The webbed penis is a congenital condition in which a skin fold tethers the scrotum to the ventral penile shaft obscuring the penoscrotal angle. This anomaly is usually discovered in infancy or at circumcision. This anomaly usually leads to penile shortening and is considered a common cause of delayed circumcision [1].

Circumcision in the case of a webbed penis without releasing this web results in the downward urinary stream during childhood and makes future sexual function difficult during adulthood so circumcision without excision of the web is usually contraindicated and web correction is mandatory [2].

The main target of the treatment of penoscrotal web is to incise the web with ventral penile skin lengthening; this is conventionally done by transversely incising that web with vertical closure (Heineke-Mikulicz incision) [3].

Other innovations including Z-plasty, lateral para-penile incision, and other flap methods, like preputial skin flap rotation, etc., have been also described for the treatment of such conditions [4].

The Heineke-Mikulicz scrotoplasty is the most commonly used method for such conditions in the form of longitudinal incision and transverse closure. History of this technique belongs to Heineke who performed pyloroplasty for the first time for a patient presented with an obstructing pyloric mass in 1886. One year later in1887, Mikulicz described the same technique but for treatment of a bleeding peptic ulcer [5].

It was also described by Emmanuel Lee in 1976 in the treatment of intestinal strictures following Crohn’s disease [6].

RN Katariya et al. reported the usage of the same technique in the management of terminal ileal strictures [7].

This procedure was then widely used by many surgeons for variable conditions in which there is narrowing or stenosis to provide an additional length and/or width to a luminal structure. Its usage in the penoscrotal web involves transverse incision centered on the expected point of release of the web followed by longitudinal closure [1].

This study aimed to compare the surgical outcome of Z-scrotoplasty versus Heineke-Mikulicz scrotoplasty in the management of congenital penoscrotal web in the pediatric age group.

This prospective randomized interventional study was conducted on 40 patients having congenital penoscrotal web who were presented to Elshatby University Hospital from January 2019 to January 2021. Patients with any other congenital penile anomalies were excluded from our study (Fig. 1).

Congenital penoscrotal web

The age and weight at operation as well as the main complaint of parents or caregivers were recorded. The main complaint was an apparent small size penis, penoscrotal webbing, or a postponed circumcision by another surgeon due to the presence of the web. Patients with hypospadias, circumcised patients, micropenis, and/or torsion were excluded from this study. The studied patients were divided randomly into two groups; Group A included 20 patients who were treated by Z- scrotoplasty and Group B included another 20 patients who were treated by Heineke-Mikulicz scrotoplasty.

Pre-operative investigations included the routine laboratory tests; PT, PTT, INR, BT, CT & CBC. Operative intervention was conducted under general anesthesia with skin preparation using povidone-iodine. The surgical procedure started in patients of Group A with the creation of a Z-shape incision with its longitudinal arm extending along the web and its two lateral limbs extending alongside the web (Fig. 2).

The Z- shape incision in patients of group A

Complete and meticulous lateral dissection of the two flaps was done at a sufficient depth keeping skin vascularity. Simple closure of the skin flaps was done using Vicryl 6/0 after point-to-point hemostasis using bipolar diathermy (Fig. 3).

a, b & c Ventral skin closure in patients of Group A at the end of the operation (Z—scrotoplasty)

The incision in patients of Group B was done transversely across the web at the level of the penoscrotal junction. Meticulous proximal and distal dissection of skin flaps was done preserving skin vascularity and allowing for tension-free vertical closure. Good hemostasis was done followed by longitudinal midline simple closure using the same suture material (Fig. 4).

Ventral midline closure of a patient in group B at the end of the operation (Heineke-Mikulicz scrotoplasty)

The dartos layer was dissected in the two procedures from the penoscrotal angle without the need for its excision and circumcision was done in all patients with closure of the mucocutaneous junction with the same suture material in a subcuticular fashion at the end of the procedure (Fig. 5).

Circumcision with subcuticular closure of the mucocutaneous junction at the end of the procedure

Follow-up was carried out at the end of the 1st postoperative week as well as at the 3rd, 6th, and 12th postoperative months during the regular visits at Elshatby University Hospital. The follow-up parameters included penile edema, hematoma, gangrene, recurrent webbing, and/or ventral curvature.

My study adheres to CONSORT guidelines and a checklist will be uploaded as an additional file during submission.

The IBM SPSS software package version 20.0 (Armonk, NY: IBM Corp) was used to analyze our data describing the qualitative data as numbers and percentages. On the other hand, the quantitative data were described as range (minimum and maximum), mean, standard deviation, and median (IQR). The comparison between the two groups was done by using the Chi-square test for categorical variables, Fisher’s Exact or Monte Carlo correction for chi-square when more than 20% of the cells have an expected count less than 5 and Mann Whitney test for abnormally distributed quantitative variables. The level of significance was tested at the 5% level [8].