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Dothan D, Noyman Y, Perez D, Kocherov S, Jaber J, Chertin B. Surgical Treatment of Meatal Stenosis: Lessons Learned from the Pediatric Urology Practice. Urology 2023; 171:201-204. [PMID: 35981660 DOI: 10.1016/j.urology.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/31/2022] [Accepted: 08/01/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate the indications for surgery and outcome of meatotomy and meatoplasty in a big cohort of children. METHODS We retrospectively evaluated 2211 children who underwent either meatotomy or meatoplasty between 2009 and 2020 utilizing the same operative setup. For continuous data, we performed t-test and Mann-Whitney U test. For categorical data, chi-squared test or Fisher's exact test was used. A binary logistic regression model was used to compare the indications for surgery between the groups. RESULTS Of 2211 children, 1906 underwent meatotomy and 305 meatoplasty. The mean age was 5 years (range: 1m-15y) and there was no age difference between the groups. There was no difference between duration of surgery, recovery time, or complication rates between the groups. Deviated stream was the most frequent indication for treatment 1477 (67%). On Univariate logistic regression children with the following indications: dysuria, meatitis, and urinary retention had increased odds toward meatoplasty, while the indication of deviated stream had increased odds toward meatotomy. On Multivariate Logistic regression only deviated stream (Odd-ratios 1.47, P: .005) and urinary retention (Odds-ratio 4.5, P: .027) remained significant for meatotomy and meatoplasty respectively. Eleven (0.58%) children who underwent meatotomy developed recurrent Urethral Meatal Stenosis and underwent another surgery. Sixty-nine children (3.6%) after meatotomy required manual opening of the meatus on the first post-operative visit. None of the children, who underwent meatoplasty needed reoperation. CONCLUSION Meatotomy had a higher reoperation rate and frequently required manual meatal spreading in early postoperative period. We believe meatoplasty is a preferable surgery for pediatric UMS.
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Affiliation(s)
- David Dothan
- The Department of Pediatric Urology, Shaare Zedek Medical Center, The Faculty of the Medicine, The Hebrew University, Jerusalem, Israel.
| | - Yehuda Noyman
- The Department of Pediatric Urology, Shaare Zedek Medical Center, The Faculty of the Medicine, The Hebrew University, Jerusalem, Israel
| | - Dolev Perez
- The Department of Pediatric Urology, Shaare Zedek Medical Center, The Faculty of the Medicine, The Hebrew University, Jerusalem, Israel
| | - Stanislav Kocherov
- The Department of Pediatric Urology, Shaare Zedek Medical Center, The Faculty of the Medicine, The Hebrew University, Jerusalem, Israel
| | - Jawdat Jaber
- The Department of Pediatric Urology, Shaare Zedek Medical Center, The Faculty of the Medicine, The Hebrew University, Jerusalem, Israel
| | - Boris Chertin
- The Department of Pediatric Urology, Shaare Zedek Medical Center, The Faculty of the Medicine, The Hebrew University, Jerusalem, Israel
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ElAgami H, Naqvi S, Murphy F. Post-operative steroids in boys with histologically proven balanitis xerotica obliterans reduce the need for subsequent meatal dilatation. J Paediatr Child Health 2022; 58:2034-2038. [PMID: 35932250 DOI: 10.1111/jpc.16145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/19/2022] [Accepted: 07/17/2022] [Indexed: 11/29/2022]
Abstract
AIM Post-circumcision topical steroids may reduce the number of patients with balanitis xerotica obliterans (BXO) who require subsequent meatal dilatation. However, their use has only been investigated in the presence of an abnormal urethral meatus. The aim of this study is to determine if post-operative topical steroids reduce the need for subsequent meatal dilatation in patients with histologically proven BXO independent of the appearance of the urethral meatus. To determine if post-operative topical steroids reduce the need for subsequent meatal procedures in patients with histologically proven BXO. To determine if the appearance of the meatus at circumcision affects the need for subsequent meatal procedure. METHODS We performed a retrospective review of all paediatric patients with histologically confirmed BXO post circumcision. We excluded all those with 'chronic inflammation' or 'early BXO'. Patients were divided into groups based on whether post-operative topical steroids were prescribed. The appearance of the urethral meatus at circumcision was recorded. Primary outcome was progression to subsequent meatal dilatation. Statistical significance was calculated using Fisher's exact test. A P value < 0.05 was considered significant. RESULTS One hundred and seventeen patients with histologically confirmed BXO were identified between October 2012 and December 2017. Fifty-nine patients were prescribed post-operative topical steroids (50%). Nine patients required subsequent meatal dilatation procedure (8%) and only one of these had been prescribed post-operative topical steroids (P = 0.0165). Abnormal meatus was noted in 24 (21%) patients. Three patients in this group required subsequent meatal dilatation compared with 6 in the group with a normal meatal appearance (P = 0.385). CONCLUSIONS Post-operative topical steroids can reduce the need for subsequent meatal dilatation in boys with BXO. The appearance of the urethral meatus at circumcision does not predict the need for subsequent meatal dilatation.
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Affiliation(s)
- Hesham ElAgami
- Department of Paediatric Surgery, St George's Hospital, London, United Kingdom
| | - Sheryer Naqvi
- Department of Paediatric Surgery, St George's Hospital, London, United Kingdom
| | - Feilim Murphy
- Department of Paediatric Surgery, St George's Hospital, London, United Kingdom
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Shokri Varniab Z, Pourabhari Langroudi A, Neishabouri A, Torabinavid P, Arbab M, Heidari F, Milani SM, Eftekharzadeh S, Sabetkish S, Kajbafzadeh AM. Meatal stenosis following three types of circumcision with frenular artery preservation (FAP), the Plastibell device (PD), and frenular artery ligation (FAL): a long-term follow-up. Ir J Med Sci 2022; 192:707-711. [PMID: 35657540 DOI: 10.1007/s11845-022-03040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite the simplicity of male circumcision, complications occur frequently. Post-circumcision meatal stenosis is a concerning complication that might require several interventions. AIM This study aims to evaluate the incidence of meatal stenosis in long-term follow-up, following three common circumcision methods: frenular artery preservation, frenular ligation, and the Plastibell device. METHODS This study is the continuation of the previous randomized clinical trial, the preliminary abstract of which has been accepted in the annual meeting of the American Urological Association in 2011. However, in this paper, we only included the patients with results of long-term follow-up. Patients were followed for a median of 11 years (range, 7-17). Follow-ups were recorded by evaluation of meatus and signs and symptoms of meatal stenosis. RESULTS Two hundred six boys (80 neonates and 126 non-neonates) at the time of procedure were included in this study. The circumcision was conducted on 23.3% (48/206) of boys with the Plastibell device (PD) and 39.3% (81/206) of cases with frenular artery preservation (FAP) and 37.4% (77/206) of cases with frenular artery ligation (FAL). Meatal stenosis presented in 13 children during follow-up. Considering the three methods of circumcision, a significant difference in the incidence of meatal stenosis among the types of circumcisions was observed (6.3% in PD and 1.2% in FAP, 11.7% in FAL, P = 0.026). CONCLUSION The present study revealed that the technique preserving the frenular artery is associated with a significantly lower incidence of meatal stenosis. Hence, the FAP is the recommended technique for circumcision as compared to two other methods.
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Affiliation(s)
- Zahra Shokri Varniab
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran
| | - Ashkan Pourabhari Langroudi
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran
| | - Afarin Neishabouri
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran
| | - Parham Torabinavid
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran
| | - Mona Arbab
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran.,Department of Radiation Oncology, Indiana University, Indianapolis, IN, USA
| | - Firouzeh Heidari
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran
| | - Seyed Mohammad Milani
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran
| | - Sahar Eftekharzadeh
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran
| | - Shabnam Sabetkish
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran
| | - Abdol-Mohammad Kajbafzadeh
- Department of Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Tehran University of Medical Science, Tehran, Iran.
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Mekayten M, Meir E, Yutkin V, Gofrit ON, Duvdevani M, Landau EH, Hidas G. Is there a correlation between meatal stenosis severity, lower urinary tract symptoms and uroflowmetry? J Pediatr Urol 2022; 18:342.e1-342.e6. [PMID: 35491305 DOI: 10.1016/j.jpurol.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/03/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION We have recently validated a meatal Stenosis (MS) severity grading system that is based on physical examination. OBJECTIVES The study objective was to examine the correlation between this grading system, patients' urinary symptoms, uroflowmetry and postvoid residual parameters. STUDY DESIGN Patients referred for our clinic for urinary and non-urinary complaints, were prospectively enrolled. Urinary symptoms questionnaire, uroflowmetry parameters and post-voiding residuals (PVR) were assessed, and photographs of the urethral meatus were taken for each patient. The photographs were graded blindly according to the previously validated grading system and correlated with urinary symptoms, uroflowmetry parameters and PVR. RESULTS Overall, 75 patients were assessed (20 grade 0, 23 grade 1 and 32 grade 2). When using grade 0 as a reference, the odds ratio (OR) for reporting narrow stream was 6.4 (95%CI 1.65-24.77) and 4 (95%CI 1.18-14.16) for grade 1 and 2 respectively. OR for prolonged urination was 6 (95% CI 1.47-24.89) for Grade 1 and 2; OR for upward stream deviation was10.08 (95%CI -2.43-41.82) for grade 1 and 15.12 (95%CI - 3.74-61.17) for grade 2. Uroflowmetry results showed lower Qmax from 16.8(SD ± 8.0) ml/sec in grade 0-9.6 ml/s on grade 1 and 2 (p < 0.001) (Figure 1). PVR was not statistically different in the three groups. DISCUSSION Our main findings were that meatal stenosis severity grade is associated with narrow stream as reported by parent, prolonged urination, and upward deviation of urinary stream, with increasing severity with worsening stenosis. MS grade was also associated with significant worsening of uroflow measures: a lower Qmax, Qmean and a longer time-to-Qmax. Post-void residual volume was not significantly different between the different severity grades. This study showed the clinical significance of the grading system. With subjective and objective measures. The implementation of this grading system in clinics, may aid in decision making regarding surgical intervention in the appropriate patients, and avoid unnecessary procedures. CONCLUSION The Severity of MS seen on physical examination correlates well with obstructive symptoms and decrease of urine stream seen on uroflowmetry. These findings confirm the importance of the grading system in the evaluation of patients with MS and may be additional measure that assist in consulting parents on the indications to meatotomy.
