Reconstructive surgery of the sulcus of glans penis for balanopreputial adhesion due to lichen sclerosus. Our experience and medicolegal implications

AIM

Our exeperience with the reconstructive surgery of the adhesion of the glans with the preputial skin due to lichen sclerosus.

MATERIAL OF STUDY

Twentyeight patients (mean age, 44 years; range, 28-69) underwent reshaping of the balanopreputial sulcus at our institution. All patients presented with trapped penis resulting from adhesion at the sulcus of glans due to Lichen Sclerosus. The procedure entailed separating the coronal adhesion along its entire length with the use of a blunttipped forceps, then reshaping the balanopreputial sulcus. Though simple, the maneuver is delicate and requires scrupulous attention to the ventral aspect to avoid damaging the urethra. The adhesion is removed circumferentially around the glans by means of electrobistoury.

RESULTS

The duration of the follow-up period was 24 months. All patients stated they were satisfied with the cosmetic results and functional outcome. Recurrence of the condition occurred in 7% of the patients and was treated medically; recurrence of adhesion occurred in 2% of the patients and was treated with repeat surgery.

DISCUSSION

The indication for medical therapy in early LS is a selective criterion restricted to less severe cases; otherwise, the physician may be held responsible for treatment failure, justified claims for reimbursement, disease progression and the decidedly greater damage that may ensue. Such consequences can be averted when assessment is based on recent scientific evidence and the approach to treatment is appropriate in terms of efficacy and effectiveness. Surgical management is definitive and restores normal penile anatomy and function, including sexual and urinary function, thus enabling the patient to regain sexual confidence

CONCLUSIONS

Lichen sclerosus et atrophicus is a rare disease, however, its management is not devoid of medicolegal considerations. The etiopathogenesis of the disease is unknown but progression to carcinoma of the penis has been reported in untreated cases. Consequently, timely diagnosis holds medicolegal relevance for averting delayed initiation of treatment. In cases of balanopreputial adhesion with disappearance of the sulcus of glans, we proceed with lysis and reshaping of the sulcus by means of a simple technique we have developed. The technique involves separating the coronal adhesion circumferentially around the glans using a blunt-tipped forceps, then reshaping the balanopreputial sulcus. Though very simple, the procedure is also delicate as the surgeon must be careful not to damage the urethra beneath the ventral surface.

[A case of autoinjection of vaseline under penis skin]

We report the case of a 24-year-old rumanian patient who came to the emergency department complaining of glans penis pain and tight phimosis; he claimed to have undergone an injection of vaseline under penis skin. We review the literature on various nonmedical practices of penile foreign body injection to enlarge and thicken the penis.

The universal condition: medical constructions of 'congenital phimosis' in twentieth century New Zealand and their implications for child rearing

'Congenital phimosis' was one of a number of pseudo-pathologies that entered mainstream medicine in the nineteenth century. In the twentieth century Truby King, Henry Jellett, and Eric Corkill advocated premature foreskin retraction as the first intervention to manage 'congenital phimosis'. If that failed they recommended circumcision, although eventually it became more expedient to use circumcision exclusively. The nineteenth-century justification for such interventions was to prevent masturbation, but by the middle of the twentieth century this was replaced by prevention of infections. Gairdner's landmark paper of 1949 turned New Zealand doctors away from 'congenital phimosis' and non-therapeutic circumcision, although some doctors and persisting family traditions maintained both interventions until the end of the century.

Reduced bacterial colonisation of the glans penis after male circumcision in children--a prospective study

OBJECTIVE

The aim of this prospective study was to evaluate the effect of male circumcision on the bacterial colonisation of the glans penis in children.

PATIENTS AND METHODS

244 males were included in this study. The study group consisted of 143 boys admitted for circumcision between August 2009 and July 2010. Periurethral swabs were taken preoperatively and one week postoperatively. The control group included 101 boys without phimosis, in which only one swab was taken. Patients were subgrouped according to age below and above five years. Bacterial cultures were analysed, results were categorized by non-uropathogenic and uropathogenic bacteria, and compared within and between groups.

