Traditional circumcision and dorsal slit remain the mainstay treatments of bothersome phimosis as they are quick, safe, and effective. However, the overall decline of neonatal circumcision in the United States over the last decade¹ has served to increasingly normalize the uncircumcised phallus. This has led to the formation of many activist groups which aim to protest routine circumcision before the age of legal consent. As such, there arises a need to develop a reliable method of treating pathological phimosis while preserving the foreskin in order to avoid progression to malignancy and serious infection.^2-5 The Heineke-Mikulicz technique has been widely applied across surgical specialties including urology, where it has been primarily described in adult urethroplasty and repair of pediatric hypospadias and penoscrotal webbing.^6-8 There are few published reports describing foreskin-preserving surgical treatment for phimosis in the adult population and even fewer reporting the outcomes of such techniques. Our study provides a summary of both surgical technique and outcomes for Heineke-Mikulicz preputioplasty (HMP) in adults.

Our method is as follows: after administration of general anesthesia and prophylactic intravenous antibiotics, the patient is placed in the supine position, prepped, and draped. In cases where patients report pain or discomfort during sexual intercourse, HMP is initiated by injecting a 20–30 μg dose of intracavernosal alprostadil or 30 cc saline to achieve an erection. This step is omitted in patients with a clear phimotic band in the absence of tumescence. The foreskin is then retracted and the phimotic band is identified. A 2–3 cm vertical incision is made over the phimotic band on the dorsal surface to just above Buck’s fascia. The length of the incision is determined by visually assessing the release of the phimosis, and then confirming easy movement of the prepuce over the glans. A ventral counter-incision is made if phimosis remains persistent after dorsal release. If a frenulectomy is warranted, it is performed at this time by transecting the frenulum and achieving hemostasis with 4-0 poliglecaprone suture. Interrupted sutures are placed on the dartos using 4-0 polyglactin to bring the incision together in a horizontal fashion in order to produce a tension-free closure. The skin is then trimmed and closed using running 4-0 poliglecaprone. An artificial erection can once again be induced to ensure that the foreskin can be retracted and reduced. Bacitracin and a nonadherent dressing are applied, and a dorsal penile block is performed with 0.5% bupivacaine. The Figure demonstrates our technique in detail.

Figure. A, an artificial erection is induced using either intracavernosal alprostadil or injectable saline. B, a 2 cm dorsal incision is made over the phimotic band to the level of Buck’s fascia. C, given the persistent constriction, a ventral counter-incision is made. D, the incisions are closed with interrupted 4-0 polyglactin suture on the dartos and running 4-0 poliglecaprone suture on the skin. E, the foreskin is reduced.

We retrospectively reviewed all patients who underwent HMP by a single surgeon (LCZ) from May 2017 to May 2021 at our institution. Demographics and intraoperative and postoperative variables were collected. A total of 7 patients met criteria and were included in the analysis. Median age was 47.3 years (range 35.4–70.2) and median BMI was 24.3 kg/m² (20.9–29.3). Indications for surgery included bothersome phimosis, recalcitrant paraphimosis, and penoscrotal webbing/frenular tethering. Etiologies of the above diagnoses varied: 2 patients had undergone a prior frenulectomy leading to scar formation. A third patient underwent a prior attempt at foreskin-sparing circumcision for recurrent balanitis, which was unsuccessful. A fourth patient was an intraoperative consult for paraphimosis which was unable to be reduced. The remainder were deemed idiopathic. Six patients requested foreskin-sparing surgery as a personal preference, and 1 patient was an intraoperative consult and thus the decision was made to preserve the foreskin given lack of consent for circumcision. Topical betamethasone was attempted in 3/7 patients. The median time from diagnosis to surgery was 2 months.

Median operative time was 45.5 minutes (range 16–59), and median estimated blood loss was 5 cc (1–10). Two patients required both dorsal and ventral incisions. One patient underwent concurrent frenulectomy with a dorsal incision. Three patients were evaluated with an artificial erection prior to incision. No intraoperative complications were reported, and all patients were discharged the same day. Pathology was sent for just 1 patient, which returned superficial chronic inflammation. At median followup of 1.8 (0.98–15.3) months, just 1 patient reported bothersome phimosis secondary to scar formation, which was treated successfully with triamcinolone. All other postoperative courses were unremarkable.

We posit that HMP is a simple, safe, and durable approach to treatment of pathological phimosis and paraphimosis in the adult population with a minimal complication profile and short recovery time. Community and academic urologists can readily adapt this technique into their armamentarium. We anticipate that this procedure will increase in demand as cultural norms continue to shift and data on the value of universal or prophylactic circumcision remain equivocal at best.