SANTUCCI Buried Penis procedure

Richard A Santucci MD and Mang L Chen MD

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Preop:

- ancef, gent

- lithotomy w yellow fins

- mayo stand for large scrotum

- many 2-0 vicryls on SH and CT1

- skin dermotome 0.15 cm/in?

- mineral oil

Note: if pt does not have large scrotum or eschutcheon, place supine

POSITIONING:

- dorsal lithotomy, SCDs on outside

- L leg straight (or straighter) for later STSG

PROCEDURE: 3 main parts

(1) Removing diseased tissue and prepubic fat pad and skin

- demarcate lymphedematous tissue from normal tissue

- make transverse marking on prepubic fat pad about 4-5cm below where new penis opening will be created

- cut thru dermis with scalpel around markings

- use bovie and careful cautery (avoid spermatic cord) to cut thru diseased and redundant soft tissue

- use finger to locate buried penis and cut skin and soft tissue on top of finger to bivalve diseased tissue above buried penis (“gigantic dorsal slit”)

- use blunt hand dissection to locate spermatic cord and testis and reflect upward

- continue bovie excision of diseased lymphedematous tissue

(2) Penile reconstruction

- put 2-0 prolene into glans of penis dorsally (big bite) as holding stitch

- place foley catheter

- make circumcision marking and cut with scalpel

- remove diseased penile shaft skin

- bluntly dissect penis proximally–”deglove”

- estimate location of where penis will “pop out” of prepubic fat pad/skin and make circular mark

- radically defat fat below prepubic fat skin to make sure penis has room to rise (make sure not to make skin/subQ flap too thin to avoid necrosis): this is done with allis clamps for retraction of trash fat and rakes to lift flaps upward

- put penis thru prepubic fat pad hole (Santucci calls this Escutcheon)

- use 2-0 vicryl interrupted sutures to secure deep dermis/subQ tissue to base of penis

(2a) STSG time

- measure length of penis shaft and determine circumference

- put mineral oil on L leg (if eschutcheonectomy done, determine if eschutcheonectomy skin is available for STSG)

- get STSG of leg/eschutch with above measured dimensions (i.e. 10cm long x 8cm circ)

- obtain by having assistant use towel clips to pull leg/eschutch skin straight and you use dermatome to enter skin at acute 45 degree angle, level out to about 10 degrees and then finish by rising 45 degrees upward

- if leg STSG, put epi-soaked telfa on donor site and cover with moist lap

(2b) Finishing touches on penis

- put skin graft around penis and secure with 3-0 simple interrupted chromic sutures in following fashion: epidermis and dermis then bucks/dartos fascia then skin graft in that order

- do this at base and at corona

- place 3-0 interrupted chromics to secure STSG to STSG by starting first at STSG, then bucks/dartos, then STSG

- make sure to leave enough room to squirt dilute fibrin glue/tisseal underneath STSG

- NOTE: must be slow diluted tisseal air delivery system so that STSG can be molded

- wrap lap pad around penis and then squeeze excess tisseal from graft site

(3) Closure/scrotoplasty

- place 10F JP drain first near L prepubic fat pad/skin

- place allis clamps to approximate skin closure; remove dog ears

- use 2-0 vicryl interrupted deep subcuticular sutures to reapproximate skin

- use 2-0 vicryl vertical mattress sutures to close skin

POSTOP immediate

1. STSG site

- remove episoaked telfa with saline then slowly remove to prevent bleeding

- put remaining tisseal on this site

- while still sterile, put TLS (tiny little sucker drain) onto STSG donor site by puncturing dermis on donor site and tunneling cephalad with 3-4cm of normal skin coverage before popping out

- place big opsite on STSG site

- attach adaptor for TLS drain and place vacutainer to suck out excess fluid

- place silk tape on edges of opsite to prevent early removal

2. penis

- put xeroform gauze (must be xeroform) around STSG of penis and then secure with kerlix and tape to pubis and scrote

3. scrotum/wound

- bacitracin and fluffs

- cut hole in party pants/jock strap for penis to protrude

POSTOP

- bedrest x 24-48 hrs w bathroom privileges

- d/c foley POD # 1

- STSG dressing to stay on as long as it will stay on; check TLS drain to see if new vacutainer is needed

- take down dressings tomorrow and de-bleb penis

- d/c home 3 days postop; d/c TLS and JP drains prior to d/c home and teach pt how to care for wounds

- Augmentin vs cipro x 10 days

- expect 10-20% wound opening–usually very mild (dress with non-meshed “soft” 4x4s, not the thick weave ones)

- may need to splint penis with STSG “out” as occasional pannus or remaing escutcheon can “rebury” penis

- pt should be seen q 1-2 weeks in clinic to assess wounds (i.e. if wound looks less good, see weekly with deblebbing of penis)

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