RESULTS

Patients in both control group and study group before circumcision showed significant bacterial colonisation (>98%), involving known uropathogenic bacteria in over 86%. After circumcision, bacterial colonisation dropped from 100% to 86.3% (p < 0.005) in boys younger than five years and from 98.57% to 77.14% (p < 0.001) in those aged five or above, respectively. Moreover, the fraction of uropathogenic bacteria decreased significantly.

CONCLUSION

Male circumcision significantly reduces the bacterial colonisation of the glans penis with regard to both non-uropathogenic and uropathogenic bacteria.

[Shang Ring circumcision versus conventional circumcision for redundant prepuce or phimosis: a meta analysis]

OBJECTIVE

To compare the effect and safety of Shang Ring circumcision with those of conventional circumcision in the treatment of redundant prepuce or phimosis.

METHODS

We retrieved the randomized controlled trials on Shang Ring circumcision and conventional circumcision for the treatment of redundant prepuce or phimosis published at home and abroad. Relevant data were selected according to the Cochrane Handbook for Systematic Reviews by two reviewers after quality evaluation of the included trials, and the statistical software RevMan 5.0 was used for meta analysis.

RESULTS

Totally 8 randomized controlled trials with 2277 cases were included in this study. Compared with conventional circumcision, Shang Ring circumcision showed a shorter operation time (SMD = -5.82, 95% CI [ -7.39, -4.24], P<0.00001), less intraoperative blood loss (SMD = -3.28, 95% CI [ -3.47, -3.09], P<0.00001), lower rate of infection (OR = 0.44, 95% CI [0.26, 0.72], P=0.001), lower rate of postoperative bleeding (OR =0.05, 95% CI [0.02, 0.12], P<0.00001), higher rate of satisfaction with the postoperative penile appearance (OR=12.72, 95% CI [1.30, 124.56], P=0.03), lower intraoperative pain score (SMD = -3.32, 95% CI [ -3.50, -3.14], P<0.00001), and lower 24-hour-postoperative pain score (SMD = -3.28, 95% CI [ - 3.47, - 3.00], P<0.00001), but longer wound healing time (OR=1.46, 95% CI [1.03, 1.90], P<0.00001).

CONCLUSION

In comparison with conventional circumcision, Shang Ring circumcision has the advantages of shorter operation time, fewer complications, mild pain, and higher rate of satisfaction with the postoperative penile appearance. However, more high-quality randomized controlled trials with large samples are required to lend further support to our findings.

[Effectiveness of penile ventral scrotum cohesion place wedge cutting and improved Brisson technique for congenital buried penis]

OBJECTIVE

To investigate the effectiveness of the penile ventral scrotum cohesion place wedge cutting and improved Brisson technique for congenital buried penis.

METHODS

Between March 2010 and June 2012, 68 boys with congenital buried penis were treated by the penile ventral scrotum cohesion place wedge cutting and improved Brisson technique, with a median age of 4 years and 10 months (range, 3 months-13 years). Of 68 cases, 14 were classified as phimosis type, 14 as rope belt type, 20 as moderate type, and 20 as severe type. The body of penis developed well and had no deformity. After operation, complications were observed, and the effectiveness was evaluated by the designed questionnaire.

RESULTS

Early postoperative complications occurred in 11 cases, including obvious adhesion of the outside wrapping mouth in 4 cases, scrotal skin bloat in 5 cases, and distal foreskin necrosis in 2 cases; long-term complications occurred in 9 cases, including abdominal incision scar formation in 4 cases, wrapping mouth scar stricture in 3 cases, and short penis in 2 cases. Primary healing of incision was obtained in the other boys. Fifty-four cases were followed up 6-12 months (mean, 8 months). According to the designed questionnaire, satisfaction rate with the overall view in parents was 77.78% (42/54); the clinical improvement rate was 85.19% (46/54); exposure of the penis was satisfactory in parents of 50 cases; and the parents had no psychological burden of penis exposure in 46 cases, which were significantly improved when compared with preoperative ones (P < 0.05). The boys had no psychological burden of penis exposure in 29 cases (53.70%) after operation, showing no significant difference when compared with preoperative one (18 cases, 33.33%) (chi2 = 1.22, P = 0.31).

