Comparative efficacy of flap transfer combined with modified Devine or Brisson procedure for correction of concealed penis in children following misdiagnosed circumcision*

Comparative efficacy of flap transfer combined with modified Devine or Brisson procedure for correction of concealed penis in children following misdiagnosed circumcision* | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative efficacy of flap transfer combined with modified Devine or Brisson procedure for correction of concealed penis in children following misdiagnosed circumcision* Zhou Hai-yang, Zheng Bing, Zhu Dong-mei, Ji Ru-ru This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6843618/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Objective To compare the efficacy of flap transfer combined with either the modified Devine procedure (MDP) or the modified Brisson procedure (MBP) in correcting concealed penis (CP) in children following misdiagnosed circumcision. Methods This study included 92 children with CP who had previously undergone misdiagnosed circumcision and were admitted to Nantong First People's Hospital between September 2020 and January 2023. Using a random number table, participants were randomly assigned to either the control group ( n = 46), which received flap transfer combined with the modified Devine procedure (FT-MDP), or the study group ( n = 46), which underwent flap transfer combined with the modified Brisson procedure (FT-MBP). All patients were followed up for six months postoperatively. Surgical parameters, pain levels, perioperative stress response, postoperative recovery, complications, and family satisfaction were compared between the two groups. Results There was no statistically significant difference in operation time between the groups ( P > 0.05); however, the study group experienced significantly lower intraoperative blood loss ( P < 0.05). FLACC scores at 4, 12, and 24 hours postoperatively showed significant differences across time points ( P 0.05) or in the trend of FLACC score changes over time ( P > 0.05). Preoperative and 24-hour postoperative levels of adrenaline (Adr) and cortisol (Cor) were comparable between groups ( P > 0.05). Postoperative penile length increased significantly in both groups ( P < 0.05), with the study group showing significantly greater penile and penile extension lengths ( P 0.05), as was the overall complication rate ( P > 0.05). Notably, family satisfaction was significantly higher in the study group ( P < 0.05). Conclusion Both FT-MDP and FT-MBP are safe and effective surgical options for correcting CP in children following misdiagnosed circumcision. However, FT-MBP provides additional benefits in enhancing penile length and improving family satisfaction. flap transfer modified Devine procedure modified Brisson procedure pediatric concealed penis efficacy Figures Figure 1 Figure 2 Introduction Concealed penis (CP) is a congenital malformation of the external genitalia in children, with an incidence second only to phimosis and redundant prepuce. It is characterized by abnormal attachment of the penile skin to the shaft, resulting in a shortened penile appearance where the penis is hidden beneath the skin, leaving only the prepuce visible externally [1-2]. Pediatric CP (PCP) can adversely affect both the physical and psychological health of affected children. Physically, the redundant prepuce increases the risk of infection and inflammation and may cause urinary retention, difficulty during urination, and potential impacts on future sexual function and fertility. Psychologically, PCP can lead to self-esteem issues and distress related to sexual identity [3]. However, due to cognitive biases, the condition is often clinically misdiagnosed as micropenis or phimosis, resulting in inappropriate treatment. Some children consequently undergo circumcision based on this misdiagnosis, which fails to address the underlying CP. Moreover, the removal of potentially usable inner and outer prepuce during circumcision results in deficient penile skin, significantly complicating subsequent reconstructive correction [4]. Therefore, clinical focus has shifted toward developing efficient and safe surgical strategies to correct CP in children following misdiagnosed circumcision. Surgical correction is currently the clinically recognized and effective treatment for PCP. Several procedures are commonly used, including the Devine, Brisson, and Shiraki procedures. While these techniques can increase penile length, they are often associated with varying degrees of postoperative prepuce edema. Additionally, some children experience persistent prepuce swelling, which compromises the penile appearance and reflects limited overall effectiveness. Modified techniques, such as the modified Devine procedure (MDP) and modified Brisson procedure (MBP), have demonstrated improvements in reducing postoperative prepuce edema and further increasing penile length [5-6]. Despite these advancements, no unified standard or clearly defined standardized procedure currently exists for treating PCP. With ongoing progress in medical technology, flap transfer (FT) has increasingly been incorporated into CP treatment. This technique effectively increases the exposed penile length and achieves satisfactory cosmetic outcomes [7-8]. However, comparative studies evaluating the efficacy of flap transfer combined with the modified Devine procedure (FT-MDP) versus the modified Brisson procedure (FT-MBP) for correcting CP in children following misdiagnosed circumcision remain limited. To address this gap, the present study aims to compare the outcomes of these two procedures, providing a reference for selecting the optimal surgical approach for correcting CP in this patient population. Materials and Methods 1.1 General Information This study included 92 children with CP who had undergone misdiagnosed circumcision and were admitted to Nantong First People's Hospital between September 2020 and January 2023. Participants were randomly assigned to a control group ( n = 46) or a study group ( n = 46) using a random number table. Inclusion criteria were: (1) diagnosis of CP according to the Chinese Expert Consensus on the Diagnosis and Treatment of Concealed Penis in Children [9]; (2) normal development of testes and epididymides; (3) history of misdiagnosed circumcision; and (4) age between 6 and 14 years. Exclusion criteria included: (1) disorders of sex development (DSDs); (2) hematological diseases; (3) other urogenital conditions such as buried or trapped penis; and (4) loss to follow-up. There were no statistically significant differences between groups in age, height, weight, preoperative penile length, time since circumcision, or seasonal distribution of surgery (all p > 0.05) (Table 1). This study was approved by the hospital ethics committee ( n o. 2022KT100), and guardians provided written informed consent. 1.2 Methods 1.2.1 Control Group (FT-MDP): Under general anesthesia, the preputial orifice was dilated, adhesions were separated, and a traction suture was placed on the glans penis. A longitudinal incision was then made along the dorsal aspect of the penis. Table 1 comparison of clinical data ( n =46) Group Age (years, ±s) Height (cm, ±s) Weight (kg, ±s) Preoperative Penile Length (cm, ±s) Time Interval since Circumcision (months, ±s) Seasonal Distribution of Surgery (%) Spring Summer Autumn Winter Control Group 9.45±1.69 130.23±5.75 29.98±2.41 1.95±0.35 9.93±1.67 7 (15.22) 30 (65.22) 5 (10.87) 4 (8.69) Study Group 9.12±1.58 131.47±6.01 30.54±2.75 2.01±0.32 9.75±1.52 10 (21.74) 25 (54.35) 8 (17.39) 3 (6.52) t/χ 2 value 0.967 1.011 1.039 0.858 0.541 1.819 P value 0.336 0.315 0.302 0.393 0.590 0.611 The constricting ring was incised down to the penile root. A circumferential incision was made in the prepuce approximately 0.8 cm proximal to the coronal sulcus, and the penile skin was degloved. Abnormal fibrous tissue and dartos fascia were excised. A longitudinal incision was made along the midline of the dorsal prepuce. The dorsal penile skin was then designed, and excess inner prepuce was excised. Bilateral pedicled wing-shaped preputial flaps were mobilized. The pedicled flaps were simultaneously sutured and trimmed from the dorsal to the ventral side. An inverted V-shaped incision was made at the ventral penile root, and the ventral penile skin was degloved down to the bulb of the urethra. Buck's fascia and the dermis of the prepuce were anchored at the 3 o’clock and 9 o’clock positions on the penile root. Redundant dartos tissue was excised. Finally, fixation sutures were placed to recreate the penoscrotal angle. 