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Affiliation(s)
- Matan Mekayten
- Department of Urology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel.
| | - Eyal Meir
- Department of Urology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel.
| | - Vladimir Yutkin
- Department of Urology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel.
| | - Ofer N Gofrit
- Department of Urology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel.
| | - Mordechai Duvdevani
- Department of Urology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel.
| | - Ezekiel H Landau
- Pediatric Urology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Guy Hidas
- Department of Urology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, PO Box 12000, Ein Kerem, Jerusalem 91120, Israel.
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Acimi S, Abderrahmane N, Debbous L, Bouziani N, Mansouri JM, Acimi MA, Boukhari Y, Hadjeb N, Yazi AE. Prevalence and causes of meatal stenosis in circumcised boys. J Pediatr Urol 2022; 18:89.e1-89.e6. [PMID: 34740536 DOI: 10.1016/j.jpurol.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The prevalence of meatal stenosis after circumcision remains unclear, and its causes are unknown. OBJECTIVE To know the prevalence and the causes of meatal stenosis after circumcision in boys. STUDY DESIGN Between October 2018 and April 2019, we carried out a prospective cross-sectional study on 1031 circumcised boys, aged 5-8 years (mean age 6.1 years ± 0.3 years), enrolled in the first level of primary school. All enrolled children underwent genitourinary examination. Moreover, an anonymous questionnaire was filled-in by one of the parents. RESULTS The screening revealed the presence of meatal stenosis in 185 children, representing a prevalence of 17.9% of cases (95% CI = 15.6-20.3). Analysis of the results using both the univariate and multivariate mode brought out some common risk factors such as a foreskin that completely adheres to the glans with forceful retraction of the prepuce and the use of a healing product: Beta-sitosterol and Hydrocotyl (Centella Asiatica), rarely Trolamine. In addition, this study showed that boys circumcised during their first week of life are twice as likely to develop meatal stenosis than those circumcised between 7 and 12 months (OR = 2.08; 95% CI = 1.10-3.92, p = 0.021). DISCUSSION We believe that when the foreskin is fully attached to the glans, forced retraction of the prepuce most often causes a loss of the mucous membrane that covers the glans, making the glans less resistant to chemical attack, and therefore may play an important role in the development of meatal stenosis. However, This study is limited by the absence of a cohort of uncircumcised boys for comparison to see if the small diameter of the meatus is also present in this group. CONCLUSIONS This study showed that stenosis of the urethral meatus is a frequent complication of circumcision. Circumcision in the first week of life, complete adhesion of the foreskin to the glans, and the use of a healing product were associated with the risk of stenosis development.
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Affiliation(s)
- Smail Acimi
- Department of Visceral Surgery, Children's Hospital Canastel, Faculty of Medicine, University of Oran, Algeria.
| | - Naima Abderrahmane
- Department of Visceral Surgery, Children's Hospital Canastel, Faculty of Medicine, University of Oran, Algeria
| | - Lamia Debbous
- Department of Visceral Surgery, Children's Hospital Canastel, Faculty of Medicine, University of Oran, Algeria
| | - Nacim Bouziani
- Department of Epidemiology, Children's Hospital Canastel, Faculty of Medicine, University of Oran, Algeria
| | | | - Mohammed Ali Acimi
- Department of Urology, EHU of Oran, Faculty of Medicine, University of Oran, Algeria
| | - Youcef Boukhari
- Responsible of Medical School, Department of Health, Oran, Algeria
| | - Naziha Hadjeb
- School Health Doctor, Department of Health, Oran, Algeria
| | - Aboubakr Essedik Yazi
- Department of Pediatric Surgery, CHU of Sidi Bel Abbes, Faculty of Medicine, University of Sidi Bel Abbes, Algeria
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O'Hagan LA, Larsen PD, Nataraja RM, Pacilli M, Taghavi K. Nomogram of paediatric male urethral size: A systematic review. J Pediatr Urol 2022; 18:79-85. [PMID: 34782235 DOI: 10.1016/j.jpurol.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/05/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Knowledge of the normal size of the urethral meatus in boys is important for safely performing urethral catheterization and fundamental to the diagnosis and treatment of paediatric urological conditions. However, clinicians often rely subjectively on previous experience and clinical judgement, rather than a robust evidence-base. A systematic review of the literature was undertaken to define the calibre of the male urethral meatus in paediatric age-groups. METHODS The MEDLINE and EMBASE databases were systematically searched from inception to December 2020 for studies measuring meatal calibre in boys up to 16 years of age. Google Scholar searches along with forward and backward citation tracking identified additional studies. Studies of subjects >16 years, females, or patients with urethral diseases were excluded. RESULTS Nine articles (2084 paediatric subjects) were included in the final review. Mean meatal calibre increases non-linearly with age, with accelerated growth occurring during infancy (mini-puberty) and adolescence (puberty). Meatal calibre can be approximately grouped by age as follows: neonate (6-10Fr); infant (10-12Fr); child (12-14Fr); and adolescent (14-18Fr). There is substantial individual variability for same-aged children. Meatal calibre has been independently related to height, weight, and penile size, but the effects of ethnicity and circumcision remain unclear. CONCLUSIONS The evidence-base for this fundamental aspect of paediatric urology includes only a few low-quality studies and is largely derived from one early study of circumcised American boys. Further studies are warranted to establish normative urethral size values based on rigorous, contemporary data with known dependent variables also included.
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Affiliation(s)
- Lomani A O'Hagan
- School of Medicine, The University of Auckland, Auckland, New Zealand
| | - Peter D Larsen
- Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - Ramesh M Nataraja
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Monash Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Kiarash Taghavi
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia; Department of Paediatric Urology, Monash Children's Hospital, Melbourne, Victoria, Australia; Department of Urology, Royal Children's Hospital, Melbourne, Victoria, Australia.
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Deacon M, Muir G. What is the medical evidence on non-therapeutic child circumcision? Int J Impot Res 2022; 35:256-263. [PMID: 34997197 DOI: 10.1038/s41443-021-00502-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 10/24/2021] [Accepted: 11/15/2021] [Indexed: 01/02/2023]
Abstract
Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and children.
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Affiliation(s)
| | - Gordon Muir
- Urology Department, King's College Hospital, London, UK.
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Akman M. Penile skin length can be predicted before frenuloplasty during routine circumcision. Niger J Clin Pract 2022; 25:1792-1798. [DOI: 10.4103/njcp.njcp_2038_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Madec FX, Karsenty G, Yiou R, Robert G, Huyghe E, Boillot B, Marcelli F, Journel NM. [Which management for anterior urethral stricture in male? 2021 guidelines from the uro-genital reconstruction urologist group (GURU) under the aegis of CAMS-AFU (Committee of Andrology and Sexual Medicine of the French Association of Urology)]. Prog Urol 2021; 31:1055-1071. [PMID: 34620544 DOI: 10.1016/j.purol.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/17/2021] [Accepted: 07/08/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology). MATERIAL AND METHODS These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables. RESULTS Anterior urethral strictures are a common condition (0,1 à 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (<2cm) may benefit from endourethral treatment (direct visual internal urethrotomy or dilation). In case of recurrence or when the stenosis measures more than 2 cm, a urethroplasty will be proposed. Repeated endourethral treatment management are no longer recommended except in case of palliative option. Urethroplasty is usually done with oral mucosa graft as the primary option, in one or two stages approach depending on the extent of the stenosis and the quality of the tissues. Excision and primary anastomosis or non-transecting techniques are discussed for bulbar urethra strictures. Follow-up by clinical monitoring with urethroscopy, or retrograde urethrography with voiding cystourethrography, is performed at least the first year and then on demand according to symptoms. CONCLUSION Anterior urethral strictures need an open surgical approach and should be treated by urethroplasty in most cases. This statement requires a major paradigm shift in practices. Training urologist through reconstructive surgery is the next challenge in order to meet the demand.
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Affiliation(s)
- F-X Madec
- Service d'urologie, hôpital Foch, 40, rue de Worth, 92150 Suresnes, France.
| | - G Karsenty
- Service d'urologie, hôpitaux universitaires de Marseille Conception, 147, boulevard Baille, 13005 Marseille, France
| | - R Yiou
- Service d'urologie, hôpital Henri-Mondor, CHU Paris est, 51, avenue du Marechal de Lattre de Tassigny, 94010 Créteil Cedex, France
| | - G Robert
- Service d'urologie, CHU de Bordeaux GH Pellegrin, 30000 Bordeaux, France
| | - E Huyghe
- Département d'urologie, transplantation rénale et andrologie, CHU de Toulouse, 1, avenue du Professeur Jean-Poulhès, 31400 Toulouse, France
| | - B Boillot
- Service d'urologie et de la transplantation rénale, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France
| | - F Marcelli
- Service d'urologie, CHRU-hopital huriez, rue Michel Polonowski, 59037 Lille, France
| | - N M Journel
- Service d'urologie, Centre Hospitalier Lyon Sud (HCL), chemin du Grand Revoyet, 69310 Pierre Benite, France
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Pyrgidis N, Sokolakis I, Dimitriadis F, Hatzichristodoulou G. Frenuloplasty: from alpha to omega. Int J Impot Res 2021; 34:347-352. [PMID: 34007064 DOI: 10.1038/s41443-021-00446-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/23/2021] [Accepted: 05/04/2021] [Indexed: 11/09/2022]
Abstract
Frenuloplasty is a common surgical procedure performed on an outpatient basis either for the treatment of frenulum breve alone or as an additional intervention in patients undergoing circumcision. We aimed to provide tips and tricks on performing frenuloplasty, either alone or in combination with circumcision, and to generate a comprehensive review of the available literature on the matter. We suggest that the frenulum should be divided with a scalpel without the use of diathermy and reapproximated with interrupted 4-0 absorbable sutures. Moreover, the frenular artery should be maintained and any injury of the glans must be avoided to ensure optimal functional outcomes. After the procedure, a paraffin gauze filled with antibiotic paste followed by a light compression dressing for one day should be placed to maximize cosmetic results. Regarding the available literature, several methods of frenuloplasty have been described, varying from simple division of the frenulum to more sophisticated grafting or plasty techniques. Both the use of diathermy and the application of laser, with or without suturing of the released frenulum, seem to provide optimal functional and esthetic results. However, the findings of all available studies were mitigated by the relatively small number of included participants and low response rates. Additionally, comparative data or high-quality, long-term functional and cosmetic results on the matter are lacking. Therefore, until high-level evidence regarding frenuloplasty is available, individual clinical judgment should prevail.