CONCLUSION

Application of the penile ventral scrotum cohesion place wedge cutting and improved Brisson technique can effectively correct congenital buried penis.

[Shang Ring, sleeve and conventional circumcisions for redundant prepuce and phimosis: A comparative study of 918 cases]

OBJECTIVE

To compare the clinical effects of conventional, sleeve and Shang Ring circumcisions in the treatment of redundant prepuce and phimosis.

METHODS

We reviewed the clinical data of 918 patients with redundant prepuce or phimosis, 279 treated by conventional circumcision, 354 by sleeve circumcision and 285 by Shang Ring circumcision. We documented the preoperative characteristics, intra-operative blood loss, operation time, 4-hour and 7-day postoperative visual analogue scores, surgeons' satisfaction, incision healing time, degrees of preputial edema, postoperative complications, patients' satisfaction with penile appearance and peri-operative cost, and compared them among the three groups.

RESULTS

Shang Ring circumcision significantly reduced the operation time and intra-operative blood loss as compared with conventional and sleeve circumcisions (P < 0.05). The postoperative incision healing time was (18.6 +/- 5.2) d in the conventional circumcision group, (11.4 +/- 3.7) d in the sleeve circumcision group and (20.3 +/- 5.7) d in the Shang Ring circumcision group, significantly shorter in the sleeve group than in the other two (P < 0.05). As for the surgeons' satisfaction, postoperative complications, degree of preputial edema and patients' satisfaction with penile appearance, sleeve circumcision showed similar effects to Shang Ring circumcision but significantly better than conventional circumcision (P < 0.05). The 7-day postoperative visual analogue score and peri-operative cost were significantly lower in the conventional and sleeve circumcision groups than in the Shang Ring group (P < 0.05).

CONCLUSION

Each of the three circumcision methods has its own advantages and disadvantages. The treatment decision should be individualized and based on a comprehensive consideration of the patients' age and economic status as well as surgeons' advice and surgical skills.

A report of 918 cases of circumcision with the Shang Ring: comparison between children and adults

OBJECTIVE

To compare the clinical outcome and surgical complications in circumcision using the Shang Ring between children and adults.

METHODS

Circumcision using the Shang Ring was performed on 702 adults and 216 children. Comparative analysis on indices including operative time, healing time, postoperative edema, postoperative bleeding, postoperative pain, and postoperative infection was conducted.

RESULTS

When the ring was removed after surgery, the pain was tolerable in the adult group, but more substantial in the child group. The optimal time for removing the ring was 2 weeks after surgery.

CONCLUSION

Special attention to the pain management is needed when using the Shang Ring to treat redundant foreskin or phimosis in children. The timing of the ring removal is critical to avoiding complications. Surgeons' knowledge in urology is also critical to the clinical outcome.

[Sarcolemma tissue of prepubertal concealed penis: pathological characterization and clinical implication]

OBJECTIVE

To evaluate the histopathological characteristics and clinical implication of sarcolemma tissue in prepubertal concealed penis.

METHODS

After measurement of the penile length, 10 prepubertal children with congenital concealed penis underwent modified Devine's operation (treatment group), and another 10 normal prepubertal children received circumcision (control group). The anatomic features of the penile sarcolemma tissue was observed intraoperatively, and its fibrosis was evaluated by Masson trichrome staining.

RESULTS

The penile length of the treatment group was significantly shorter than that of the control group preoperatively ([1.49 +/- 0.17 ] cm vs [4.26 +/- 0.23 ] cm, P < 0.01). The degree of penile concealment was correlated with the distal point of the attachment of its sarcolemma fibrous tissue: the closer the distal attachment point was to the coronary ditch, the more serious was penile concealment. The proportion of the area of collagen fibers in the penile sarcolemma tissue was significantly higher in the treatment group than in the control ([65.6 +/- 6.9]% vs [37.1 +/- 4.7]%, P < 0.01).

