Original Article

Preputialplasty: can be considered an alternative to circumcision?

When, how, why? Experience of Italian centre
Rossella Angotti, Francesco Molinaro, Francesco Ferrara, Chiara Pellegrino, Edoardo Bindi, Giulia Fusi,
Mario Messina

Division of Pediatric Surgery, Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
Contributions: (I) Conception and design: R Angotti, F Ferrara; (II) Administrative support: F Molinaro; (III) Provision of study materials or patients:
C Pellegrino, E Bindi, G Fusi; (IV) Collection and assembly of data: R Angotti, F Ferrara, F Molinaro; (V) Data analysis and interpretation: M
Messina, R Angotti; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Rossella Angotti. Division of Pediatric Surgery, Department of Medical, Surgical and Neurological Sciences, University of Siena,
viale Bracci 16, 53100 Siena, Italy. Email: rossellaangotti@me.com.

Background: Phimosis is a condition in which the foreskin cannot be portrayed on the glans. It is
a physiological and common condition in the pediatric age. The pathological form derives from an
inflammatory or traumatic lesion. Circumcision is the most common surgical treatment of phimosis but it is
a controversial practice, especially in occidental world.
Methods: We enrolled 61 patients with pathological phimosis (22/balanoposthitis, 18/painful erection, 21/
urinary discomfort) between 2015–2017.
Results: All patients underwent preputialplasty.
Conclusions: Various alternatives to circumcision have been described, as manual retraction therapy,
topical steroid therapy, and many types of preputialplasty. We report our technique.

Keywords: Phimosis; preputialplasty; circumcision

Submitted Feb 18, 2018. Accepted for publication Feb 25, 2018.
doi: 10.21037/gs.2018.02.04
View this article at: http://dx.doi.org/10.21037/gs.2018.02.04

Introduction in 210 patients. All of them were European children. One

hundred and two patients had recurrent balanoposthitis
Phimosis is a condition in which the prepuce cannot be
(15 of them underwent reduction of paraphimosis in
retracted over the glans penis. It is a physiologic and
emergency), 43 had painful erections, 50 had urinary
common condition in pediatric age. Pathologic form results
discomfort, 15 recurrent urinary tract infections.
from inflammatory or traumatic injury (1-3). The most The mean age of diagnosis was 8.5 years (range, 2–16 years).
common treatment of phimosis is circumcision. However, We excluded patients <2 years, with previous preputial
it is not devoid of adverse psychological effects. Many surgery.
children, indeed, refuse circumcision because they do not Of 210 patients, 160 (76.1%) underwent topical steroids
accept the possibility to have the exposed glans. For this cream according to two protocols of our Clinic. Ninety
reason, it is important to process alternative treatment’s patients applied “fluticasone Propionate Cream 0.05%”
options. We describe our experience in correcting phimosis twice a day for 3 alternate months. Seventy patients applied
by preputialplasty. “betamethasone 0.05%” twice a day over a 4-week.
Of 210 patients, 185 patients underwent surgery and
they have been included in this study.
Methods
Twenty-five patients: 11 went to a healing, 14 were lost
Between 2015 and 2017 we diagnosed pathological phimosis to follow-up.

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Gland Surgery, Vol 7, No 2 April 2018 229

Figure 1 Preoperative; dorsal incisions: (A) inverted V at the apex of the foreskin; (B) regular lower V.

Figure 2 The cup on the tip of foreskin is removed.

One hundred twenty four patients accepted circumcision. the two mucocutaneous flaps of the prepuce are widely
Sixty-one underwent preputialplasty (22/balanoposthitis, separated and then sutured with interrupted Vicryl-Rapide
18/painful erection, 21/urinary discomfort). 5-0 stitches. In this way, a dorsal widening of the ring of
Three outcomes were measured: time of surgery; prepuce is obtained.
intraoperative and postoperative complications; cosmetic Figures 1-6 report all phases of technique. A
assessment. postoperative dressing involved a gauze around penis with
anesthetic ointment (lidocaine).