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Affiliation(s)
- Nikolaos Pyrgidis
- Department of Urology, Martha-Maria Hospital Nuremberg, Nuremberg, Germany
| | - Ioannis Sokolakis
- Department of Urology, Martha-Maria Hospital Nuremberg, Nuremberg, Germany
| | - Fotios Dimitriadis
- Department of Urology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Jones P, Rooney H, Hawary A. Pediatric Circumcision in the 21st Century National Health Service: A Snapshot of Practice in a United Kingdom Center. Surg J (N Y) 2020; 6:e188-e191. [PMID: 33335988 PMCID: PMC7735869 DOI: 10.1055/s-0040-1721430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/14/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction
Pediatric circumcision is a commonly performed operation, yet outcomes related to procedures performed for medical indications remain underreported.
Aim
The aim of this study was to report outcomes of therapeutic circumcision from our center.
Methods
Prospective registry of elective circumcisions was maintained and analyzed at a single institution in the United Kingdom. Data collected included information on complications (early and late), emergency presentations, and referrals back from primary care services.
Results
Between August 2015 and June 2019, 300 patients (mean age: 9 years; range: 3–16 years) underwent therapeutic circumcision. The average length of follow-up data available was 2.1 years (range: 6 months to 4 years). The overall complication rate was 4.7% (
n
= 16). There were no unplanned admissions and no cases returned to the operating room as emergency. Only 1% (
n
= 3) of patients presented with an early complication (minor bleeding, pain, urinary retention), and 3.7% (
n
= 11) suffered a late complication (meatal stenosis [2.7%]). All cases of meatal stenosis had lichen sclerosus confirmed on histology. Cosmetic satisfaction was 99%.
Conclusion
Therapeutic circumcision is an effective procedure in the pediatric population, which carries a low risk of early and late complications. Our study found that meatal stenosis only occurred in those patients with confirmed lichen sclerosus histology.
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Affiliation(s)
- Patrick Jones
- Department of Urology, Great Western Hospital, Swindon, United Kingdom
| | - Helen Rooney
- Department of Urology, Great Western Hospital, Swindon, United Kingdom
| | - Amr Hawary
- Department of Urology, Great Western Hospital, Swindon, United Kingdom
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12
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Mekayten M, Meir E, Ben-Chaim J, Landau EH, Khoury AE, Gofrit ON, Duvdevani M, Hidas G. Formulation and validation of meatal stenosis grading system. J Pediatr Urol 2020; 16:205.e1-205.e5. [PMID: 31964617 DOI: 10.1016/j.jpurol.2019.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Meatal stenosis (MS) is a common finding in circumcised children. Indication for surgical correction is based on urinary symptoms such as strength and direction of urine stream as well as physical examination, including direction and caliber of the urinary stream. There is no objective grading of MS severity, and therefore indications for surgery and management protocols are vague. OBJECTIVE We aimed to formulate a standardized, validated, and reliable grading system for MS severity based on the physical examination finding. STUDY DESIGN Photographs of the urethral meatus were taken in patients scheduled for meatotomy due to MS, whereas patients without this condition served as control. The photographs were rated by three experienced fellowship trained pediatric urologists. The study was conducted in two phases: 1) development of a grading system by the expert panel and 2) testing of the proposed grading system for inter- and intra-rater reliability. To estimate the correlation between different rates, the intra-class correlation coefficient (ICC) was calculated. RESULTS Three grades were generated: Grade 0 (wide open meatus, visible mucosa), Grade 1 (minimal mucosa/fibrotic tissue visible), and Grade 2 (pinpoint meatus/no mucosa visible/large fibrotic layer). A panel of 51 raters (pediatric urologist, community urologist, pediatricians) participated in the survey evaluating the representative photos from 86 patients. Inter-rater reliability was high ICC = 0.99 (95% confidence interval [CI] of 0.983-0.996, P < 0.0001) Cronbach's alpha = 0.992. In total, 18 raters participated in the same survey two weeks later for intra-rater reliability. An identical grading was obtained in 83.3% of photographs (kappa = 0.455 [P < 0.05]). CONCLUSION We propose a grading system that is a valid, reliable, and reproducible method to classify the severity of MS on physical exam. This grading system could improve the healthcare provider's and parent's communication and can be a building block for further research in this field. A further research should assess the correlation with clinical signs and symptoms.
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Affiliation(s)
- Matan Mekayten
- Pediatric Urology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Eyal Meir
- Pediatric Urology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Jacob Ben-Chaim
- Tel Aviv Sourasky Medical Center, Paediatric UroIogy Unit, Department of Urology, Tel Aviv, Israel
| | - Ezekiel H Landau
- Pediatric Urology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Antoine E Khoury
- CHOC Children's Hospital of Orange County, Orange, CA, USA; Department of Urology, University of California, Irvine, CA, USA
| | - Ofer N Gofrit
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mordechai Duvdevani
- Department of Urology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Guy Hidas
- Pediatric Urology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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13
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Nabavizadeh B, Akbari P, Ladi Seyedian SS, Nabavizadeh R, Kajbafzadeh AM. Increased risk of atopic diseases in boys with meatal stenosis: a possible pathophysiological relation. J Pediatr Surg 2020; 55:490-492. [PMID: 31375283 DOI: 10.1016/j.jpedsurg.2019.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 07/08/2019] [Accepted: 07/17/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the role of atopy (i.e. atopic dermatitis, allergic rhinitis, asthma, and food allergies) and its consequences on developing meatal stenosis in boys. METHODS After obtaining ethics approval from institutional review board, a retrospective chart review was conducted to gather records of patients with meatal stenosis (Group A) presented to our pediatric urology center between August 2012 and May 2016. History of any allergic reactions including allergic rhinitis, asthma, skin, food and drug allergies was considered as positive history of atopy. A control group of children referring to our center due to other etiologies were considered as control group (Group B). Data were analyzed using student t-test and Chi-square test. RESULTS During the study period, a total of 206 boys (mean age 41.01 months) were assigned to group A and 221 (mean age 35.56 months) to group B. 126 (61.16%) boys had history of allergic reactions in group A compared to 29 (13.12%) in the control arm (group B). Patients with meatal stenosis have a significantly higher (P-value <0.001) likelihood of suffering from allergic reactions. CONCLUSIONS The pathophysiology of meatal stenosis remains not fully understood yet. This study reveals a significant relation between hypersensitivity reactions and meatal stenosis in boys. Persistent inflammation in meatal area could potentially lead to scarring and stenosis. However, more investigation is required to elucidate this pathophysiology. TYPE OF STUDY Case-control study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Behnam Nabavizadeh
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Parya Akbari
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Sanam Ladi Seyedian
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Nabavizadeh
- Department of Urology, Emory University School of Medicine, Atlanta, GA, USA
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
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14
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Abstract
Lichen sclerosus (LS) is a chronic inflammatory disease of the skin. It mainly affects the anogenital area. More knowledge of the disease is needed to avoid delay in diagnosis as early treatment may cure the disease in some and reduce or prevent scarring. Initial treatment for girls and boys comprises the daily application of a potent cortisone ointment for 3 months. After remission the treatment should be continued long-term intermittently. If there is no complete remission in boys complete circumcision is recommended. LS usually cannot be healed but only well suppressed, and also after circumcision recurrences may occur years later. Therefore, patients have to be well informed and should be followed up long-term.
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15
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Are mechanical and chemical trauma the reason of meatal stenosis after newborn circumcision? Eur J Pediatr 2019; 178:77-80. [PMID: 30280224 DOI: 10.1007/s00431-018-3261-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/24/2018] [Accepted: 09/24/2018] [Indexed: 01/12/2023]
Abstract
Mechanical and chemical trauma are a widely accepted theories to explain the pathogenesis of meatalstenosis after newborn circumcision. The aim of the present study was to explore the theory that an exposed glans is prone to meatal stenosis. This was done by a novel investigation of boys who were born with "hooded prepuce", a condition in which the glans is completely exposed. Physical examination, lower urinary tract symptoms, urethral meatus configuration, and surgical procedures of 18 children admitted for routine circumcision, who had congenital hooded prepuce with normally located urethral meatus, were analyzed. The study period was 2013 and 2018. All the cases have been seen because of neonatal circumcision request, but was postponed due to hooded prepuce. The only presenting complaint in children was a cosmetically unattractive appearance. There were no symptoms associated with meatal stenosis, they circumcised in an average of 6 years and non of them required any additional procedure.Conclusion: Meatal stenosis did not occur in cases whose glans penis are naked with hooded prepuce. These findings do not support the default chemical and mechanical trauma theories. Hooded prepuce without any penile anomalies is only a cosmetically unattractive appearance and circumcision can correct this. What is known: • The common theory of meatal stenosis etiology is that the meatus undergoes irritation with chemical/mechanical trauma in the absence of a prepuce after newborn circumcision. • Circumcision is usually postponed in newborns with hooded prepuce. What is new: • We did not notice meatal stenosis in cases whose urethral meatus were not covered with a prepuce congenitally. Ammoniacal dermatitis or mechanical trauma theories may not explain the cause of meatal stenosis. • Hooded prepuce is not a handicap to newborn circumcision. It is just a cosmetic problem and circumcision can solve it.