CONCLUSION

Sarcolemma fibrosis was obvious in congenital concealed penis, and the key to its management is drastic removal of all the fibrous sarcolemma tissue.

Prepuce-sparing plasty and simple running suture for phimosis

AIM

Circumcision is the most common procedure for phimosis. In recent years, the value of foreskin properties as well as aesthetic reasons determined to other operations preserving the foreskin. We report 5-years experience with a technique that preserve the physical foreskin appearance intact.

PATIENTS AND METHODS

Fifty-two patients, eligible to undergo phimosis surgery, underwent prepuce-sparing plasty and simple running suture. Evaluation of results was made with photos comparative and verified by using presence/absence of recurrence, scarring evaluation, and VAS for patient satisfaction.

RESULTS

Forty-eight patients reported no complications. There were no cases of bleeding, infection, pathological scarring, phimosis recurrence. The scar showed a good pliability and a thin thickness. Patient satisfaction was high.

CONCLUSIONS

The association of prepuce-sparing plasty and simple running suture highlighted an effective and easy method for the correction of acquired phimosis in adult patients, with excellent functional and cosmetic results.

Severe phimosis leading to obstructive uropathy in a boy with lichen sclerosus

Lichen sclerosus (LS) is a chronic, inflammatory condition which commonly involves the anogenital skin. This condition may affect the foreskin, glans, frenulum, meatus and urethra in males. It manifests itself with voiding symptoms. Obstructive uropathy is an extremely rare clinical presentation in childhood. This study reports the case of a 13-year-old boy presenting with obstructive uropathy due to LS and reviews the published data on the diagnosis, management and follow-up of this condition.

[Benefits of promoting male circumcision among the general population in the high HIV prevalence areas of Guangxi Province]

OBJECTIVE

To evaluate the effect of promoting male circumcision among the general population in the high HIV prevalence areas of Guangxi Province.

METHODS

We interviewed 590 male residents from Hezhou and Qinzhou areas of Guangxi Province and conducted intervention using male circumcision promotion materials and various methods. If the subjects were willing and had no contraindication, they were referred to the appointed hospitals to receive circumcision. We conducted follow-up visits at 6 and 9 months after intervention for the changes in the subjects' knowledge, attitude and practice related to male circumcision.

RESULTS

The male circumcision knowledge, willingness and operation rate were significantly improved after intervention (P < 0.05), but with no significant difference between the two follow-up visits (P > 0.05). The number of those who knew that phimosis and redundant prepuce were the reasons for circumcision increased from 66.1% at baseline to 81.9% and 79.8% at the two follow-up visits; those who knew that circumcision could prevent AIDS and sexually transmitted diseases increased from 28.0% to 77.4% and 78.6%; those who knew that surgical complications could be pain, bleeding and infection increased from 29.5%, 19.3% and 39.3% to 72.5%, 58.2% and 59.4% at the first follow-up and 75.0%, 57.0% and 63.0% at the second; those who were willing to receive circumcision increased from 35.3% at baseline to 59.6% and 61.3% at the two follow-up visits; and the rate of surgery increased from zero to 12.7% and 16.1%.

CONCLUSION

The promotion of male circumcision among the general population in the high HIV prevalence areas of Guangxi Province significantly improved their knowledge, attitude and practice related to AIDS prevention. And the promotion activities should focus on the publicity of AIDS knowledge, risks of phimosis and redundant prepuce, and safety of circumcision.

Local steroid therapy as the first-line treatment for boys with symptomatic phimosis - a long-term prospective study

AIM

Phimosis is a common paediatric urological disorder and often necessitates circumcision. We prospectively evaluated local steroid therapy (LST) as the first choice therapy for such children.