1.2.2 Study Group (FT-MBP): Under general anesthesia, the preputial orifice was dilated and adhesions were separated. A traction suture was placed on the glans penis. A longitudinal incision was made on the dorsal aspect of the penis, and the constricting band was incised down to the penile root. A circumferential incision was made in the prepuce approximately 0.8 cm proximal to the coronal sulcus. The penile skin was degloved to the root along the loose tissue plane between Buck's fascia and the preputial dartos fascia. Abnormal fibrous tissue and the dartos fascia were excised. The dermis of the prepuce and Buck's fascia were sutured at the 3 o’clock and 9 o’clock positions at the penile root. Additionally, the scrotal dartos fascia and Buck's fascia at the ventral penile root were anchored to reconstruct the penoscrotal angle. Transillumination with a cold light source was performed to visualize the dorsal penile vasculature and preserve the blood supply to the flap. The prepuce was then clipped to form wing-shaped preputial flaps, which were sutured and fixed at the midpoint of the inner prepuce on the dorsal aspect of the coronal sulcus. One flap was rotated ventrally to cover the preputial defect and sutured into place. The other flap was also rotated ventrally, and a pedicled segment of the inner prepuce was trimmed to the appropriate size and used to cover the remaining ventral defect without tension or torsion before being sutured in place. In both groups, the penis was dressed with sterile gauze, and routine postoperative care, including anti-infective and analgesic measures, was administered. 1.3 Observation Indicators 1.3.1 Surgical parameters: Operation time and intraoperative blood loss were compared. 1.3.2 Pain levels: Postoperative pain at 4, 12, and 24 hours was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) scale [10]. The scale has a maximum score of 10 points, with higher scores indicating greater pain severity. 1.3.3 Stress response: Fasting venous blood samples (3 mL) were collected from the children both preoperatively and 24 hours postoperatively. The samples were centrifuged at 3,500 r/min for 10 minutes, and the supernatant was collected. Serum levels of adrenaline (Adr) and cortisol (Cor) were measured using enzyme-linked immunosorbent assay (ELISA), with assay kits purchased from Wuxi Tiancui Biotechnology Co., Ltd. 1.3.4 Postoperative recovery: Preoperative penile length, postoperative penile length, penile extension length, and duration of postoperative prepuce edema were compared. 1.3.5 Complications: Complications occurring within 6 months postoperatively, including infection, flap necrosis, and penile retraction, were recorded and compared. 1.3.6 Satisfaction: At 6 months postoperatively, family satisfaction was assessed using the "Long-term Follow-up Questionnaire for the Modified Brisson Procedure in Treating Concealed Penis," developed by Tao C et al. [11]. Satisfaction levels were categorized as "fairly satisfied," "satisfied," or "dissatisfied." The overall satisfaction rate was calculated by combining the percentages of "fairly satisfied" and "satisfied" responses. 1.4 Statistical Methods s Data were analyzed using SPSS 18.0 software. Continuous variables were expressed as mean ± standard deviation (x̄ ± s) and compared using the t-test, repeated measures analysis of variance (ANOVA), or one-way ANOVA, as appropriate. Categorical variables were presented as frequencies or percentages (%) and compared using the chi-square (χ 2 ) test. A P-value of less than 0.05 ( P 0.05). However, the study group showed significantly lower intraoperative blood loss compared to the control group ( P < 0.05) (Table 2). Table 2 comparison of surgical parameters ( n =46, ±s) Group Operation time (min) Intraoperative blood loss (mL) Control Group 49.21±5.32 9.93±1.69 Study Group 51.04±6.23 8.91±1.45 t value 1.515 3.107 p -value 0.133 0.003 2.2 Comparison of Postoperative Pain Levels at Different Time Points Comparison of FLACC scores at 4, 12, and 24 hours postoperatively revealed that the scores differed significantly across time points (F = 9.658, p = 0.000). However, there was no statistically significant difference in FLACC scores between the groups (F = 1.813, p = 0.168), nor was there a significant difference in the trend of score changes over time between the two groups (F = 2.328, p = 0.100) (Table 3). Table 3 comparison of FLACC scores at 4h, 12h and 24 h postoperatively ( n =46, points, ±s) Group 4h postoperatively 12h postoperatively 24h postoperatively Control Group 2.26±0.32 3.78±0.38* 2.65±0.29*# Study Group 2.19±0.29 3.61±0.36* 2.59±0.27*# Note: * compared to 4h postoperatively, P<0.05; # compared to 12h postoperatively, P<0.05. 2.3 Comparison of Stress Response No statistically significant differences were observed in Adr or Cor levels between the two groups, either preoperatively or 24 hours postoperatively (t-test, p > 0.05) (Table 4). Table 4 comparison of stress response ( n =46, ±s) Group Adr ( n g/L) Cor ( n mol/L) Preoperative 24h postoperatively Preoperative 24h postoperatively Control Group 78.43±11.29 104.96±15.13† 221.36±25.41 310.58±32.37† Study Group 79.26±12.01 101.08±14.74† 219.89±24.13 301.46±30.61† t value 0.342 1.246 0.478 1.388 p -value 0.734 0.216 0.634 0.168 Note: † compared to preoperative condition, P<0.05. 2.4 Comparison of Postoperative Recovery Postoperative penile length and penile extension length were both significantly greater in the study group compared to the control group (t-test, p 0.05) (Table 5). Table 5 comparison of postoperative recovery ( n =46, ±s) Group Postoperative Penile Length (cm) Penile Extension Length (cm) Duration of Prepuce Edema (d) Control Group 4.01±0.24 2.06±0.19 4.96±0.81 Study Group 4.29±0.27 2.15±0.16 4.73±0.79 t value 2.816 2.457 1.379 p -value 0.006 0.016 0.171 2.5 Comparison of Complications There was no statistically significant difference in the overall complication rate (χ 2 = 2.853, p = 0.091) (Table 6). Table 6 comparison of complications [ n =46, cases (%)] Group Infection Flap Necrosis Penile Retraction Total Control Group 1 (2.17) 3 (6.52) 1 (2.17) 5 (10.87) Study Group 1 (2.17) 0 (0.00) 0 (0.00) 1 (2.17) 2.6 Comparison of Satisfaction Rates The overall satisfaction rate was significantly higher in the study group (χ 2 =4 .929, p = 0.026) (Table 7). Table 7 comparison of satisfaction rates [ n = 46, cases (%)] Group Fairly Satisfied Satisfied Dissatisfied Overall Satisfaction Rate Control Group 29 (63.04) 10 (21.74) 7 (15.22) 39 (84.78) Study Group 36 (78.26) 9 (19.57) 1 (2.17) 45 (97.83) 2.7 Representative Case Pictures Figure 1 shows the preoperative appearance, immediate postoperative outcome following correction with FT-MDP, and the appearance at 6 months postoperatively in a 7-year-old boy with CP after misdiagnosed circumcision. Figure 2 presents the corresponding stages, preoperative, immediate postoperative following FT-MBP, and 6-month postoperative appearance, in a 10-year-old boy with CP following misdiagnosed circumcision. Discussion Penile reconstruction surgery is an effective treatment for CP. The primary surgical goals include restoring a normal penile appearance through key steps such as degloving the penile skin down to its root, excising fibrous bands that restrict extension, and securing the skin at the penoscrotal junction and dorsal penile root to the tunica albuginea using fixation sutures (Zhao et al., 2012) [12]. While circumcision is commonly performed to treat redundant prepuce and related conditions, it is not effective for CP, as it fails to correct the underlying issue of inadequate penile exposure. Moreover, circumcision can worsen the condition by removing critical preputial tissue, thereby increasing the difficulty of subsequent reconstructive surgery. Therefore, surgical intervention remains the only effective option for correcting CP in children following misdiagnosed circumcision. However, there is limited evidence on which specific surgical procedures yield the most favorable outcomes. The MDP and the MBP are two widely used surgical techniques for treating pediatric CP. Compared to the traditional Devine procedure, MDP offers several advantages. It avoids the excision of the suprapubic fat pad, reducing trauma to surrounding tissues, and allows for precise trimming of both