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16
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Neheman A, Rappaport YH, Darawsha AE, Leibovitch I, Sternberg IA. Uroflowmetry Before and After Meatotomy in Boys with Symptomatic Meatal Stenosis Following Neonatal Circumcision - A Long-term Prospective Study. Urology 2018; 125:191-195. [PMID: 30552933 DOI: 10.1016/j.urology.2018.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 11/28/2018] [Accepted: 12/04/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess uroflowmetry in the long-term follow-up of symptomatic meatal stenosis patients prior to and following meatotomy. Severity of symptoms and treatment success has been defined by patient history, physical examination, and witnessed voiding. Uroflowmetry might add objective parameters for the assessment, however long-term data are lacking. METHODS A prospective study following 25 symptomatic toilet-trained boys before and after meatotomy was performed with short and long-term follow-up after surgery. Patient history, physical examination, and uroflowmetry variables were recorded. RESULTS Fifteen patients were fully evaluable. Mean age at operation was 6.4 years (2.5-10.5) with an average follow-up of 43 months. All patients were symptomatic before surgery; complete symptomatic resolution was achieved in all patients at short-term follow-up, and in 12 at long-term follow-up. A stenotic meatus was seen in all patients before surgery, at long-term follow-up 12 of 15 (80%) had an open appearing meatus (P = .0001). Abnormal uroflowmetry pattern was present in 8 of 15 (53%) prior to surgery and 2 of 15 (13%) at long-term follow-up (P = .02). Normal maximal flow rate as defined by ICCS were seen in 5, 11, and 12 patients before, 1 month after and at long-term follow-up (P = .06 and 0.02, respectively). PVR improved significantly at long-term follow-up (P = .0012). CONCLUSION Symptom evaluation and physical examination should be the hallmark assessing children with meatal stenosis. Clinical assessment one month after surgery suffices and long-term follow-up is unnecessary. Uroflowmetry provides objective assessment as well as surgical success; however, it is unnecessary since it does not change the management.
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Affiliation(s)
- Amos Neheman
- Urology Department, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel Aviv University, Israel
| | - Yishai H Rappaport
- Urology Department, Assaf Harofeh Medical Center, Zerifin, affiliated to Sackler School of Medicine, Tel Aviv University, Israel.
| | - Abd E Darawsha
- Urology Department, Meir Medical Center, Kfar Saba, affiliated to Sackler School of Medicine, Tel Aviv University, Israel
| | - Ilan Leibovitch
- Urology Department, Meir Medical Center, Kfar Saba, affiliated to Sackler School of Medicine, Tel Aviv University, Israel
| | - Itay A Sternberg
- Urology Department, Meir Medical Center, Kfar Saba, affiliated to Sackler School of Medicine, Tel Aviv University, Israel
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17
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences, University of Sydney, Sydney, NSW, Australia,
- Bosch Institute, University of Sydney, Sydney, NSW, Australia,
| | | | - John N Krieger
- Department of Urology, University of Washington School of Medicine, Seattle, WA, USA
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18
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Karami H, Abedinzadeh M, Moslemi MK. Assessment of meatal stenosis in neonates undergoing circumcision using Plastibell Device with two different techniques. Res Rep Urol 2018; 10:113-115. [PMID: 30310773 PMCID: PMC6166766 DOI: 10.2147/rru.s171292] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose It was intended to compare meatal stenosis (MS) as a late complication of neonatal circumcision by using two different methods of Plastibell Device circumcision. Materials and methods A total of 2,307 healthy term newborns (6–36 hours) who were born between 2007 and 2009 in Niknafs Medical Center of Rafsanjan, Iran, were simply randomized into two groups in a controlled, nonblinded clinical trial. In group A (1,102 neonates), the frenulum was maintained intact without any manipulation, and in group B (1,205 neonates) frenular hemostasis was performed in all cases by thermal cautery. MS was assessed by follow-up visits that were made for all cases at the 24–72 hours, 60th day, 12th month, and 16th month after circumcision. Results At 2 months follow-up visit, the rate of MS in group A was 4.9% (54) and in group B was 5.9% (71), which was not statistically significant. After 12 months, MS in group A was 8.5% (94) and in group B was 13.7% (165), which was statistically significant (P<0.001). At 16 months after circumcision, in the frenulum intact group, MS was 13.8% (152) and in the cautery group, it was 18.9% (228), which was compatible with significant difference (P=0.001). Conclusion Our experience with large group of cases revealed that neonatal circumcision by using Plastibell Device with intact frenulum technique decreases the rate of delayed MS.
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Affiliation(s)
- Hormoz Karami
- Department of Urology, Shahid Rahnemoon Hospital, School of Medicine, Yazd University of Medical Sciences, Yazd, Iran,
| | - Mehdi Abedinzadeh
- Department of Urology, Shahid Rahnemoon Hospital, School of Medicine, Yazd University of Medical Sciences, Yazd, Iran,
| | - Mohammad Kazem Moslemi
- Department of Urology, Shahid Rahnemoon Hospital, School of Medicine, Yazd University of Medical Sciences, Yazd, Iran,
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19
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Purpura V, Bondioli E, Cunningham EJ, De Luca G, Capirossi D, Nigrisoli E, Drozd T, Serody M, Aiello V, Melandri D. The development of a decellularized extracellular matrix-based biomaterial scaffold derived from human foreskin for the purpose of foreskin reconstruction in circumcised males. J Tissue Eng 2018; 9:2041731418812613. [PMID: 30622692 PMCID: PMC6304708 DOI: 10.1177/2041731418812613] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 10/22/2018] [Indexed: 12/18/2022] Open
Abstract
The circumcision of males is emphatically linked to numerous sexual dysfunctions. Many of the purported benefits do not hold up to the scrutiny of extensive literature surveys. Involuntary circumcision, particularly when not medically warranted, is also associated with many psychological and emotional traumas. Current methods to reconstruct the ablated tissue have significant drawbacks and produce a simple substitute that merely imitates the natural foreskin. Extracellular matrix-based scaffolds have been shown to be highly effective in the repair and regeneration of soft tissues; however, due to the unique nature of the foreskin tissue, commercially available biomaterial scaffolds would yield poor results. Therefore, this study discusses the development and evaluation of a tissue engineering scaffold derived from decellularized human foreskin extracellular matrix for foreskin reconstruction. A chemicophysical decellularization method was applied to human foreskin samples, sourced from consenting adult donors. The resulting foreskin dermal matrices were analyzed for their suitability for tissue engineering purposes, by biological, histological, and mechanical assessment; fresh frozen foreskin was used as a negative control. Sterility of samples at all stages was ensured by microbiological analysis. MTT assay was used to evaluate the absence of viable cells, and histological analysis was used to confirm the maintenance of the extracellular matrix structure and presence/integrity of collagen fibers. Bioactivity was determined by submitting tissue extracts to enzyme-linked immunosorbent assay and quantifying basic fibroblast growth factor content. Mechanical properties of the samples were determined using tensile stress tests. Results found foreskin dermal matrices were devoid of viable cells (p < 0.0001) and the matrix of foreskin dermal matrices was maintained. Basic fibroblast growth factor content doubled within after decellularization (p < 0.0001). Tensile stress tests found no statistically significant differences in the mechanical properties (p < 0.05). These results indicate that the derived foreskin dermal matrix may be suitable in a regenerative approach in the reconstruction of the human foreskin.
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Affiliation(s)
- Valeria Purpura
- Emilia Romagna Regional Skin Bank and
Burn Centre, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Elena Bondioli
- Emilia Romagna Regional Skin Bank and
Burn Centre, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Eric J Cunningham
- Department of Biomedical Engineering,
Illinois Institute of Technology, Chicago, IL, USA
| | - Giovanni De Luca
- Department of Human Pathology, Bufalini
Hospital, AUSL Romagna, Cesena, Italy
| | - Daniela Capirossi
- Department of Human Pathology, Bufalini
Hospital, AUSL Romagna, Cesena, Italy
| | - Evandro Nigrisoli
- Department of Human Pathology, Bufalini
Hospital, AUSL Romagna, Cesena, Italy
| | | | | | | | - Davide Melandri
- Emilia Romagna Regional Skin Bank and
Burn Centre, Bufalini Hospital, AUSL Romagna, Cesena, Italy
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20
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Gyftopoulos KI. Meatal stenosis after surgical correction of short frenulum: Is the "pull-and-burn" method the way to go? Urol Ann 2018; 10:354-357. [PMID: 30386085 PMCID: PMC6194789 DOI: 10.4103/ua.ua_25_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background and Objectives The surgical correction of a short frenulum includes several procedures that vary in complexity of the technique and the use of stitches, lasers, or skin grafts. However, little is known about the effect of these procedures on meatal stenosis. A possible association of frenular artery trauma during circumcision and subsequent meatal stenosis has raised concerns regarding the importance of frenulum preservation. We hereby report our experience over 15 years of applying the "pull-and-burn" method for short frenulum correction. Patients and Methods A total of 236 patients underwent the "pull-and-burn" procedure for short frenulum under local anesthesia on an outpatient basis between November 2002 and November 2017. The method is suture free and involves tearing the frenulum superficially and vertically by the aid of a low-power, high-frequency hyfrecator, avoiding the underlying frenular vessels. Patients were advised for a regular follow-up visit at 2-3 months postoperatively and were reviewed for symptoms and signs suggestive of meatal stenosis. Results Follow-up files were available for 228 patients (96.6%). No symptoms suggestive of meatal stenosis (dysuria and stream pattern abnormalities) were reported by any patient. Examination of the urethral meatus revealed normal appearance, with no signs of edema or scarring in all the 228 patients. Conclusions The "pull-and-burn" method is a simple and safe procedure for the correction of short frenulum that respects anatomically the delicate vasculature of the frenular area, resulting in the preservation of the integrity of the urethral meatus.
