th century, circumcision was known to be Data extraction
performed as “ultima ratio” for masturbation, seizures, epilepsy, All subsequent articles including case reports which describe a
and paraplegia. Only in the modern time, beginning form the surgical technique were cross-referenced to ensure capturing of
middle of the 20th century, circumcision has become a medical all relevant papers. In general, 16 articles regarding to the topic of
indication as a surgical option in the treatment of phimosis [3]. the current review were identified. Only 9 original research articles
Circumcision is the most-performed surgical procedure in modern reflecting current evidence without considering the time of
medicine [4]. The main indications are: non-retractable foreskin publication were included. Case reports or original articles with
due to phimosis or paraphimosis, still as a part of cultural and low number of patients were excluded from the evaluation. The
religious beliefs, and finally as a prevention of penile cancer, available articles were catalogued in a table which included the
sexually transmitted diseases [4]. name of the journal, the number of patients, the type of
There are a number of non-surgical alternatives to circumcision reconstruction as well as the success rate. In this review, we will
that have been described in the literature, such as a retraction demonstrate and discuss the different surgical procedures.
therapy, variations of the steroid applications, and finally systemic
antibiotics are recommended in case of balanoposthitis [5–10]. Surgical procedures
All the latter treatments have the goal to retract the foreskin
and do not aim at the removal of the entire foreskin. Alternative
surgical treatments include different types of preputioplasty. The 1. Triple incision plasty as first described by Nils Wåhlin (1991) [11]. The
term preputioplasty denotes various surgical techniques directed foreskin is gently retracted until it is too narrow to pull any further
at resolving phimosis without radical or partial circumcision. This (Fig. 1). Three longitudinal incisions are made as demonstrated
narrative review summarizes the best-known surgical techniques (Fig. 1). It is recommended to sever all transverse structures until the

1
Department of Urology and Pediatric Urology, University hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany. 2Department of Pediatric Surgery, University hospital
Schleswig-Holstein, Campus Kiel, Kiel, Germany. 3Urology Department, Hospital Universitario 12 Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12),
Madrid, Spain. ✉email: [email protected]

Received: 22 June 2021 Revised: 14 November 2021 Accepted: 17 November 2021

 D. Osmonov et al.
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Fig. 1 Triple incision plasty (the figure explores the three longitudinal incisions of the foreskin, retracted and movable skin, the place of made
incisions, and suture lines).