the inner and outer prepuce, addressing issues of preputial insufficiency. Additionally, MDP includes excision of the superficial suspensory ligament and fixation of the penile root skin to the tunica albuginea, significantly enhancing penile exposure (Liu et al., 2017) [13]. In contrast, MBP is a less invasive alternative to the conventional Brisson procedure and offers several distinct benefits. It combines the resection of the inner and outer prepuce with the release and lengthening of the corpora cavernosa, thereby improving penile exposure and cosmetic outcomes. MBP also emphasizes preservation of the periurethral region, which is vital for maintaining penile sensation and physiological function, critical for the child's sexual development and future sexual health. Furthermore, its meticulous handling of penile tissues reduces the risk of postoperative complications such as bleeding and infection. Since MBP does not involve suprapubic fat pad resection, it minimizes disruption to surrounding tissues, resulting in a more natural postoperative appearance and more durable outcomes (Wang et al., 2019) [14]. The blood supply and drainage of the penile skin and prepuce primarily depend on the superficial dorsal penile artery and vein [15]. A dense vascular plexus is located at the junction between the inner and outer prepuce, where these superficial vessels converge. This area is highly vascularized and relatively easy to dissect, making it ideal for creating pedicled island flaps. Therefore, during surgery to correct CP in children following misdiagnosed circumcision, precise identification of the preputial vascular supply and meticulous dissection of the prepuce are essential. The results of this study show that FT-MDP resulted in significantly less intraoperative blood loss compared to FT-MBP. In the study group, cold light transillumination was used to guide dorsal preputial flap creation. Flaps were designed in avascular zones to form wing-shaped configurations, with the dorsal pedicled preputial flap dissected ventrally to cover the ventral skin defect. This technique prioritizes the preservation of the blood supply to the prepuce and pedicled flap. In contrast, the control group utilized a dorsal preputial incision combined with ventral preputial and pedicled flaps. Consequently, the FT-MDP approach better preserved flap vascularity, which likely contributed to the reduced intraoperative blood loss and lower risk of postoperative flap necrosis observed. These findings are consistent with those of Xiao Z. X. et al.[16], whose research demonstrated that MBP combined with flap clipping techniques results in less intraoperative blood loss and greater penile exposure compared to MBP alone in severe PCP cases. Moreover, the study group underwent simultaneous reconstruction of the penopubic and penoscrotal angles, along with excision of excess adipose tissue at the dorsal penile root to maximize penile exposure. The control group, however, involved only resection of the dorsal penile fat pad without penoscrotal angle reconstruction. This study found that FT-MBP provided superior penile length extension compared to FT-MDP in correcting CP following misdiagnosed circumcision. The authors suggest that penoscrotal angle reconstruction enhances penile exposure by optimizing anatomic positioning. This observation is supported by Hu Z. Z. et al.[17], who reported MBP’s advantages in penile lengthening and cosmetic outcomes over MDP for severe CP. Additionally, the incisions in the study group—placed proximal to the coronal sulcus and along the ventral aspect, resulted in concealed scarring, improved aesthetic outcomes, and consequently higher family satisfaction rates. In summary, both FT-MDP and FT-MBP are safe and effective surgical procedures for correcting CP in children following misdiagnosed circumcision. However, FT-MBP offers more advantages in extending penile length and improving family satisfaction. Nevertheless, it is still necessary to conduct a long-term follow-up study of these two procedures for correcting CP in children following misdiagnosed circumcision. Abbreviations MDP:modified Devine procedure; MBP : modified Brisson procedure; CP:concealed penis; FT:flap transfer; FT-MDP:flap transfer combined with the modified Devine procedure; FT-MBP:flap transfer combined with the modified Brisson procedure; PCP:Pediatric concealed penis; FLACC:the Face, Legs, Activity, Cry, Consolability; Declarations Ethical approval Ethical and regulatory approvals were sought and obtained from theNantong First People's Hospital, China( n o. 2022KT100). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Consent to Publish declaration Availability of data and materials :The data are not publicly avaliable due to [their containing information that could romise the privacy of research participants];Data cannot be shared openly but are avaliable on request from corresponding author; Conflict of interest The authors declare that they have no conflict of interest Acknowledgement : The research project was funded by the Health and Family Planning Commission of Nantong City, Jiangsu Province with a major scientific fund number of BK20200203 Author contributions ： Haiyang Zhou project development;data analysis;Manuscript writing/editing;Bing Zheng project development;Dongmei Zhu Data collection；Ruru Ji Data collection; This study is a retrospective study and does not belong to a clinical trial. There is no clinical registration information available Corresponding author: Zheng Bing Email: bingzheng 2017 @163.com References CHEN H K, CHU Y S, HU Y F. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6843618","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475076518,"identity":"9ace2064-abe4-4355-b8a3-0d0f98765ad9","order_by":0,"name":"Zhou Hai-yang","email":"","orcid":"","institution":"Nantong First People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhou","middleName":"","lastName":"Hai-yang","suffix":""},{"id":475076519,"identity":"291eca14-fc37-405f-95d5-1a1424287967","order_by":1,"name":"Zheng Bing","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBACA2YgwdgAJNgbGw7/qZCQkydeC8/hgwd4zlgYGzYQ0sIA0yKRlnyAt60ikeEAAS3m7LyHX/7cYZMn75BjcEBynkQCYwPzw0c38GixbOZLs5A8k1ZseOCMwQHDbRJ57AxsxsY5+Bx2mMfMwLDtcOLGxh6DA4nbJIoZG3jYpAlqSWz7n7ixmcfgwME5EokNBwhrMX5wsO1A4nw2toSDjQ1EaLFs5jFjbGxLTtzAw3zgMMMxCWPDZgJ+Mec/Y/zxZ5td4vz5D5s/M9TUycmzNz98jE8LELBJgF14AMZnxq8crOQDiJRvIKxyFIyCUTAKRigAALWPUi2TyAsVAAAAAElFTkSuQmCC","orcid":"","institution":"Nantong First People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Zheng","middleName":"","lastName":"Bing","suffix":""},{"id":475076520,"identity":"5efd252c-a5cb-477f-9c6c-8b1ab9e6baa6","order_by":2,"name":"Zhu Dong-mei","email":"","orcid":"","institution":"Nantong First People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhu","middleName":"","lastName":"Dong-mei","suffix":""},{"id":475076521,"identity":"6ee7ad7a-1671-48a8-aa53-b017c65d3ef5","order_by":3,"name":"Ji Ru-ru","email":"","orcid":"","institution":"Nantong First People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ji","middleName":"","lastName":"Ru-ru","suffix":""}],"badges":[],"createdAt":"2025-06-07 15:23:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6843618/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6843618/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85642746,"identity":"acf7dc52-c96d-4ce8-b8a6-5b9a29a54cea","added_by":"auto","created_at":"2025-06-30 08:03:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":281354,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative and postoperative appearance of a child with CP following misdiagnosed circumcision, corrected with FT-MDP\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6843618/v1/19913da5c7d649ee408fcf97.png"},{"id":85642749,"identity":"80965f18-e7b5-4a96-b875-4cc9f4d8b576","added_by":"auto","created_at":"2025-06-30 08:03:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":260362,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative and postoperative appearance of a child with CP following misdiagnosed circumcision, corrected with FT-MBP\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6843618/v1/024c14ed9dbf514c8a3ccf0e.png"},{"id":85645704,"identity":"d40243bf-bb53-45a2-8940-3058f302474e","added_by":"auto","created_at":"2025-06-30 08:27:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1796606,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6843618/v1/b7e73ebc-57c5-44b3-92a5-e265f66bab96.