METHODS

Two hundred and sixty symptomatic boys up to 15 years of age (mean 34 months) with phimosis were started on betamethasone dipropionate (0.05%) application on gently stretched prepuce twice a day. Follow-up visits were arranged at the end of weeks 1, 2 and 4 and 6 months. Grade of phimosis was objectively graded.

RESULTS

Ninety one percent of the boys showed a successful outcome at the end of 4 weeks; 72% responded in first week, further 16% responded in week 2, and only 2.6% achieved alleviation of phimosis on further application of LST beyond 2 weeks. Fourty two (17.8%) boys had a recurrence of phimosis on a long-term follow-up (mean - 25.4 months, range 6-48 months); thus, the long-term success rate was 77%, while 60 (23%) boys underwent surgery.

CONCLUSION

Local steroid therapy is safe and successful in alleviating symptomatic tight foreskin in a large majority of children. The response can be seen as early as 1 week; most of the children respond by week 2 and continuing therapy further may not be very effective.

[Circumcision anastomat in the treatment of phimosis and redundant prepuce in children]

OBJECTIVE

To summarize the experience in the application of circumcision anastomat in the treatment of phimosis and redundant prepuce in children.

METHODS

A total of 551 children with phimosis or redundant prepuce were treated by circumcision from 2008 to 2010, 342 with circumcision anastomat and the other 209 by traditional circumcision. Their clinical data were retrospectively analyzed.

RESULTS

Compared with traditional circumcision, circumcision with the anastomat showed the advantages of less operation time (P < 0.05), fewer complications, no need for dressing, and better cosmetic appearance, but it also exhibited the disadvantages of longer healing time (P < 0.05) and more obvious postoperative pain (P < 0.05).

CONCLUSION

Circumcision with the anastomat and traditional circumcision for the treatment of phimosis and redundant prepuce in children each have their own advantages and disadvantages, but the former is more advantageous and more feasible clinically.

[Phimosis: dorsal slit or circumcision?]

INTRODUCTION

Phimosis is perhaps one of the most frequent consultation on pediatric surgery clinics throught the world. The aim of this study is to compare the two procedures more frequently performed in our hospital: dorsal slit and circumcision. PATIENTS Y METHODS: Retrospective study of 1698 patients who were admitted for elective surgical treatment of phimosis between 2003 and 2009. We analyzed age, surgical and anesthethic times, surgical technique and complications. We also did transversal descriptive study through telephonic survey on parents and patients older than 16 years old.

RESULTS

There was 76.6% of dorsal slit (n = 1300) and 23.4% (n= 398) of circumcisions. Mean age was 7.15 years y mean time of follow up was 42.3 months. Surgical time was significantly higher in circumcision (p < 0.0001). There were 3% (n = 51) of reoperations, no differences between groups. We didn't find differences in postoperative stenosis, but bleeding was more frequent in circumcision group (1.7%; p = 0.03). There were no differences on parental appreciation of postoperative pain, or functional and esthetic satisfaction between groups.

CONCLUSIONS

We didn't find differences on subjective satisfaction between groups. Even if there are differences n postoperative bleeding, global incidence is very low. In our experience both techniques are valid and safe, so surgeon and parents must jointly make the decision.

[Updated treatments for neonatal phimosis and redundant prepuce]

Phimosis and redundant prepuce, as common problems in andrology, are found in the majority of male neonates. Early treatment of neonatal phimosis and redundant prepuce has the advantages of better cost--effectiveness and higher safety, and contributes much to the prevention of childhood urinary tract infection and adult sexually transmitted diseases, as well as to the improvement of genital hygiene. Neonatal circumcision is commonly performed in some countries, but remains at a low rate in China. This article updates surgical and non-surgical treatments of neonatal phimosis and redundant prepuce, introduces the benefits of neonatal circumcision, and appeals for more attention to the management of neonatal phimosis and redundant prepuce.

[Shang Ring circumcision versus conventional surgical procedures: comparison of clinical effectiveness]

OBJECTIVE

To compare the efficacy and complications of the Shang Ring circumcision with those of conventional surgical procedures.