Operative technique
Results
Foreskin was pulled up carefully.
Two markings on the dorsal skin of foreskin are done: All patients received general anesthesia with the addition
an inverted V at the apex of the foreskin and a regular of penile block. They were treated in day surgery. Short-
lower V up to a millimeter from the scarring ring. The term antibiotic therapy was dispensed before anesthesia
last one is continuous on the one side and dotted on the induction. Two surgeons performed procedures. The mean
other side. The cup on the tip of foreskin is removed operation time was 19 minutes (range, 10–45 minutes).
and sent to histological exam. Foreskin is incised on No intraoperative complications were observed. Early
the skin along the marked continuous line and on the postoperative complications in term of edema and bleeding
mucosa along the marked dotted line. By these incisions, were present in 23% of patients (14/61) (edema 9/14,

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230 Angotti et al. The preputialplasty can be purposed to selected patients who refuse circumcision

Figure 3 Foreskin is incised on the mucosa along the marked dotted line and on the skin along the marked continuous line and on the
mucosa along the marked dotted line.

Figure 4 Foreskin is incised on the mucosa along the marked dotted line and on the skin along the marked continuous line and on the
mucosa along the marked dotted line.

bleeding 5/14). One of them 1/14 (7%) underwent surgical exam showed a lichen sclerosus in 7 patients (11.5%). We
revision to stop bleeding. purposed a circumcision but all of them refused. One of
Long term postoperative complications in term of them is in treatment with urethral dilatation for meatal
recurrence of phimosis were present in 3.2% of patients urethral stenosis from 8 months. The mean follow-up is
(2/61). All of them were under 3 years. The recurrence was 14.3 months (range, 2–24 months). All patients underwent
evaluated in a mean of 6 postoperative months. Histological three postoperative evaluations: after 1 week, after 1 month

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Gland Surgery, Vol 7, No 2 April 2018 231

Figure 5 Final prepuce—opened.

Figure 6 Final prepuce—closed.

and after 6 months. Report each phases of follow up. At last The inner epithelial lining of the foreskin and the glans
follow-up, 6 months after surgery, all children underwent a are fused. Over time, they spontaneously separate and
cosmetic assessment by a different surgeon. the foreskin becomes retractile. In a small percentage of
A valuation of this outcome was done using a modified children (about 2%) continue to be non-retractability. This
Hollander wound evaluation scale (WES) that we used before is known as pathologic phimosis. It can be due to strong
for others studies (3-5). Wound clinical examination is based attempts to retract foreskin in physiological phimosis
on: absence of step off, contour irregularities, wound margin causing bleeding, infection and subsequent scarring, poor
separation >2 mm, edge inversion, excessive distortion, and hygiene and recurrent balanitis or balanoposthitis (1-3).
overall cosmetic appearance. Each of these categories was The treatment of phimosis can be managed by
graded on a 0- or l-point scale. A total cosmetic score was circumcision or preputialplasty with preservation of the
derived from the addition of the six categorical variables. A foreskin. This is usually proposed as an alternative especially
score of 6 was considered optimal, while a score of < or =5 in Occidental countries in absence of specific conditions as
suboptimal. Forty-seven patients (77%) had optimal score and balanitis xerotica obliterans (BXO) that need circumcision.
14 (23%) with suboptimal score. Over the years many prepuce-saving techniques have
been described: V-flap, Z-flap repair, triple incision plasty,
limited dorsal slit, multiple Y-V plasty and Triple T (6-15).
Discussion
In our center, we purpose a limited dorsal Y-V incision
Physiologic phimosis is normal in newborn males. During that is enough to divide the fibrous ring. It is an easy
neonatal development, the prepuce adheres to glans. procedure, with easy learning curve, with satisfactory results

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232 Angotti et al. The preputialplasty can be purposed to selected patients who refuse circumcision

and a lower rate of complication. We usually purpose this to declare.

surgery as alternative to circumcision in selected cases.
The ideal patient is a pre-puberal male, with a prepuce no Ethical Statement: Ethics Committee Approval was informed
more long, in absence of suspicion of lichen sclerosus, with but it was no necessary to perform the study, because this
a good compliance to postoperative retraction of prepuce is a retrospective descriptive study. Informed consent form,
at least two times per day for a month. We introduced this however, was obtained from children’s parents before
technique to our Institute in 2010. Previous preputialplasty each procedure. We performed the study without external
consisted in a linear dorsal incision that caused a foreskin’s founds.
anomalies known as “dog ears”. Many parents complained
for these findings. Parents and children usually refuse
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Cite this article as: Angotti R, Molinaro F, Ferrara F,

Pellegrino C, Bindi E, Fusi G, Messina M. Preputialplasty: can
be considered an alternative to circumcision? When, how, why?
Experience of Italian centre. Gland Surg 2018;7(2):228-233. doi:
10.21037/gs.2018.02.04

© Gland Surgery. All rights reserved. gs.amegroups.com Gland Surg 2018;7(2):228-233