foreskin can be moved (Fig. 1). Each incision is closed by somewhat 5. Trident plasty described by Pedersini et al. (2017) [15]. A linear mark is
oblique locking stiches, thereby rotating around the foreskin and drawn as a transversal line on the proximal side of the prepuce, 2 mm
the suture lines so that they lie parallel to each other obliquely distal to the stenotic ring. The length of this line is approximately one-
(Fig. 1). quarter of the circumference. Three small longitudinal lines were
Postoperatively, no dressing is applied. There are no specific drawn on the distal side of the prepuce [15] (Fig. 5). An inverted “V”,
recommendations for the described Wåhlin procedure, except that with the apex extended from the perpendicular line, made at the
the patient should avoid manipulating the foreskin during the first midpoint of the transversal line, and keeping an angle of 60°, is drawn
week to achieve proper wound healing [11]. in the proximal prepuce (Fig. 5). It is mandatory for the edges of all
2. Preputial plasty as described by Cuckow et al. (1994) [12]. The flaps to be of the same length. The mucocutaneous flaps of the
foreskin is mobilized by severing the glandular adhesions and prepuce are incised, dissected, and then sutured with interrupted
retracted (Fig. 2). The constricted tissue is incised longitudinally, polyfilament 6/0 stitches, thus transforming “Y” to “V “[15] (Fig. 5).
alongside the dorsum of the penis. The underlying tissue is spread Patients are discharged on the day of surgery. The follow-up
with artery forceps to expose Buck’s fascia, and the incision is closed assessments were carried out at 1 and 2 weeks, as well as 1, 6, and
transversally using absorbable sutures [12] (Fig. 2). 12 months postsurgically [15] (Fig. 5).
Apart from lidocaine gel applied to the glans and suture line, no 6. Z-plasty described by Emmett (1982) [16]. The principle of this
other local anesthetic is used. Parents are advised to mobilize the procedure is based on the Heineke-Mikulicz principle of lateral
foreskin regularly once the initial discomfort has subsided [12]. incisions made longitudinally and closed transversally [16, 17] (Fig. 6).
3. Ventral V-plasty (VVP) as described by Alexander et al. (2009) [13]. The scarred phimotic ring is excised, resulting in a circular incision
This procedure was proposed as a surgical treatment option for [16, 17] (Fig. 6). Z-plasties are performed at 3 and 9 o′clock positions.
congenital megaprepuce. The VVP technique allows for preservation Two flaps of equal dimension are created [16, 17] (Fig. 6). The flaps are
of the full length of shaft skin [13] (Fig. 3). To preserve this skin, the then mobilized, rotated, and transposed to the contralateral apex, and
circumferential incision on the shaft is performed at a level that will finally sutured in place with a 6/0 chromic suture (Fig. 6). A
ensure sufficient skin length and disregards the constriction tissue. compressive dressing with gauze and tegaderm is applied. All patients
This is then incised in the midline, ventrally as shown in the are discharged on the day of surgery.
illustration (Fig. 3). This incision must be of sufficient length to
completely divide the area of stenosis. By doing so, a V-shaped
defect of variable width and length is created [13] (Fig. 3). Then a
circumferential incision is performed on the subcoronar collar at a
DISCUSSION
level that approximates a standard circumcision. This incision is
modified ventrally to preserve a V-shaped flap with the exact
The treatment options of phimosis are not limited to radical or
dimensions of the defect in the proximal ventral shaft skin [13] partial circumcision [5–10], which—while being a quick and
(Fig. 3). The V-plasty is built by interposing the subcoronar V of skin straightforward solution—should not be the only one. Moreover,
into the corresponding V-shaped defect in the shaft skin. Traction/ current clinical recommendations from pediatric surgeons recom-
apposition sutures are placed into the angles of the V to aid skin mend preputioplasty as the method of choice with the goal to
closure as illustrated [13] (Fig. 3). achieve retractibility of the foreskin [1]. Our aim was neither to
4. Y-V plasty as described by Nieuwenhuijs et al. (2006) [14]. This favorize one over the other treatment options, nor to under-
procedure starts with an inverted “V” with 1 cm “legs” at the narrowest estimate the role of circumcision as a radical surgical option,
part of the external foreskin, which are then extended to form a “Y” on but to present the best-described options from which we can
the inner part of the prepuce [14] (Fig. 4). The tunica dartos layer is
severed and the wound is closed as a “V” with six–eight polyglycolic choose in daily clinical routine. Without doubt, the topical
acid sutures (6.0). No dressing is applied. Parents are advised to retract treatment of phimosis is a first-line treatment in pediatric practice.
the prepuce daily starting on day 3 [14] (Fig. 4). Such medical approaches include a topical corticoid cream

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(betamethasone 0.05–0.1%) applied twice a day over a period of [11, 18] (Table 1). Preputioplasty procedures can be categorized
20–30 days (LE: 1; GR: A) [5–10]. This treatment has no side effects, into procedures with either a single incision and subsequent
and, which is very important to mention, it does not increase the suture, or multiple incisions (two or more) around the circumfer-
mean bloodspot cortisol levels (LE: 1) [10]. ence, based on geometrical patterns such as “V”/”Y”, “Z”, or
The treatment of phimosis is multimodal and should be complicated sliding plasty [11, 18] (Table 1). Procedures with
adapted to the clinical and individual situation, considering the multiple incisions have been invented to apportion the widening
presence of local infections, cultural and religious aspects as well of the constriction more consistently to the whole circumference
as the patient’s respective parents’ preferences. Medical consulta- and thus to achieve better functional and cosmetic outcomes [11].
tion must explore all known treatment options in the treatment of Despite numerous plasties previously described, not all of them
phimosis and should be clearly documented [1, 2]. seem to have found their way into general use, probably due to
Different methods of preputioplasty are useful and can be technical or cosmetic drawbacks.
recommended and performed in nearly all cases of phimosis Triple incision plasty is one of the very common variations of
the preputioplasty and was first published by Nils Wåhlin, a
Swedish pediatric surgeon [11] (Fig. 1). In the original publication,
63 patients between 2 and 27 years old were evaluated. Major
surgical complications according to the current Clavien-Dindo
score were not reported [11] (Fig. 1). There were also no Clavien-
Dindo 2 complications that needed revision. One patient had a
slightly prolonged bleeding for 2 days, 2 patients showed
swellings and one incurred a superficial infection, the total of all
complications was 6/63 = 9.5% with a follow-up of at least 1 year
[11] (Fig. 1).
The next procedure by Cuckow et al. describes a simple
preputial plasty [12]. In effect, it is a simple dorsal slit. The
procedure is easy to perform and widely used in both adult and
pediatric urology. In all, 50 patients were evaluated retrospectively
in the initial paper [12]. The authors compare the outcome of the
simple preputial plasty to that of classic circumcision. Evaluation
regarding the operative morbidity and patient satisfaction was
obtained by sending a questionnaire to all patients’ respective
parents. No complications of Clavien-Dindo 2 or higher were
reported in the group of preputial plasty, whereas 6% (N = 3) of
the patients in the circumcision group were reported to have
required surgical revision due to bleeding problems [12] (Table 1).
Fig. 2 Limited dorsal slit (mobilized the foreskin by performing The respective distribution of complications in the preputioplasty
longitudinal incision on the penis dosum, deep incision to expose vs. the circumcision group was as follows: infections (10% vs. 12%),
Buck’s fascia, and transversally closed incision). huge edema (2% vs. 0%), recurrent adhesion (2% in both), a non-
retractile foreskin (4% vs. 0%), and poor cosmetics (2% vs. 6%) [12].