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative efficacy of flap transfer combined with modified Devine or Brisson procedure for correction of concealed penis in children following misdiagnosed circumcision*","fulltext":[{"header":"Introduction","content":"\u003cp\u003eConcealed penis (CP) is a congenital malformation of the external genitalia in children, with an incidence second only to phimosis and redundant prepuce. It is characterized by abnormal attachment of the penile skin to the shaft, resulting in a shortened penile appearance where the penis is hidden beneath the skin, leaving only the prepuce visible externally [1-2]. Pediatric CP (PCP) can adversely affect both the physical and psychological health of affected children. Physically, the redundant prepuce increases the risk of infection and inflammation and may cause urinary retention, difficulty during urination, and potential impacts on future sexual function and fertility. Psychologically, PCP can lead to self-esteem issues and distress related to sexual identity [3]. However, due to cognitive biases, the condition is often clinically misdiagnosed as micropenis or phimosis, resulting in inappropriate treatment. Some children consequently undergo circumcision based on this misdiagnosis, which fails to address the underlying CP. Moreover, the removal of potentially usable inner and outer prepuce during circumcision results in deficient penile skin, significantly complicating subsequent reconstructive correction [4]. Therefore, clinical focus has shifted toward developing efficient and safe surgical strategies to correct CP in children following misdiagnosed circumcision.\u003c/p\u003e\n\u003cp\u003eSurgical correction is currently the clinically recognized and effective treatment for PCP. Several procedures are commonly used, including the Devine, Brisson, and Shiraki procedures. While these techniques can increase penile length, they are often associated with varying degrees of postoperative prepuce edema. Additionally, some children experience persistent prepuce swelling, which compromises the penile appearance and reflects limited overall effectiveness. Modified techniques, such as the modified Devine procedure (MDP) and modified Brisson procedure (MBP), have demonstrated improvements in reducing postoperative prepuce edema and further increasing penile length [5-6]. Despite these advancements, no unified standard or clearly defined standardized procedure currently exists for treating PCP. With ongoing progress in medical technology, flap transfer (FT) has increasingly been incorporated into CP treatment.\u003c/p\u003e\n\u003cp\u003eThis technique effectively increases the exposed penile length and achieves satisfactory cosmetic outcomes [7-8]. However, comparative studies evaluating the efficacy of flap transfer combined with the modified Devine procedure (FT-MDP) versus the modified Brisson procedure (FT-MBP) for correcting CP in children following misdiagnosed circumcision remain limited. To address this gap, the present study aims to compare the outcomes of these two procedures, providing a reference for selecting the optimal surgical approach for correcting CP in this patient population.\u003c/p\u003e"},{"header":"Materials and Methods ","content":"\u003cp\u003e\u003cstrong\u003e1.1 General Information\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study included 92 children with CP who had undergone misdiagnosed circumcision and were admitted to Nantong First People\u0026apos;s Hospital between September 2020 and January 2023. Participants were randomly assigned to a control group (\u003cem\u003en\u003c/em\u003e = 46) or a study group (\u003cem\u003en\u003c/em\u003e = 46) using a random number table. Inclusion criteria were: (1) diagnosis of CP according to the Chinese Expert Consensus on the Diagnosis and Treatment of Concealed Penis in Children [9]; (2) normal development of testes and epididymides; (3) history of misdiagnosed circumcision; and (4) age between 6 and 14 years. Exclusion criteria included: (1) disorders of sex development (DSDs); (2) hematological diseases; (3) other urogenital conditions such as buried or trapped penis; and (4) loss to follow-up. There were no statistically significant differences between groups in age, height, weight, preoperative penile length, time since circumcision, or seasonal distribution of surgery (all\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003e\u0026gt; 0.05) (Table 1). This study was approved by the hospital ethics committee (\u003cem\u003en\u003c/em\u003eo. 2022KT100), and guardians provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2 Methods\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.2.1 Control Group (FT-MDP): Under general anesthesia, the preputial orifice was dilated, adhesions were separated, and a traction suture was placed on the glans penis. A longitudinal incision was then made along the dorsal aspect of the penis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 comparison of clinical data\u0026nbsp;\u003c/strong\u003e(\u003cem\u003en\u003c/em\u003e=46)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 10px;\"\u003e\n \u003cp\u003eAge (years, \u003cimg width=\"12\" height=\"23\" src=\"data:image/wmf;base64,R0lGODlhDAAXAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAAABAAEAgAAAAAECAwICRAEAOw==\" alt=\"image\"\u003e\u003cimg width=\"5\" height=\"16\" src=\"data:image/png;base64,R0lGODlhBQAQAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAAFAAwAgwAAAAAAADpmtmZmkLZmkLbb/7b//9u2kNvbkNvb29v////bkP/b2///2wECAwECAwQWsKWpJAU46x1636DWEMZRMMhQYIuARQA7\" alt=\"image\"\u003e\u0026nbsp;\u0026plusmn;s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 9px;\"\u003e\n \u003cp\u003eHeight (cm, \u003cimg width=\"5\" height=\"16\" src=\"data:image/png;base64,R0lGODlhBQAQAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAAFAAwAgwAAAAAAADpmtmZmkLZmkLbb/7b//9u2kNvbkNvb29v////bkP/b2///2wECAwECAwQWsKWpJAU46x1636DWEMZRMMhQYIuARQA7\" alt=\"image\"\u003e\u0026nbsp;\u0026plusmn;s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 9px;\"\u003e\n \u003cp\u003eWeight (kg, \u003cimg width=\"5\" height=\"16\" src=\"data:image/png;base64,R0lGODlhBQAQAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAAFAAwAgwAAAAAAADpmtmZmkLZmkLbb/7b//9u2kNvbkNvb29v////bkP/b2///2wECAwECAwQWsKWpJAU46x1636DWEMZRMMhQYIuARQA7\" alt=\"image\"\u003e\u0026nbsp;\u0026plusmn;s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 14px;\"\u003e\n \u003cp\u003ePreoperative Penile Length\u003c/p\u003e\n \u003cp\u003e(cm, \u003cimg width=\"5\" height=\"16\" src=\"data:image/png;base64,R0lGODlhBQAQAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAAFAAwAgwAAAAAAADpmtmZmkLZmkLbb/7b//9u2kNvbkNvb29v////bkP/b2///2wECAwECAwQWsKWpJAU46x1636DWEMZRMMhQYIuARQA7\" alt=\"image\"\u003e\u0026nbsp;\u0026plusmn;s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 15px;\"\u003e\n \u003cp\u003eTime Interval since Circumcision (months, \u003cimg width=\"5\" height=\"16\" src=\"data:image/png;base64,R0lGODlhBQAQAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAAFAAwAgwAAAAAAADpmtmZmkLZmkLbb/7b//9u2kNvbkNvb29v////bkP/b2///2wECAwECAwQWsKWpJAU46x1636DWEMZRMMhQYIuARQA7\" alt=\"image\"\u003e\u0026nbsp;\u0026plusmn;s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 31px;\"\u003e\n \u003cp\u003eSeasonal Distribution of Surgery (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003eSpring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003eSummer \u0026nbsp;Autumn\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003eWinter\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e9.45\u0026plusmn;1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e130.23\u0026plusmn;5.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e29.98\u0026plusmn;2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e1.95\u0026plusmn;0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e9.93\u0026plusmn;1.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e7 (15.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e30 (65.22) 5 (10.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e4 (8.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eStudy Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e9.12\u0026plusmn;1.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e131.47\u0026plusmn;6.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e30.54\u0026plusmn;2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e2.01\u0026plusmn;0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e9.75\u0026plusmn;1.