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Affiliation(s)
- Kostis I Gyftopoulos
- Department of Anatomy, University of Patras Medical School and Olympion Hospital, Patras, Greece
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21
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Morris BJ, Krieger JN. Does Circumcision Increase Meatal Stenosis Risk?-A Systematic Review and Meta-analysis. Urology 2017; 110:16-26. [PMID: 28826876 DOI: 10.1016/j.urology.2017.07.027] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/11/2017] [Accepted: 07/20/2017] [Indexed: 12/30/2022]
Abstract
CONTEXT Meatal stenosis (MS) as a potential complication of male circumcision and controversy regarding the magnitude of risk. OBJECTIVES To conduct a systematic review and meta-analyses to assess (1) MS diagnosis after circumcision, (2) the potential association of MS with circumcision, and (3) a potential method of prevention. DATA SOURCES PubMed, Google Scholar, Cochrane Library and bibliographies of original studies were searched using the keywords circumcision and stenosis or stricture. STUDY SELECTION Studies containing original data on MS following circumcision at any age. DATA EXTRACTION Two reviewers independently verified study design and extracted data. RESULTS Thirty eligible studies were retrieved. A random effects meta-analysis of 27 studies (350 MS cases amongst 1,498,536 males) found that the risk of MS in circumcised males was 0.656% (95% confidence interval 0.435-0.911). Meta-analysis of 3 observational studies that compared MS prevalence in circumcised and uncircumcised males found non-significantly higher prevalence in circumcised males (odds ratio 3.20; 95% confidence interval 0.73-13.9). Meta-analysis of 3 randomized controlled trials investigating the effect of petroleum jelly application to the glans after circumcision found that this intervention was associated with MS risk reduction (relative risk 0.024; 95% confidence interval 0.0048-0.12). CONCLUSION MS risk after circumcision is low (< 1%). Weak evidence suggests that MS risk might be higher in circumcised boys and young adult males. Risk is reduced by petroleum jelly application. Further research on MS arising from lichen sclerosus in older uncircumcised males is needed.
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Affiliation(s)
- Brian J Morris
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, New South Wales, Australia; University of Washington School of Medicine, Department of Urology, Seattle, WA.
| | - John N Krieger
- School of Medical Sciences and Bosch Institute, University of Sydney, Sydney, New South Wales, Australia; University of Washington School of Medicine, Department of Urology, Seattle, WA
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22
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Abstract
INTRODUCTION Meatal stenosis (MS) is a known complication of newborn circumcision. Symptoms are usually masked in young kids with a diaper. Deflation of urinary stream, dysuria, urinary frequency, and incontinence are the most common reported symptoms. Diagnosis of MS is still controversial. A narrow pinpoint urethral meatus is the current accepted diagnostic criteria. OBJECTIVE In our practice, we observed that our cases do not overlap to the classic definition and presentation of MS. In this study, we presented our cases and aimed to share our observations. MATERIALS AND METHODS Records of children who had meatoplasty between 2014 with 2016 were analyzed retrospectively. Only children with MS who had had newborn circumcision performed in our clinic were included in the study. Over 500 newborn circumcisions are performed per year in our clinic using the Gomco Clamp technique. Age at diagnosis, presenting complaints, penile anomalies including urethral meatus configuration, urinary symptoms, operation methods, and postoperative follow-up were gathered. RESULTS A total of 13 boys who were circumcised in the newborn period had undergone meatoplasty with the diagnosis of MS. The mean age at the time of meatoplasty was 52.5 ± 17.9 (range 37-93 months). All children were examined before and during the circumcision. There were no associated penile anomalies, including MS. The only presenting complaint was upward deflation of urinary stream instead of other lower urinary tract symptoms. Although the appearance of the meatus was pinpoint in all cases (Figure); it was easy to calibrate with an 8-10 Fr feeding tube. There was no stenosis, but a ventral web was detected. Meatoplasty with removal of this web was performed under general anesthesia. Two sutures were applied at 5 and 7 o'clock with 7/0 PDS. Mean postoperative follow-up time was 16.9 ± 7.5 months. Children were pleased with direction of urinary stream. DISCUSSION Both the diagnosis and morphological definition of MS have some controversies. To our knowledge, there is no similar reported study with pinpoint appearance and normal calibration of the meatus. There was no stenosis in any of them. Unlike classical MS presentations, upward deflation of urinary stream resulting from ventral web was a single presenting complaint. CONCLUSIONS Upward deflation of urinary stream can develop after neonatal circumcision because of a meatal web without stenosis, and can be cured easily with meatoplasty. Instead of 'meatal stenosis', 'meatal web' may be a more appropriate term to explain the pathology in these patients.
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Affiliation(s)
- Mehmet Ali Özen
- Department of Pediatric Surgery, Koç University Hospital, Istanbul, Turkey
| | - Gökhan Gündoğdu
- Department of Pediatric Surgery, Koç University Hospital, Istanbul, Turkey
| | - Mehmet Taşdemir
- Department of Pediatric Nephrology, Koç University Hospital, Istanbul, Turkey
| | - Egemen Eroğlu
- Department of Pediatric Surgery, Koç University Hospital, Istanbul, Turkey; Department of Pediatric Surgery, Koç University, School of Medicine, Istanbul, Turkey.
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23
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Frisch M, Simonsen J. Cultural background, non-therapeutic circumcision and the risk of meatal stenosis and other urethral stricture disease: Two nationwide register-based cohort studies in Denmark 1977-2013. Surgeon 2016; 16:107-118. [PMID: 28017691 DOI: 10.1016/j.surge.2016.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/04/2016] [Accepted: 11/30/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Meatal stenosis is markedly more common in circumcised than genitally intact males, affecting 5-20 per cent of circumcised boys. However, no population-based study has estimated the relative risk of meatal stenosis and other urethral stricture diseases (USDs) or the population attributable fraction (AFp) associated with non-therapeutic circumcision. METHODS In two nationwide cohort studies (comprising 4.0 million males of all ages and 810 719 non-Muslim males aged 0-36 years, respectively), we compared hospital contact rates for USD during 1977-2013 between circumcised and intact Danish males. Hazard ratios (HRs) were obtained using Cox proportional hazards regression, and the AFp estimated the proportion of USD cases in <10 year-old boys that is due to non-therapeutic circumcision. RESULTS Muslim males had higher rates of meatal stenosis than ethnic Danish males, particularly in <10 year-old boys (HR 3.44, 95 per cent confidence interval 2.42-4.88). HRs linking circumcision to meatal stenosis (10.3, 4.53-23.4) or other USDs (5.14, 3.48-7.60) were high, and attempts to reduce potential misclassification and confounding further strengthened the association, particularly in <10 year-old boys (meatal stenosis: 26.3, 9.37-73.9; other USDs: 14.0, 6.86-28.6). Conservative calculations revealed that at least 18, 41, 78, and 81 per cent of USD cases in <10 year-old boys from countries with circumcision prevalences as in Denmark, the United Kingdom, the United States and Israel, respectively, may be attributable to non-therapeutic circumcision. CONCLUSION Our study provides population-based epidemiological evidence that circumcision removes the natural protection against meatal stenosis and, possibly, other USDs as well.
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Affiliation(s)
- Morten Frisch
- Statens Serum Institut, Department of Epidemiology Research, DK-2300 Copenhagen S, Denmark; Aalborg University, Department of Clinical Medicine, Center for Sexology Research, DK-9000 Aalborg, Denmark.
| | - Jacob Simonsen
- Statens Serum Institut, Department of Epidemiology Research, DK-2300 Copenhagen S, Denmark
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24
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Abstract
A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.
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Affiliation(s)
- Robert S Van Howe
- Department of Pediatrics, Michigan State University College of Human Medicine, Marquette, Michigan, USA.
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Frisch M, Earp BD. Circumcision of male infants and children as a public health measure in developed countries: A critical assessment of recent evidence. Glob Public Health 2016; 13:626-641. [DOI: 10.1080/17441692.2016.1184292] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Morten Frisch
- Department of Epidemiology Research, Division of Epidemiology and Disease Surveillance, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Medicine, Center for Sexology Research, Aalborg University, Aalborg, Denmark
| | - Brian D. Earp
- The Hastings Center Bioethics Research Institute, Garrison, NY, USA
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Shenoy SP, Marla PK, Sharma P, Bhat N, Rao AR. Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique. J Clin Diagn Res 2016; 9:PC01-3. [PMID: 26816940 DOI: 10.7860/jcdr/2015/14972.6860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 10/15/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Circumcision, by most conventional methodologies, involves division of the frenulum and excision of the entire foreskin covering the glans. This seemingly simple procedure is occasionally associated with dreadful and devastating complications. We describe a new frenulum-sparing technique that circumvents some of the potential complications of conventional techniques and could also potentially help preserve preputial role in sexual function. MATERIALS AND METHODS An initial dorsal slit, three fourths of the way up to the corona is extended laterally and obliquely on either side, to meet the preputial edge, 3-4 mm from the frenulum. A broad sleeve of sub-coronal mucosa is thus preserved. The frenulum is left untouched, leaving a wide skin bridge connecting the mucosal sleeve with the shaft skin. The raw area is closed with interrupted, synthetic absorbable sutures. Over a three year period, 42 patients were circumcised using this technique. RESULTS No significant complications like frenular bleed, painful postoperative erections, chordee, meatal stenosis, or urethra-cutaneous fistula were observed in any patient. The cosmetic results were pleasing. CONCLUSION The frenulum-sparing technique of circumcision is a promising modification to the various existing techniques. The method described is technically easier to perform than conventional frenulum-dividing procedures and has an acceptable cosmesis. Further randomised controlled studies on larger cohorts are necessary to establish the true benefits of this technique over established procedures.