METHODS

A total of 724 patients, 521 with redundant prepuce and 203 with phimosis, were randomly assigned to receive the Shang Ring circumcision (n = 402) and conventional surgical procedures (n = 322). Comparisons were made between the two groups in the surgical duration, blood loss, pain score, as well as postoperative complications, satisfaction with the penile appearance, and the quality of sexual life.

RESULTS

The surgical duration, blood loss, postoperative satisfaction and IIRF-5 score were (4.70 +/- 1.30) min, (2.60 +/- 1.80) ml, 99.50% (400/402) and 23.45 +/- 3.43, respectively, in the Shang Ring group as compared with (25.6 +/- 8.3) min, (11.20 +/- 3.50) ml, 69.57% (224/322) and 23.12 +/- 3.26 in the conventional surgery group, with statistically significant differences in the first three parameters (P < 0.01), but not in IIRF-5 score (P > 0.05).

CONCLUSION

Compared with the conventional surgical procedures, the Shang Ring circumcision has the advantages of shorter operation time, less blood loss, mild pain, fewer complications, better penile appearance, lower expenses, and higher satisfaction and acceptance of the patients.

[Circumcision with the Chinese Shang Ring in children: outcomes of 824 cases]

OBJECTIVE

To observe the clinical effects of using the Chinese Shang Ring in circumcision children with either phimosis or redundant prepuce, and to investigate its superiority over the similar devices available.

METHODS

A total of 824 children with phimosis or redundant prepuce underwent circumcision with the Shang Ring. The clinical data were assessed concerning the duration of the procedure, incidence of post-operative complications, time of recovery and appearance of the penis.

RESULTS

The procedure duration was (2.6 +/-1.2) min, and the complications included infection in 4 (0.6%), edema in 21 (3.2%), delayed removal of the ring in 10 (1.5%), redundant and asymmetric mucosa attributable to performance in 6 (0.9%) of the cases. The wounds healed and the rings were removed at 13.4 +/- 5.8 days after circumcision, with well-smoothed incision and good cosmetic results.

CONCLUSION

Child circumcision with the Chinese Shang Ring is easy and simple in performance, with less operative time, fewer complications and better cosmetic results.

[Foreskin surgery]

Balanitis, phimosis and foreskin adhesions are common indications for foreskin surgery during childhood. In phimosis, the foreskin cannot be drawn behind the glans penis because of the narrow external opening of the former. It is important to be able to distinguish between physiologic and pathologic phimosis, since their treatment is different. In adulthood, the need for surgery can be caused by phimosis, a difficult sequel of paraphimosis, recurrent inflammations of the glans penis and foreskin, diseases and cancers of the skin as well as difficulties at intercourse due to the shortness of the frenulum of the prepuce of the penis.

Day care surgery in a metropolitan government hospital setting--Indian scenario

Day care surgery has generated a lot of interest, among both surgeons and the common people. This study aims to explore the management and advantages, including the cost benefits and cost effectiveness, of day care surgery in a government hospital setting. A prospective, single-center, single-unit study was carried out over 1 year from August 2006 to January 2008. The total number of patients studied was 327. Surgeries for hernia, hydrocele, fibroadenoma, fissure in ano, and phimosis were included. Patients were admitted on the day of surgery and were discharged the same day or evening. Patients were analyzed with respect to failure to discharge, wound infection, duration of stay in the ward, cost benefits, cost effectiveness, and postoperative pain. A total of 157 patients were treated for hernia, 61 for hydrocele, 52 for fibroadenoma, 34 for fissure in ano, and 23 for phimosis. Day care surgery is a fast growing and well accepted way of providing care to patients. Most of the patients studied had a favorable impression of the day care surgical procedure compared with inpatient care. In a country like India, in spite of problems of financial constraints and insufficient grants for health care, we are able to enjoy all the advantages of day care surgery, even in a government hospital setting.