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e10 (21.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e25 (54.35) 8 (17.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e3 (6.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003et/\u0026chi;\u003csup\u003e2\u003c/sup\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e1.039\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.541\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1.819\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e0.336\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 9px;\"\u003e\n \u003cp\u003e0.302\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 14px;\"\u003e\n \u003cp\u003e0.393\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.590\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.611\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe constricting ring was incised down to the penile root. A circumferential incision was made in the prepuce approximately 0.8 cm proximal to the coronal sulcus, and the penile skin was degloved. Abnormal fibrous tissue and dartos fascia were excised. A longitudinal incision was made along the midline of the dorsal prepuce. The dorsal penile skin was then designed, and excess inner prepuce was excised. Bilateral pedicled wing-shaped preputial flaps were mobilized. The pedicled flaps were simultaneously sutured and trimmed from the dorsal to the ventral side. An inverted V-shaped incision was made at the ventral penile root, and the ventral penile skin was degloved down to the bulb of the urethra. Buck\u0026apos;s fascia and the dermis of the prepuce were anchored at the 3 o\u0026rsquo;clock and 9 o\u0026rsquo;clock positions on the penile root. Redundant dartos tissue was excised. Finally, fixation sutures were placed to recreate the penoscrotal angle.\u003c/p\u003e\n\u003cp\u003e1.2.2 Study Group\u0026nbsp;(FT-MBP): Under general anesthesia, the preputial orifice was dilated and adhesions were separated. A traction suture was placed on the glans penis. A longitudinal incision was made on the dorsal aspect of the penis, and the constricting band was incised down to the penile root. A circumferential incision was made in the prepuce approximately 0.8 cm proximal to the coronal sulcus. The penile skin was degloved to the root along the loose tissue plane between Buck\u0026apos;s fascia and the preputial dartos fascia. Abnormal fibrous tissue and the dartos fascia were excised. The dermis of the prepuce and Buck\u0026apos;s fascia were sutured at the 3 o\u0026rsquo;clock and 9 o\u0026rsquo;clock positions at the penile root. Additionally, the scrotal dartos fascia and Buck\u0026apos;s fascia at the ventral penile root were anchored to reconstruct the penoscrotal angle.\u003c/p\u003e\n\u003cp\u003eTransillumination with a cold light source was performed to visualize the dorsal penile vasculature and preserve the blood supply to the flap. The prepuce was then clipped to form wing-shaped preputial flaps, which were sutured and fixed at the midpoint of the inner prepuce on the dorsal aspect of the coronal sulcus. One flap was rotated ventrally to cover the preputial defect and sutured into place. The other flap was also rotated ventrally, and a pedicled segment of the inner prepuce was trimmed to the appropriate size and used to cover the remaining ventral defect without tension or torsion before being sutured in place.\u003c/p\u003e\n\u003cp\u003eIn both groups, the penis was dressed with sterile gauze, and routine postoperative care, including anti-infective and analgesic measures, was administered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3 Observation Indicators\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.3.1 Surgical parameters:\u0026nbsp;Operation time and intraoperative blood loss were compared.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.3.2 Pain levels:\u0026nbsp;Postoperative pain at 4, 12, and 24 hours was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) scale [10]. The scale has a maximum score of 10 points, with higher scores indicating greater pain severity.\u003c/p\u003e\n\u003cp\u003e1.3.3 Stress response: Fasting venous blood samples (3 mL) were collected from the children both preoperatively and 24 hours postoperatively. The samples were centrifuged at 3,500 r/min for 10 minutes, and the supernatant was collected. Serum levels of adrenaline (Adr) and cortisol (Cor) were measured using enzyme-linked immunosorbent assay (ELISA), with assay kits purchased from Wuxi Tiancui Biotechnology Co., Ltd.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.3.4 Postoperative recovery:\u0026nbsp;Preoperative penile length, postoperative penile length, penile extension length, and duration of postoperative prepuce edema were compared.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.3.5 Complications: Complications occurring within 6 months postoperatively, including infection, flap necrosis, and penile retraction, were recorded and compared.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.3.6 Satisfaction: At 6 months postoperatively, family satisfaction was assessed using the \u0026quot;Long-term Follow-up Questionnaire for the Modified Brisson Procedure in Treating Concealed Penis,\u0026quot; developed by Tao C et al. [11]. Satisfaction levels were categorized as \u0026quot;fairly satisfied,\u0026quot; \u0026quot;satisfied,\u0026quot; or \u0026quot;dissatisfied.\u0026quot; The overall satisfaction rate was calculated by combining the percentages of \u0026quot;fairly satisfied\u0026quot; and \u0026quot;satisfied\u0026quot; responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.4 Statistical Methods s\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using SPSS 18.0 software. Continuous variables were expressed as mean \u0026plusmn; standard deviation (x̄ \u0026plusmn; s) and compared using the t-test, repeated measures analysis of variance (ANOVA), or one-way ANOVA, as appropriate. Categorical variables were presented as frequencies or percentages (%) and compared using the chi-square (\u0026chi;\u003csup\u003e2\u003c/sup\u003e) test. A P-value of less than 0.05 (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05) was considered statistically significant.\u003c/p\u003e"},{"header":"Results ","content":"\u003cp\u003e\u003cstrong\u003e2.1 Comparison of Surgical Parameters\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference in operation time between the two groups (t-test,\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003e\u0026gt; 0.05). However, the study group showed significantly lower intraoperative blood loss compared to the control group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 comparison of surgical parameters\u003c/strong\u003e (\u003cem\u003en\u003c/em\u003e =46, \u003cimg width=\"5\" height=\"16\" src=\"data:image/png;base64,R0lGODlhBQAQAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAAFAAwAgwAAAAAAADpmtmZmkLZmkLbb/7b//9u2kNvbkNvb29v////bkP/b2///2wECAwECAwQWsKWpJAU46x1636DWEMZRMMhQYIuARQA7\" alt=\"image\"\u003e\u0026plusmn;s)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eOperation time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eIntraoperative blood loss (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e49.21\u0026plusmn;5.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e9.93\u0026plusmn;1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003eStudy Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e51.04\u0026plusmn;6.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e8.91\u0026plusmn;1.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003et value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e1.515\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e3.