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Affiliation(s)
- Sunil Purshotham Shenoy
- Head, Department of Urology, A J Institute of Medical Sciences & Research Centre , Mangaluru, Karnataka, India
| | - Prashanth Kallaje Marla
- Professor, Department of Urology, A J Institute of Medical Sciences & Research Centre , Mangaluru, Karnataka, India
| | - Pritham Sharma
- Assistant Professor, Department of Urology, A J Institute of Medical Sciences & Research Centre , Mangaluru, Karnataka, India
| | - Narayana Bhat
- Professor, Department of Paediatric Surgery, A J Institute of Medical Sciences & Research Centre , Mangaluru, Karnataka, India
| | - Amrith Raj Rao
- Consultant Urological Surgeon, Wexham Park Hospital , Wexham, Royal County of Berkshire, SL2 4HL, UK
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Dalela D, Gupta P, Dalela D, Bansal A, Govil T, Goel A, Sankhwar SN. Meatal Occlusive Disease in Adult Males: Are There Any Clinical Variations? Urol Int 2016; 97:212-7. [DOI: 10.1159/000446221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 04/14/2016] [Indexed: 11/19/2022]
Abstract
<b><i>Objective:</i></b> The study aimed to document the types of meatal occlusive disease (MOD) in adult males in terms of its clinical presentation, management and prognosis. <b><i>Material and Methods:</i></b> Eighty-six adult males with MOD were assessed during the study period. The patients were divided into Group 1, having meatal opening that was occluded by flimsy adhesions (meatal synechia/adhesive type MOD), and Group 2 that included patients who had circumferential constriction of the meatus (meatal stenosis/constrictive type MOD). All patients underwent meatal dilatation up to 18 Fr followed by self-dilatation for 3 months with topical clobetasol for 4 weeks. Degree of discomfort during self-dilation, improvement in flow rate, International Prostate Symptom Score (IPSS score) and recurrences were recorded at pre-determined intervals. <b><i>Results:</i></b> Twenty-eight patients had meatal synechia (Group 1) and 48 had meatal stenosis (Group 2). Discomfort during self-dilatation in Group 1 patients was significantly less; there was improvement in IPSS and peak flow rate (mean follow-up 26.8 months) as compared to Group 2. With dilation alone, no recurrence was noted in Group 1; however, Group 2 showed 62.8% recurrence indicating poor outcome in this subset of patients. <b><i>Conclusion:</i></b> MOD in adult males consists of 2 separate clinical entities with different therapeutic outcomes.
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Karakoyunlu N, Polat R, Aydin GB, Ergil J, Akkaya T, Ersoy H. Effect of two surgical circumcision procedures on postoperative pain: A prospective, randomized, double-blind study. J Pediatr Urol 2015; 11:124.e1-5. [PMID: 25842991 DOI: 10.1016/j.jpurol.2015.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 01/08/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Male circumcision (MC) is one of the most commonly used surgical procedures worldwide for medical and traditional reasons. No studies have compared the postoperative pain advantages of conventional techniques (i.e., sleeve and dorsal slit). OBJECTIVE In this prospective randomized double-blind study, we investigated the effect of two surgical techniques (i.e., sleeve and dorsal slit) on postoperative pain and emergence agitation. STUDY DESIGN This prospective study was conducted between January and July 2013. Approval was obtained from the local Ethical Committee on 17 December 2012, 06/23 (CLINICAL TRIALS IDENTIFIER: NCT 01909765). We compared two surgical techniques (i.e., the dorsal slit incision technique (Group A) and the double incision (i.e., sleeve) technique (Group B) in 60 children who were subjected to MC surgery under general anesthesia. All children received dorsal nerve blocks with bupivacaine. The modified objective pain scale (MOPS) was used for pain assessment, and the Ramsey Sedation Scale was used for the assessment of agitation during anesthesia emergence. RESULTS The MOPS scores were lower in Group B than in Group A in the post-anesthesia care unit and during the 4th hour post-surgery (p = 0.01 and p = 0.037, respectively). Twelve children (40%) in Group A and 23 children (76.6%) in Group B required no additional analgesia on postoperative day one (p = 0.004). The Ramsey sedation scores were lower in Group A (p = 0.018). DISCUSSION Dorsal slit is often the primary method in cases with paraphimosis; during this procedure, the frenulum frequently cannot be preserved at the 6-o'clock position of the mucosa, because of traction applied to skin and mucosa. As a result, the frenular artery is injured. In contrast, the sleeve technique protects the frenulum and the anatomic structures of the glans. In the sleeve technique, providing hemostasis and preventing partial ischemia by protecting the frenular artery reduces postoperative pain and complications. This present study demonstrated that the sleeve technique, which preserved the frenular artery, caused less bleeding, reduced electrocautery use and less ischemia than the dorsal slit technique. The sleeve technique effectively reduces early postoperative pain and agitation after circumcision, provided that adequate postoperative analgesia has been achieved. While all variables except the employed surgical techniques were similar, Group B had advantages with respect to analgesic requirement and pain control during the first 8 h after the operation. CONCLUSION The sleeve technique provides lower pain scores and a reduced incidence of agitation after elective MC.
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Affiliation(s)
- N Karakoyunlu
- Department of Urology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, İrfan Baştuğ Cad. Dışkapı, Ankara 06110, Turkey.
| | - R Polat
- Department of Anaesthesiology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, İrfan Baştuğ Cad. Dışkapı, Ankara 06110, Turkey
| | - G B Aydin
- Department of Anaesthesiology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, İrfan Baştuğ Cad. Dışkapı, Ankara 06110, Turkey
| | - J Ergil
- Department of Anaesthesiology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, İrfan Baştuğ Cad. Dışkapı, Ankara 06110, Turkey
| | - T Akkaya
- Department of Anaesthesiology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, İrfan Baştuğ Cad. Dışkapı, Ankara 06110, Turkey
| | - H Ersoy
- Department of Urology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, İrfan Baştuğ Cad. Dışkapı, Ankara 06110, Turkey
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SIU/ICUD Consultation on Urethral Strictures: Epidemiology, Etiology, Anatomy, and Nomenclature of Urethral Stenoses, Strictures, and Pelvic Fracture Urethral Disruption Injuries. Urology 2014; 83:S1-7. [DOI: 10.1016/j.urology.2013.09.009] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/10/2013] [Accepted: 09/16/2013] [Indexed: 12/23/2022]
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Svoboda JS, Van Howe RS. Out of step: fatal flaws in the latest AAP policy report on neonatal circumcision. JOURNAL OF MEDICAL ETHICS 2013; 39:434-441. [PMID: 23508208 DOI: 10.1136/medethics-2013-101346] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The American Academy of Pediatrics recently released a policy statement and technical report on circumcision, in both of which the organisation suggests that the health benefits conferred by the surgical removal of the foreskin in infancy definitively outweigh the risks and complications associated with the procedure. While these new documents do not positively recommend neonatal circumcision, they do paradoxically conclude that its purported benefits 'justify access to this procedure for families who choose it,' claiming that whenever and for whatever reason it is performed, it should be covered by government health insurance. The policy statement and technical report suffer from several troubling deficiencies, ultimately undermining their credibility. These deficiencies include the exclusion of important topics and discussions, an incomplete and apparently partisan excursion through the medical literature, improper analysis of the available information, poorly documented and often inaccurate presentation of relevant findings, and conclusions that are not supported by the evidence given.
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Affiliation(s)
- J Steven Svoboda
- Attorneys for the Rights of the Child, 2961 Ashby Avenue, Berkeley, CA 94707, USA.
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Peycelon M, Parmentier B, Raquillet C, Boubnova J, Chouikh T, Grosos C, Honart JF, Pichon A, Auber F, Larroquet M, Audry G. [Abnormalities of the penis in boys]. Arch Pediatr 2012; 19:1347-53. [PMID: 23121902 DOI: 10.1016/j.arcped.2012.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 08/24/2012] [Accepted: 09/25/2012] [Indexed: 10/26/2022]
Abstract
Abnormalities of the male genitalia have increased in the last 2 decades in numerous developed countries and remain a frequent reason of consultation in pediatric surgery. The diagnostic spectrum is wide, and surgeons should pay particular attention to these abnormalities because of their potential psychological effect. Anatomically, these abnormalities can affect one of three parts of the penis. First, the foreskin may not be fully retracted. This is normal at birth and can be caused by prepuce adherents that can continue until adolescence. Today, true phimosis is treated with topical corticoids from the age of 3 years. If medical treatment fails, a surgical procedure is required. Second, the urethra can be affected by hypospadia, which is the most frequent abnormality of the urethra. It is associated with ectopic urethral meatus, hypoplastic foreskin, and penis curvature. Its pathogenic background is not clearly understood. Surgery options differ according to the type of hypospadia and according to the surgeon's experience. It is sometimes hard to deal with, especially in a perineal form, where genetic and hormonal studies are recommended. These interventions can lead to complications ranging from stenosis to fistula. Therefore, parents have to be informed of the benefits and risks of the surgical procedures. Epispadias is rare but more serious because of the increasing risk of urinary incontinence. Finally, abnormalities of the corpora cavernosa - often associated with hypospadias - can include penis curvature and micropenis, for which an endocrinological analysis is essential.
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Affiliation(s)
- M Peycelon
- Service de chirurgie viscérale pédiatrique et néonatale, hôpital Trousseau, AP-HP, 75012 Paris, France
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Tailored sutureless meatoplasty: a new technique for correcting meatal stenosis. J Pediatr Urol 2012; 8:92-6. [PMID: 20980203 DOI: 10.1016/j.jpurol.2010.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 10/06/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Standard practice for meatoplasty includes the use of sutures to evert the mucosa. We present a novel technique that is equivalent to standard meatoplasty without the need for suturing. MATERIALS AND METHODS A retrospective chart review was performed of patients who presented with primary meatal stenosis in 2007-2009. One group underwent a tailored, sutureless meatoplasty performed by one surgeon. The second group underwent a standard meatoplasty with mucosal advancement and suturing of the mucosal edges by another surgeon. Data were collected regarding demographics, presenting symptoms, symptom resolution, and postoperative complications. These were then compared between the two groups. Preoperative and postoperative uroflowmetry data were collected for the sutureless group to demonstrate objective improvement. RESULTS Of 85 patients, aged 2-17 years, 60 underwent the tailored, sutureless procedure while 25 had a standard meatoplasty. The majority of patients presented with a deviated and/or narrowed stream of urine. There was no statistical difference between the two groups in regard to symptom resolution. Uroflowmetry data analyzed for 20 patients in the sutureless group demonstrated a significant improvement in Q(max) and flow pattern; there was no significant change in % post-void residual. No patient had a complication in either group, or presented with recurrence. CONCLUSIONS Tailored sutureless meatoplasty is comparable to meatoplasty with mucosal advancement in resolving symptoms, improving uroflowmetry parameters, and complication rate, but is more efficient and cost effective.