Fig. 3 Ventral V-plasty (VVP) for treatment of congenital megaprepuce (circumferential incision of the graft is performed as shown; then a
ventral midline incision is performed; a V-shaped defect of variable width and length is created; circumferential subcoronal incision is
performed; V-plasty is built by interposing the subcoronal V into the V-shaped defect).

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Fig. 4 Y-V plasty (characterised by the transformation of the inverted “V” incision to the “Y” on the inner part of the Prepuce.

Fig. 5 Trident preputial plasty (an inverted “V” is made at the midpoint, full-thickness flaps of the prepuse are incised and dissected, and
transformation of “Y” to “V” is performed).

Fig. 6 Z-plasty (based on the lateral incision made longitudinally and closed transversally).

In cases of a congenital megaprepuce with a concomitant follow-up of 24 months [17]. All patients showed satisfactory
buried penis, the VVP was described as a method of choice by wound healing without infections, hematoma, or flap necrosis. All
Alexander et al. [13] (Table 1). In the initial evaluation, he patients had previously failed to respond to the topical treatment
described the surgical outcome in 10 children. Parental satisfac- with betamethasone. During follow-up, the prepuce was fully
tion was high in 10/10 children. One child required a secondary retractable in all patients [17].
minor cosmetic procedure. No complications were reported. The trident plasty, at last, presents a combination of the afore-
The study on Y-V plasty was carried out in 65 cases [14] described Y-V plasty and Z-plasty without diminution of the
(Table 1). The presented Y-V technique was compared to the surgical outcomes during the assessed follow-up [15].
transversally closed longitudinal incisions on the narrow part of Comparison of the outcome of different surgical options
the prepuce [14]. Revision surgery in the Y-V group was 4.3% and confirms that the single plasties, which are essentially equivalent
11% in the control group. No major complications were reported to a dorsal slit and easy to perform, tend to give a cosmetically
in either group. The cosmetic results were excellent in all Y-V cases unsatisfactory result, with a visible cleft or deformity. Radical
performed [14]. circumcision, by contrast, carries a higher risk of complications,
One of the oldest variants of preputioplasty is Z-plasty [16]. among them is, for example, fibrotic healing. Therefore, the
There are but few of studies describing the efficacy of Z-plasty. In surgical options that preserve the foreskin should be given priority
a recent study, a cohort of 28 patients was described with a in the treatment of non-complicated phimosis.

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 D. Osmonov et al.
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95.7% vs. 89%

Success rate Limitations
In general, evidence is poor and based on retrospective, single-

97.6%

70.6%
92%
98%

82%

N/A

N/A

N/A
center studies with a limited number of patients as well as on case
reports. Moreover, the studies are limited from reporting success
rats as well as complication rates based on non-standardized
criteria. Nevertheless, current article explores all known surgical

Y-V plasty vs. transverse closure of longitudinal

techniques of preputioplasty and may have a practical guidance in
the daily clinical routine.

incisions of the narrow preputial ring.

Circumcision vs. limited dorsal slit
“Trident” preputial plasty
Type of reconstruction

Simple running suture

Standard vs. Z-plasty

Triple incision plasty

CONCLUSION

Ventral V-plasty
Various surgical options are available for preputioplasty. The
Z-plasty

complication rates of all surgical procedures presented here are

N/A
reported to be low. In cases of medical (rather than cultural and
religious) indications, foreskin-preserving procedures present
useful alternatives to circumcision in the routine clinical practice
of urologists and pediatric surgeons.

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ACKNOWLEDGEMENTS
[20]

[21]

The authors thank Ms. Almut Kalz and Mr. Basil Blackwell for the editing of the
final draft.

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AUTHOR CONTRIBUTIONS
J.R.O. and D.O. conception and design. D.O. and A.E. acquisition of data. C.H. Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims
composition of figures. D.O. drafting the article. D.M. and R.B. revising it for in published maps and institutional affiliations.
intellectual content. A.K. editing and grammar proof. D.O. and J.R.O. final approval of
the completed article.

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