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e0.133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Comparison of Postoperative Pain Levels at Different Time Points\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eComparison of FLACC scores at 4, 12, and 24 hours postoperatively revealed that the scores differed significantly across time points (F = 9.658,\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003e= 0.000). However, there was no statistically significant difference in FLACC scores between the groups (F = 1.813,\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003e= 0.168), nor was there a significant difference in the trend of score changes over time between the two groups (F = 2.328,\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003e= 0.100) (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 comparison of FLACC scores at 4h, 12h and 24 h postoperatively\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(\u003cem\u003en\u003c/em\u003e=46, points,\u0026nbsp;\u003cimg width=\"5\" height=\"16\" src=\"data:image/png;base64,R0lGODlhBQAQAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAAFAAwAgwAAAAAAADpmtmZmkLZmkLbb/7b//9u2kNvbkNvb29v////bkP/b2///2wECAwECAwQWsKWpJAU46x1636DWEMZRMMhQYIuARQA7\" alt=\"image\"\u003e\u0026plusmn;s)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e4h postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e12h postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e24h postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e2.26\u0026plusmn;0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e3.78\u0026plusmn;0.38*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e2.65\u0026plusmn;0.29*#\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eStudy Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e2.19\u0026plusmn;0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e3.61\u0026plusmn;0.36*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e2.59\u0026plusmn;0.27*#\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: * compared to 4h postoperatively, P\u0026lt;0.05; # compared to 12h postoperatively, P\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Comparison of Stress Response\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo statistically significant differences were observed in Adr or Cor levels between the two groups, either preoperatively or 24 hours postoperatively (t-test,\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003e\u0026gt; 0.05) (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 comparison of stress response\u003c/strong\u003e (\u003cem\u003en\u003c/em\u003e=46,\u0026nbsp;\u003cimg width=\"5\" height=\"16\" src=\"data:image/png;base64,R0lGODlhBQAQAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAAFAAwAgwAAAAAAADpmtmZmkLZmkLbb/7b//9u2kNvbkNvb29v////bkP/b2///2wECAwECAwQWsKWpJAU46x1636DWEMZRMMhQYIuARQA7\" alt=\"image\"\u003e\u0026plusmn;s)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 12px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 43px;\"\u003e\n \u003cp\u003eAdr (\u003cem\u003en\u003c/em\u003eg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 43px;\"\u003e\n \u003cp\u003eCor (\u003cem\u003en\u003c/em\u003emol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e24h postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e24h postoperatively\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e78.43\u0026plusmn;11.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e104.96\u0026plusmn;15.13\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e221.36\u0026plusmn;25.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e310.58\u0026plusmn;32.37\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eStudy Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e79.26\u0026plusmn;12.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e101.08\u0026plusmn;14.74\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e219.89\u0026plusmn;24.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e301.46\u0026plusmn;30.61\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003et value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e1.246\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.478\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e1.388\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.734\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.634\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e0.168\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: \u0026dagger; compared to preoperative condition, P\u0026lt;0.05.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Comparison of Postoperative Recovery\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative penile length and penile extension length were both significantly greater in the study group compared to the control group (t-test,\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003e\u0026lt; 0.05). However, there was no statistically significant difference in the duration of postoperative prepuce edema between the two groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05) (Table 5). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5 comparison of postoperative recovery\u003c/strong\u003e (\u003cem\u003en\u0026nbsp;\u003c/em\u003e=46,\u0026nbsp;\u003cimg width=\"8\" height=\"16\" src=\"data:image/png;base64,R0lGODlhCAAQAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAABAAFAAwAgwAAAAAAADpmtmZmkLZmkLbb/7b//9u2kNvbkNvb29v////bkP/b2///2wECAwECAwQWsKWpJAU46x1636DWEMZRMMhQYIuARQA7\" alt=\"image\"\u003e\u0026plusmn;s)\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26px;\"\u003e\n \u003cp\u003ePostoperative Penile Length (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003ePenile Extension Length (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003eDuration of Prepuce Edema (d)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26px;\"\u003e\n \u003cp\u003e4.01\u0026plusmn;0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e2.06\u0026plusmn;0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e4.96\u0026plusmn;0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eStudy Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26px;\"\u003e\n \u003cp\u003e4.29\u0026plusmn;0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e2.15\u0026plusmn;0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e4.73\u0026plusmn;0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003et value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26px;\"\u003e\n \u003cp\u003e2.816\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e2.457\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e1.379\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26px;\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e0.171\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e2.5 Comparison of Complications\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no statistically significant difference in the overall complication rate (\u0026chi;\u003csup\u003e2\u003c/sup\u003e = 2.853,\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003e= 0.091) (Table 6). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6 comparison of complications\u003c/strong\u003e [\u003cem\u003en\u003c/em\u003e =46, cases (%)]\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003eFlap Necrosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003ePenile Retraction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1 (2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e3 (6.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e1 (2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26px;\"\u003e\n \u003cp\u003e5 (10.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eStudy Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1 (2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e0 (0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 26px;\"\u003e\n \u003cp\u003e1 (2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e2.6 Comparison of Satisfaction Rates\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall satisfaction rate was significantly higher in the study group (\u0026chi;\u003csup\u003e2\u003c/sup\u003e =4 .929,\u003cem\u003e\u0026nbsp;p\u0026nbsp;\u003c/em\u003e= 0.026) (Table 7). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7 comparison of satisfaction rates\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e[\u003cem\u003en\u003c/em\u003e = 46, cases (%)]\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003eFairly Satisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eSatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003eDissatisfied\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003eOverall Satisfaction Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eControl Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e29 (63.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e10 (21.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e7 (15.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e39 (84.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003eStudy Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e36 (78.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e9 (19.