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Becker K. Lichen sclerosus in boys. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:53-8. [PMID: 21307992 DOI: 10.3238/arztebl.2011.053] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 03/08/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Lichen sclerosus (LS) is a sclerosing skin disease. When it appears in boys, it nearly always affects the penis and usually causes phimosis requiring surgical treatment. The clinical significance of this disease in boys is inadequately recognized. METHODS The etiology, clinical manifestations, diagnosis, and treatment of LS in boys are presented in the light of a review of selected literature. We also present our own experience with this disease in an ambulatory pediatric surgery practice. RESULTS LS has long been recognized as a disease of the prepubertal male genitalia (in such cases, the condition is also called "balanitis xerotica obliterans"). It is thought to be the main cause of acquired phimosis, and it can also involve the meatus and urethra as it progresses. Its possible association with squamous cell carcinoma of the penis remains unclear. Its etiology is unknown; its pathophysiological mechanism involves T-lymphocyte-mediated inflammation. The treatment of choice is complete circumcision. There is still controversy regarding the conservative treatment of LS with topical steroids. CONCLUSION LS is much more common in boys than is generally assumed. Lichen sclerosus should be suspected in any case of acquired phimosis. Treatment with complete circumcision does not necessarily bring about a definitive cure. Further research on the pathogenesis of this disease is needed.
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Affiliation(s)
- Karl Becker
- Kinderchirurgische Praxis, Prinz-Albert-Str. 26, 53113 Bonn, Germany.
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Abstract
Meatal stenosis is a common urologic complication after circumcision. Children present to their primary care physicians with complaints of deviated urinary stream, difficult-to-aim, painful urination, and urinary frequency. Clinical exam reveals a pinpoint meatus and if the child is asked to urinate, he will usually have an upward, thin, occasionally forceful urinary stream with incomplete bladder emptying. The mainstay of management is meatoplasty (reconstruction of the distal urethra /meatus). This educational video will demonstrate how this is performed.
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Affiliation(s)
- Ming-Hsien Wang
- Department of Urology, Pediatric Urology, Johns Hopkins School of Medicine, USA
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Méndez-Gallart R, Estévez E, Bautista A, Rodríguez P, Taboada P, Armas AL, Pradillos JM, Varela R. Bipolar scissors circumcision is a safe, fast, and bloodless procedure in children. J Pediatr Surg 2009; 44:2048-53. [PMID: 19853772 DOI: 10.1016/j.jpedsurg.2009.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 05/11/2009] [Accepted: 06/01/2009] [Indexed: 01/07/2023]
Abstract
PURPOSE The aim of this study is to evaluate bipolar scissors circumcision by comparing it with standard freehand scalpel procedure. PATIENTS AND METHODS Data were analyzed from a prospective, randomized study, comparing 2 different surgical techniques for pediatric circumcision: the bipolar diathermy scissors circumcision technique with those of a conventional scalpel technique. A total of 230 pediatric patients younger than 16 years (115 in each arm of the trial) who were undergoing circumcision were reviewed prospectively. Operative time, surgical bleeding, complications, and postoperative morbidity were analyzed. Differences between bipolar scissors circumcision and conventional surgery were compared. RESULTS Median blood loss for bipolar circumcision was 0.2 mL (range, 0-0.8 mL) compared with 2.1 mL in the standard group (range, 0.9-4.2 mL) (P < .001). Operative time in the bipolar diathermy treated group was significantly decreased compared with conventionally treated patients (10.8 +/- 1.2 vs 19.1 +/- 2.6 minutes; P < .01). Early and late postoperative morbidity were significantly decreased in circumcised patients who underwent the bipolar circumcision technique as compared with those who underwent the conventional approach regardless of the postoperative edema (22 vs 10; P = .02). CONCLUSIONS Bipolar scissors circumcision approach is an effective and safe procedure alternative to the standard scalpel technique in pediatric circumcision with no significant morbidity.
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Affiliation(s)
- Roberto Méndez-Gallart
- Department of Pediatric Surgery, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, Spain.
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Diallo AB, Toure BM, Camara C, Barry M, Bah I, Keita M, Balde I, Diallo MB. Les accidents de la circoncision: aspects anatomo-cliniques et thérapeutiques au CHU de Conakry, Guinée. A propos de 44 cas. ACTA ACUST UNITED AC 2008. [DOI: 10.1007/bf03040374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Calcagno C. Balanitis Xerotica Obliterans. Urologia 2007. [DOI: 10.1177/039156030707400403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Balanitis xerotica obliterans (BXO), first described by Stuhmer in 1928, is a chronic, progressive, atrophic, sclerosing process involving prepuce, glans and urethra. Its aetiology is unknown. After a short terminological excursus and a review of the aetiological hypothesis, we have focused on BXO in daily urological practice. We are here describing the clinical presentation and its differential diagnosis with premalignant and malignant lesions of the penis. We tried to define the relationship between BXO and squamous cell carcinoma of the penis. Particular attention was then cast on urethral stenosis. Finally, we focused on the treatment of BXO: corticosteroid local therapy as first line treatment or as adjuvant therapy after circumcision, surgical therapy including circumcision, laser therapy of the glans lesions, meatoplasty in the stenosis of the anterior urethra. We also stressed the need for histological examination of the preputial specimen for a correct follow-up and for medicolegal reasons.
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Affiliation(s)
- C. Calcagno
- Dipartimento di Urologia, Ospedale San Carlo, Genova-Voltri
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Yegane RA, Kheirollahi AR, Salehi NA, Bashashati M, Khoshdel JA, Ahmadi M. Late complications of circumcision in Iran. Pediatr Surg Int 2006; 22:442-5. [PMID: 16649052 DOI: 10.1007/s00383-006-1672-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2006] [Indexed: 12/16/2022]
Abstract
Today, circumcision is the most commonly performed surgical procedure worldwide. Early and late complications may occur due to circumcision. To find the prevalence of late complications of circumcision, we studied 3,205 elementary-school boys aged 6-12 years in 2002. All of them were Iranian and Muslim. Nearly 3,125 of the boys have been circumcised. Most of the boys (2,214 boys) had been circumcised after 2 years of age. Moreover, most of them were operated by traditional circumcisers (43.49%). Late complications (7.39%) were reported in 231 boys. Excessive residual foreskin was seen in 113 children (3.6%). Excessive removal of skin was detected in 42 boys (1.3%), meatal stenosis in 29 boys (0.9%), granoloma in 22 boys (0.7%), penile rotation in 17 boys (0.5%), and 8 boys had secondary chordee (0.2%). The complication rate was not different between the neonatal circumcision and older groups. We suggested that circumcision should only be performed in medical institutions by suitably trained specialists.
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Affiliation(s)
- Rooh-Allah Yegane
- Department of Surgery, Loqman-Hakim Hospital, Shahid Beheshti Medical University, Kamali St, Tehran, Iran.
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Abstract
Daytime wetting is a common problem with various causes that can usually be identified through a careful history, thorough physical examination, and urinalysis. Conservative approaches to therapy have a successful outcome in most children. Invasive diagnostic imaging studies and pharmacologic or surgical intervention are necessary only for carefully selected children.
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Affiliation(s)
- W Lane M Robson
- The Childrens' Clinic, Suite 111, 4411 16th Avenue NW, Calgary, Alberta T3B OM3, Canada.
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Abstract
The objective of this study was to prospectively document the incidence of meatal stenosis in boys. The study included a consecutive sample of boys whose visit with the physician included a genital examination in a private primary care pediatric practice in rural northern Wisconsin. Meatal stenosis was diagnosed in boys from 1.94 to 12.34 years of age. The diagnosis was made in 24 of 329 circumcised boys who were Tanner I development and older than 3 years of age (7.29%, 95%CI=4.48-10.10%). Nearly all required meatotomy to resolve their symptoms. All of the boys with meatal stenosis were circumcised neonatally (exact OR=3.54, 95%CI=0.62-infinity). The ratio of circumcised boys to noncircumcised boys in this study provided 80% power to demonstrate a 21.4% difference in the incidence of meatal stenosis between circumcised and noncircumcised Tanner I boys 3 years and older. Meatal stenosis may be the most common complication following neonatal circumcision. The frequency of this complication and the need for surgical correction need to be disclosed as part of the informed consent for neonatal circumcision. A careful meatal examination is indicted in any circumcised boy with abdominal or urinary complaints.
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Affiliation(s)
- Robert S Van Howe
- Department of Pediatrics, Michigan State University College of Human Medicine, Marquette, Michigan, USA
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Bréaud J, Guys JM. Décalottage ou circoncision : quelle indication dans le phimosis ? Arch Pediatr 2005; 12:1424-32. [PMID: 15979860 DOI: 10.1016/j.arcped.2005.02.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Accepted: 02/14/2005] [Indexed: 01/12/2023]
Abstract
Phimosis remains a major question for mothers and induces a high number of consultations. However, large epidemiologic series have shown that congenital phimosis may disappear spontaneously in around 80% of cases with development and should'nt need any treatment before the age of five or six years old. Theses elements go against sociocultural habits which induce many circumcisions before the age of six. Corticoid treatment of phimosis seems to be very efficient to facilitate the disparition of phimosis. The aim of this literature review is to evaluate medical, socioeconomical and therapeutics aspects of phimosis. Based on these data, we recommend never to treat phimosis before the age of one year old, to wait as long as possible for spontaneous evolution of phimosis until the age of five years old, and, in case of non evolution of congenital phimosis or pathologic phimosis to use as first step treatment corticoid topics rather than surgical treatment.
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Affiliation(s)
- J Bréaud
- Service de chirurgie infantile, hôpital l'Archet-II, CHU de Nice, route de saint-Antoine-de-Ginestière, 06202 Nice cedex 03, France.