Preputial adhesions--a misunderstood entity

OBJECTIVE

To assess the trends and outcomes in referrals of 'phimosis for circumcision' to a tertiary care pediatric surgical department.

METHODS

This is a prospective study of 100 consecutive children of presumed phimosis referred for circumcision. They were assessed and classified by the senior author as having either preputial adhesions or phimosis. The patients in the former group underwent outpatient preputial adhesiolysis while those in the latter group were offered circumcision primarily. All were followed up till resolution.

RESULTS

All 100 were referred with a non-retractile prepuce and an additional reason - preputial ballooning at voiding, dysuria or suspect UTI. Eight (mean age -58 months, referred for preputial ballooning at voiding -6/8 and dysuria -2/8) had phimosis and were primarily offered circumcision. The remaining 92 (mean age - 22 months, referred for preputial ballooning at voiding -52/92, dysuria -28/92 and suspect UTI -12/92) had preputial adhesions. In the latter group, none has a documented urinary infection on specific investigations. These 92 underwent outpatient preputial adhesiolysis. Seventy three (79 %) required a single sitting, 11 (12%) required 2 -4 sittings and 4(4.5%) required 5-8 sittings over a follow up period of 1 -24 months (median -3 weeks). 4/92(4.5%) were deemed non-responders to adhesiolysis and were circumcised later.

CONCLUSION

The majority of children referred with 'phimosis for circumcision' to this tertiary pediatric surgical centre were actually physiologic preputial adhesions that were managed with outpatient preputial adhesiolysis. This study underscores a lack of awareness amongst referring primary care physicians regarding preputial adhesions and the potential for an erroneous diagnosis of phimosis translating into unnecessary circumcisions in many young boys.

[A recommendable standard protocol of adult male circumcision with the Chinese Shang Ring: outcomes of 328 cases in China]

OBJECTIVE

Standardization of and training in adult male circumcision can significantly reduce its complication rate. Currently no such program exists for its standardization and training, making it difficult to guarantee the quality of male circumcision services. We therefore established a standardized surgical protocol for adult male circumcision in China using the Shang Ring, and applied it to a clinical study examining the performance of the Shang Ring in adult male circumcision.

METHODS

A total of 328 adult men aged 18-58 (mean 27.8) years, 25 with phimosis and 303 with redundant prepuce, underwent circumcision with the Shang Ring, and evaluation of the operation time, pain scores (using the visual analog scale), postoperative complications, time for wound healing, and their satisfaction with the postoperative appearance.

RESULTS

The operation time was 4.7 +/- 1.3 minutes. The pain scores were 0. 2 +/- 0.6 during the surgery, 1.6 +/- 1.0 twenty hours postoperatively, 1.7 +/- 1.1 twenty hours prior to the ring removal, and 2.7 +/- 1.4 during the ring removal. Complications included infection in 2 (0.6%), bleeding in 2 (0.6%), and wound dehiscence in 2 (0.6%) of the patients. None of the patients with wound dehiscence required postoperative suturing and all were managed conservatively instead. Sixteen of the patients (4.9%) experienced penile edema. The time for complete wound healing after circumcision was 20.3 +/- 6.7 days. The rate of the patients'satisfaction was 99.7% (327/328).

CONCLUSION

The standard protocol of adult male circumcision with the Shang Ring has the advantages of short operation time, slight pain, low rate of complications, and high satisfaction and acceptance of the patients. Strict standardization of the surgical protocol can maximize its clinical advantages for adult male circumcision.

[A case of urinary retention caused by true phimosis]

We report a case of urinary retention caused by true phimosis in a 67-year-old man with untreated diabetes mellitus. The patient could not void in a stream, and urine dropped out of the external urethral orifice with manual compression of the penis. Subsequently, he visited our hospital due to urinary retention. Ultrasonography revealed right hydronephrosis and ballooning of the foreskin. An emergency dorsal slit was performed, and hydronephrosis showed immediate improvement. Histopathologically, fibrosis and inflammation of the foreskin were observed. The mechanisms responsible for urinary retention in this case are discussed.