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e1 (2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e45 (97.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e2.7 Representative Case Pictures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 shows the preoperative appearance, immediate postoperative outcome following correction with FT-MDP, and the appearance at 6 months postoperatively in a 7-year-old boy with CP after misdiagnosed circumcision. Figure 2 presents the corresponding stages, preoperative, immediate postoperative following FT-MBP, and 6-month postoperative appearance, in a 10-year-old boy with CP following misdiagnosed circumcision.\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003ePenile reconstruction surgery is an effective treatment for CP. The primary surgical goals include restoring a normal penile appearance through key steps such as degloving the penile skin down to its root, excising fibrous bands that restrict extension, and securing the skin at the penoscrotal junction and dorsal penile root to the tunica albuginea using fixation sutures (Zhao et al., 2012) [12]. While circumcision is commonly performed to treat redundant prepuce and related conditions, it is not effective for CP, as it fails to correct the underlying issue of inadequate penile exposure. Moreover, circumcision can worsen the condition by removing critical preputial tissue, thereby increasing the difficulty of subsequent reconstructive surgery. Therefore, surgical intervention remains the only effective option for correcting CP in children following misdiagnosed circumcision. However, there is limited evidence on which specific surgical procedures yield the most favorable outcomes.\u003c/p\u003e\n\u003cp\u003eThe MDP and the MBP are two widely used surgical techniques for treating pediatric CP. Compared to the traditional Devine procedure, MDP offers several advantages. It avoids the excision of the suprapubic fat pad, reducing trauma to surrounding tissues, and allows for precise trimming of both the inner and outer prepuce, addressing issues of preputial insufficiency. Additionally, MDP includes excision of the superficial suspensory ligament and fixation of the penile root skin to the tunica albuginea, significantly enhancing penile exposure (Liu et al., 2017) [13].\u003c/p\u003e\n\u003cp\u003eIn contrast, MBP is a less invasive alternative to the conventional Brisson procedure and offers several distinct benefits. It combines the resection of the inner and outer prepuce with the release and lengthening of the corpora cavernosa, thereby improving penile exposure and cosmetic outcomes. MBP also emphasizes preservation of the periurethral region, which is vital for maintaining penile sensation and physiological function, critical for the child\u0026apos;s sexual development and future sexual health. Furthermore, its meticulous handling of penile tissues reduces the risk of postoperative complications such as bleeding and infection. Since MBP does not involve suprapubic fat pad resection, it minimizes disruption to surrounding tissues, resulting in a more natural postoperative appearance and more durable outcomes (Wang et al., 2019) [14].\u003c/p\u003e\n\u003cp\u003eThe blood supply and drainage of the penile skin and prepuce primarily depend on the superficial dorsal penile artery and vein [15]. A dense vascular plexus is located at the junction between the inner and outer prepuce, where these superficial vessels converge. This area is highly vascularized and relatively easy to dissect, making it ideal for creating pedicled island flaps. Therefore, during surgery to correct CP in children following misdiagnosed circumcision, precise identification of the preputial vascular supply and meticulous dissection of the prepuce are essential.\u003c/p\u003e\n\u003cp\u003eThe results of this study show that FT-MDP resulted in significantly less intraoperative blood loss compared to FT-MBP. In the study group, cold light transillumination was used to guide dorsal preputial flap creation. Flaps were designed in avascular zones to form wing-shaped configurations, with the dorsal pedicled preputial flap dissected ventrally to cover the ventral skin defect. This technique prioritizes the preservation of the blood supply to the prepuce and pedicled flap. In contrast, the control group utilized a dorsal preputial incision combined with ventral preputial and pedicled flaps. Consequently, the FT-MDP approach better preserved flap vascularity, which likely contributed to the reduced intraoperative blood loss and lower risk of postoperative flap necrosis observed. These findings are consistent with those of Xiao Z. X. et al.[16], whose research demonstrated that MBP combined with flap clipping techniques results in less intraoperative blood loss and greater penile exposure compared to MBP alone in severe PCP cases.\u003c/p\u003e\n\u003cp\u003eMoreover, the study group underwent simultaneous reconstruction of the penopubic and penoscrotal angles, along with excision of excess adipose tissue at the dorsal penile root to maximize penile exposure. The control group, however, involved only resection of the dorsal penile fat pad without penoscrotal angle reconstruction. This study found that FT-MBP provided superior penile length extension compared to FT-MDP in correcting CP following misdiagnosed circumcision. The authors suggest that penoscrotal angle reconstruction enhances penile exposure by optimizing anatomic positioning. This observation is supported by Hu Z. Z. et al.[17], who reported MBP\u0026rsquo;s advantages in penile lengthening and cosmetic outcomes over MDP for severe CP. Additionally, the incisions in the study group\u0026mdash;placed proximal to the coronal sulcus and along the ventral aspect, resulted in concealed scarring, improved aesthetic outcomes, and consequently higher family satisfaction rates.\u003c/p\u003e\n\u003cp\u003eIn summary, both FT-MDP and FT-MBP are safe and effective surgical procedures for correcting CP in children following misdiagnosed circumcision. However, FT-MBP offers more advantages in extending penile length and improving family satisfaction. Nevertheless, it is still necessary to conduct a long-term follow-up study of these two procedures for correcting CP in children following misdiagnosed circumcision.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMDP:modified Devine procedure;\u003c/p\u003e\n\u003cp\u003eMBP\u003cstrong\u003e:\u003c/strong\u003emodified Brisson procedure;\u003c/p\u003e\n\u003cp\u003eCP:concealed penis;\u003c/p\u003e\n\u003cp\u003eFT:flap transfer;\u003c/p\u003e\n\u003cp\u003eFT-MDP:flap transfer combined with the modified Devine procedure;\u003c/p\u003e\n\u003cp\u003eFT-MBP:flap transfer combined with the modified Brisson procedure;\u003c/p\u003e\n\u003cp\u003ePCP:Pediatric concealed penis;\u003c/p\u003e\n\u003cp\u003eFLACC:the Face, Legs, Activity, Cry, Consolability;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003eEthical and regulatory approvals were sought and obtained from theNantong First People's Hospital, China(\u003cem\u003en\u003c/em\u003eo. 2022KT100). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e:The data are not publicly avaliable due to [their containing information that could romise the privacy of research participants];Data cannot be shared openly but are avaliable on request from corresponding author;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest The authors declare that they have no conflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e: The research project was funded by the Health and Family Planning Commission of Nantong City, Jiangsu Province with a major scientific fund number of \u0026nbsp;BK20200203\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eHaiyang Zhou project development;data analysis;Manuscript writing/editing;Bing Zheng project development;Dongmei Zhu Data collection；Ruru Ji Data collection;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThis study is a retrospective study and does not belong to a clinical trial. There is no clinical registration information available\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author: Zheng Bing Email: bingzheng\u003c/strong\u003e\u003cstrong\u003e2017\u003c/strong\u003e\u003cstrong\[email protected]\u003c/strong\u003e\u003c/p\u003e"},{"header":" References","content":"\u003col\u003e\n\u003cli\u003eCHEN H K, CHU Y S, HU Y F. The modified Devine\u0026apos;s procedure