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Abstract
PURPOSE A novel technique is described to relieve stenosis of a ventrally placed or pinhole external urinary meatus in men and boys with lichen sclerosus. MATERIALS AND METHODS A total of 19 patients underwent the new operation in a 5-year period. Mean patient age was 42.2 years (range 6 to 74) and mean followup was 3 years 9 months (range 18 months to 6 years 7 months). The operation involves dorsal and ventral meatotomies with an inverted V-shaped relieving incision to correct puckering caused by dorsal meatotomy. Patients were mailed a questionnaire asking if they were pleased with the cosmetic results, and how often and how much they sprayed when passing urine. RESULTS Two patients died of unrelated causes and 2 were lost to followup. There were no recurrences or major complications. A total of 13 patients replied to the questionnaires. All patients were pleased or very pleased with the cosmetic result. Most patients (11 of 13 or 85%) did not spray at all or, if they did, only sprayed occasionally. No patient found it constant or severe. CONCLUSIONS The technique relieves stenosis of the external urinary meatus in the medium term. It is rapid and easy to perform on an outpatient basis and it provides good cosmesis with a low incidence of a spraying stream. Because the main axis of the operation is dorsal, it does not create a hypospadiac meatus.
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Affiliation(s)
- Peter Malone
- Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading, United Kingdom
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Abstract
Visits to the emergency department (ED) by neonates and their parents can cause anxiety for parents and the ED staff. Many of the presenting complaints are unique to the neonatal population, and an understanding of both common problems and true medical emergencies is paramount. This article discusses the complaints the EDs have seen more frequently as a result of earlier newborn discharges from hospitals.
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Affiliation(s)
- Maureen McCollough
- Department of Medicine, University of California Los Angeles School of Medicine, Pediatric Emergency Medicine, Department of Emergency Medicine, Olive View-University of California Los Angeles Medical Center, Los Angeles, California, USA
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Berdeu D, Sauze L, Ha-Vinh P, Blum-Boisgard C. Cost-effectiveness analysis of treatments for phimosis: a comparison of surgical and medicinal approaches and their economic effect. BJU Int 2001; 87:239-44. [PMID: 11167650 DOI: 10.1046/j.1464-410x.2001.02033.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare the cost-effectiveness of surgery and topical steroids as treatments for phimosis (defined as a clinically verifiable, pathological, cicatricial stenosis of the prepuce) and to evaluate the financial basis of these treatments. METHODS Data on treatment using topical steroids was obtained from published reports and those for circumcision from claims by private hospitals for children < 13 years old registered at the health insurance department of our facility. The estimate of the French national financial cost of the treatments for 1998 was calculated from public and private institutional information. RESULTS Treatment with topical steroids for 4-8 weeks was successful in approximately 85% of patients (mean age 5 years) and had no side-effects; the remaining 15% were treated by circumcision. Topical steroid therapy costs (in French francs) F 360 per patient. For those primarily treated by circumcision (81 boys, mean age 4.3 years) and diagnosed as having phimosis, the cost was F 3330 per patient in the private sector. The total number of circumcisions performed in France, regardless of sector (public or private) for 1998 was estimated to be 51 080, which represents an annual cost of F 195.7 million. CONCLUSION As topical pharmacological treatment avoids the disadvantages, trauma and potential complications of penile surgery, including anaesthesia-related risks, the use of topical steroids as a primary treatment appears to be justified in boys with clinically verifiable phimosis. This treatment could reduce costs by 75%, which represents a potential annual saving of approximately F 150 million.
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Affiliation(s)
- D Berdeu
- Service Médical de la Caisse Maladie Régionale de Provence, Marseille, France.
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Ahmed A, Mbibi NH, Dawam D, Kalayi GD. Complications of traditional male circumcision. ANNALS OF TROPICAL PAEDIATRICS 1999; 19:113-7. [PMID: 10605531 DOI: 10.1080/02724939992743] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The complications of traditional male circumcision were studied in 48 boys seen between January 1981 and December 1995. Their ages ranged from 3 days to 7 years (mean: 4 years). Haemorrhage, the commonest complication, was seen in 25 (52%) and infection in ten; one child had amputation of the penis. Other complications included meatal stenosis and urethro-cutaneous fistula. Sixty-four per cent of those with haemorrhage were neonates and their haemoglobin levels ranged between 6 and 15 g/dl. Three required blood transfusion, seven ligation of bleeding vessels and two required both. Overall, 21 patients required surgery and the average duration of hospital stay was 2-8 days. Most complications were seen between 1991 and 1995 when surgical fees had been introduced and the number of boys circumcized in our hospital decreased. We advocate the provision of adequate and safe facilities to cope with the increasing demand for circumcision in our society.
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Affiliation(s)
- A Ahmed
- Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
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Abstract
OBJECTIVE To determine the most cost-effective treatment for phimosis. DESIGN The costs of three treatment strategies for treating phimosis were evaluated using a decision-tree analysis. Three therapeutic approaches were considered: circumcision, preputial plasty (the use of plastic surgical techniques to enlarge the preputial opening without removing tissue), and topical therapy with steroids and nonsteroidal antiinflammatories. Published failure and complication rates were used to calculate the cost per case. Outcome Measures. Cost in dollars to treat each case of phimosis. RESULTS Topical steroid therapy was the most cost-effective strategy, costing between $758 and $800 per case. Preputial plasty cost between $2515 and $2580 per case. Circumcision cost between $3009 and $3241 per case. CONCLUSIONS The most cost-effective management for treating phimosis is to initiate topical therapy. Daily external application from the tip of the foreskin to the glandis corona with betamethasone 0.05% cream for 4 to 6 weeks has been demonstrated to be very effective, resulting in a 75% savings compared with circumcision. Surgical intervention should not be considered until topical therapy has been given an adequate trial. When contemplating surgery, the lower morbidity, lower costs, and tissue preservation of preputial plasty may make it preferable.
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Affiliation(s)
- R S Van Howe
- Department of Pediatrics, Marshfield Clinic-Lakeland Center, Minocqua, WI 54548, USA
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48
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Abstract
Circumcision is a commonly performed procedure, but medical indications remain controversial. Most disorders of the penis in childhood can be diagnosed and managed by the primary care pediatrician. However, some require early recognition and surgical intervention, and prompt referral to a pediatric surgeon or urologist will optimize outcome. This article discusses the recognition and initial management of these problems, particularly those most commonly seen or followed in the outpatient setting. In addition, the authors review the issues of circumcision.
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Affiliation(s)
- J C Langer
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Abstract
We have tried to review the evidence for the organisation of paediatric surgical care. Difficulties arise because of the lack of published data from district general hospitals concerning paediatric surgical conditions. Hence much of the debate about the surgical management of children is based on anecdotal evidence. However, at a time when the provision of health care is being radically reorganised to an internal market based on a system of purchasers and providers it is more important than ever to understand the issues at stake. Two separate issues have been discussed: the role of the specialist paediatric centre and the provision of non-specialist paediatric surgery in district general hospitals. There are arguments for and against large regional specialist paediatric centres. The benefits of centralisation include concentration of expertise, more appropriate consultant on call commitment, development of support services, and junior doctor training. The disadvantages include children and their families having to travel long distances for care, and the loss of expertise at a local level. If specialist paediatric emergency transport is available the benefits of centralisation far outweigh the adverse effects of having to take children to a regional paediatric intensive care centre. Specialist paediatric centres are aware of the importance of treating children and their parents as a family unit as highlighted by the Platt committee; this is an important challenge and enormous improvements have occurred to provide proper accommodation for families while their children are treated in hospital. To keep these arguments of large distances and separation from the home in context, one paediatric intensive care unit in Victoria, Australia, providing a centralised service to a region larger in are than England and with a similar admission rate, has a lower mortality rate than the decentralised paediatric intensive care provided in the Trent region of the UK. There is clear evidence that all neonatal surgery and anaesthesia should be conducted only by specialists. The debate now centres around the number of complex surgical cases a unit should treat to maintain its specialist status. The NHS executive, in its guidelines on contracting for specialist services, emphasises that "Sensible contracting needs to take into account the optimum population size not only for the stability of contracted referrals but also to give sufficient 'critical mass' for clinical effectiveness." Achieving this balance has consequences, not just for the maintenance of surgical expertise, but for the essential ancilliary services. There is clear evidence in anaesthesia that anaesthetists doing small numbers of neonatal procedures had significantly worse results. The same seems to be true in the fields of oncology, radiology, pathology, and intensive care. The reasons why the results of management of certain paediatric conditions are better at specialist centres are open to speculation. Presumably greater exposure to rare complex cases, concentration of expertise, more peer review, and a trickle down effect of the multidisciplinary approach all help to keep health care workers up to date with current world practice. In addition, it allows for appropriate specialist on call rotas and dedicated junior staff. If insufficient numbers of specialist surgical cases are being treated at a centre then the whole multidisciplinary team suffers. The 1989 NCEPOD report states "that paediatricians and general surgeons must recognise that small babies differ from other patients not only in size, and that they pose quite separate problems of pathology and management." The need for large centres of paediatric surgical expertise is now accepted by the Royal College of Surgeons of England, the British Association of Paediatric Surgeons, the Senate of Surgery of Great Britain and Ireland, the Royal College of Paediatrics and Child Health, the Royal College of Anaesthetists, the Audit
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Affiliation(s)
- G S Arul
- Department of Paediatric Surgery, Bristol Royal Hospital for Sick Children, UK
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50
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Abstract
The number of genital problems that pediatricians encounter is substantial. The most common ones have been reviewed in this article. Perhaps the most important point to reinforce is the appropriateness of nonintervention in uncircumcised boys whose foreskins have not become retractile during early school years. Without infections or pathologic phimosis, these boys do well, and most foreskins become retractile as they approach puberty. Abnormalities beyond those discussed or those not fitting the anticipated pattern probably warrant specialty referral.
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Affiliation(s)
- M R Brown
- Department of Urology, University of Utah School of Medicine, Salt Lake City, USA
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