for the management of concealed penis in children: an experience of 131 cases[J]. Eur Rev Med Pharmacol Sci, 2022, 26(13): 4592- 4596. \u003c/li\u003e\n\u003cli\u003eSTANIORSKI C J, RUSILKO\u003cem\u003e p \u003c/em\u003eJ. The concealed morbidity of buried penis: a narrative review of our progress in understanding adult-acquired buried penis as a surgical condition[J]. Transl Androl Urol, 2021, 10(6): 2536-2543. \u003c/li\u003e\n\u003cli\u003eERGASHEV K, CHUNG J M, LEE S D. Concealed index for concealed penis in prepubertal children[J]. Investig Clin Urol, 2021, 62(2): 217-223. \u003c/li\u003e\n\u003cli\u003eCAIONE P, CAVALERI Y, GEROCARNI NAPPO S, et al. The concealed penis: the \u0026quot;two-corner\u0026quot; surgical technique[J]. Minerva Urol Nephrol, 2021, 73(1): 122-127. \u003c/li\u003e\n\u003cli\u003eMAO C K, PENG B, LIU X, et al. Efficacy of the modified Brisson+Devine procedure for the treatment of concealed penis[J]. Eur Rev Med Pharmacol Sci, 2023, 27(7): 2765-2769. \u003c/li\u003e\n\u003cli\u003eZHANG Z Y, WU H, MAO W J, et al. Clinical study of modified Devine\u0026apos;s surgical technique in the treatment of concealed penis[J]. Urol J, 2023, 20(4): 229-233. \u003c/li\u003e\n\u003cli\u003eZHANG W T, FENG X Q, LIU C P, et al. Evaluation on the effect of progressive pedicled skin flap transfer combined with modified devine surgery in the treatment of concealed penis in children[J]. Journal of Clinical Surgery, 2022, 30(4): 376-378. \u003c/li\u003e\n\u003cli\u003ePENG B, YANG C, CAO Y S. Efficacy and safety evaluation of the scrotal skin transfer method in the treatment of pediatric concealed penis: a six-month follow-up data[J]. Transl Androl Urol, 2023, 12(3): 384-391. \u003c/li\u003e\n\u003cli\u003eChinese Association of Andrology. Chinese Expert Consensus on the Diagnosis and Treatment of Concealed Penis in Children[J]. National Journal of Andrology, 2021, 27(10): 941-947. \u003c/li\u003e\n\u003cli\u003eYIN L, YIN X R. Application of the FLACC scale in evaluating pain in children during the general anesthesia recovery period[J]. Sichuan Medical Journal, 2015, 36(9): 1221-1222. \u003c/li\u003e\n\u003cli\u003eTAO C, TANG D X, XU S, et al. Long-term outcome of children with buried penis treated by modified Brisson technique[J]. Chinese Journal of Pediatric Surgery, 2011, 32(11): 809-812. \u003c/li\u003e\n\u003cli\u003eELROUBY A. Concealed penis in pediatric age group: a comparison between three surgical techniques[J]. BMC Urol, 2023, 23 (1): 9. \u003c/li\u003e\n\u003cli\u003eHE H L, LI Q, XU T, et al. Treatment of adult-acquired buried penis with suprapubic liposuction combined with modified Devine operation[J]. Journal of Peking University: Health Sciences, 2022, 54(4): 741-745. \u003c/li\u003e\n\u003cli\u003eSU Q X, GAO S L, LU C, et al. Clinical effect of Brisson operation modified by Y-shaped incision for treatment of concealed penis in adolescents [J]. J Int Med Res, 2021, 49(4): 3000605211005951. \u003c/li\u003e\n\u003cli\u003eFERN\u0026Aacute;NDEZ BAUTISTA B, ORTIZ R, BURGOS L, et al. Buried penis secondary to ectopic scrotum[J]. Cir Pediatr, 2022, 35(4): 204-206. \u003c/li\u003e\n\u003cli\u003eXIAO Z X, XU D, HE S H. Modified Brisson surgery combined with skin flap clipping for the treatment of severe concealed penis in children[J]. National Journal of Andrology, 2020, 26(9): 820-825. \u003c/li\u003e\n\u003cli\u003eHU Z Z. Comparative efficacy of modified Brisson and Devine procedures in the treatment of severe concealed penis in children[J]. Maternal and Child Health Care of China, 2022, 37(23): 4536-4538. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"flap transfer, modified Devine procedure, modified Brisson procedure, pediatric concealed penis, efficacy ","lastPublishedDoi":"10.21203/rs.3.rs-6843618/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6843618/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective \u003c/strong\u003eTo compare the efficacy of flap transfer combined with either the modified Devine procedure (MDP) or the modified Brisson procedure (MBP) in correcting concealed penis (CP) in children following misdiagnosed circumcision. \u003cstrong\u003eMethods\u003c/strong\u003e This study included 92 children with CP who had previously undergone misdiagnosed circumcision and were admitted to Nantong First People's Hospital between September 2020 and January 2023. Using a random number table, participants were randomly assigned to either the control group (\u003cem\u003en\u003c/em\u003e = 46), which received flap transfer combined with the modified Devine procedure (FT-MDP), or the study group (\u003cem\u003en\u003c/em\u003e = 46), which underwent flap transfer combined with the modified Brisson procedure (FT-MBP). All patients were followed up for six months postoperatively. Surgical parameters, pain levels, perioperative stress response, postoperative recovery, complications, and family satisfaction were compared between the two groups.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThere was no statistically significant difference in operation time between the groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05); however, the study group experienced significantly lower intraoperative blood loss (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05). FLACC scores at 4, 12, and 24 hours postoperatively showed significant differences across time points (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05), but there were no significant differences in pain scores between the groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05) or in the trend of FLACC score changes over time (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). Preoperative and 24-hour postoperative levels of adrenaline (Adr) and cortisol (Cor) were comparable between groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). Postoperative penile length increased significantly in both groups (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05), with the study group showing significantly greater penile and penile extension lengths (\u003cem\u003eP\u003c/em\u003e\u0026lt; 0.05). The duration of postoperative prepuce edema was similar in both groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05), as was the overall complication rate (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). Notably, family satisfaction was significantly higher in the study group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eBoth FT-MDP and FT-MBP are safe and effective surgical options for correcting CP in children following misdiagnosed circumcision. However, FT-MBP provides additional benefits in enhancing penile length and improving family satisfaction.\u003c/p\u003e","manuscriptTitle":"Comparative efficacy of flap transfer combined with modified Devine or Brisson procedure for correction of concealed penis in children following misdiagnosed circumcision*","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-30 08:03:35","doi":"10.21203/rs.3.rs-6843618/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-18T07:24:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-14T18:44:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314797986439212104024650794232937962136","date":"2025-08-04T09:53:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-22T11:13:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-22T06:46:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"210373316762182062406254778586499853591","date":"2025-07-12T16:03:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272964747277552820577397969666789957579","date":"2025-07-09T13:06:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203078076033720247932710785507940736704","date":"2025-06-27T12:38:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-23T07:20:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-23T07:18:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-19T06:34:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-19T06:08:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2025-06-19T06:05:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ec5385bc-1d37-4a79-a2ba-9e86b606cf0b","owner":[],"postedDate":"June 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T15:53:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-30 08:03:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6843618","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6843618","identity":"rs-6843618","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}