Topical corticosteroids for treating phimosis in boys

BACKGROUND

This is an updated version of a Cochrane Review first published in 2014. Phimosis is a condition in which the prepuce (foreskin) cannot be fully retracted past the head of the penis (glans). Phimosis is often treated surgically by circumcision or prepuce plasty; however, reports of non-invasive treatment using topical corticosteroids applied for four to eight weeks have suggested favorable outcomes.

OBJECTIVES

To assess the effects of topical corticosteroids applied to the stenotic portion of the prepuce for the treatment of phimosis in boys compared with placebo or no treatment.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, and ClinicalTrial.gov. We checked reference lists of included studies and relevant reviews for additional studies. There were no restrictions on the language of publication. The date of the last search was 4 October 2023.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) that compared the use of any topical corticosteroid with placebo or no treatment for boys with any type or degree of phimosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data related to the review's primary and secondary outcomes, and assessed the studies' risk of bias. We used the random-effects model for statistical analyses and expressed dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We contacted the authors of the primary articles to request details of the study design and specific outcome data. We used GRADE to assess the certainty of evidence on a per-outcome basis.

MAIN RESULTS

In this update, we identified two new studies with 111 participants, bringing the total number of included studies to 14 (1459 randomized participants). We found that types of corticosteroids investigated, participant age, degree of phimosis, type of phimosis, and treatment duration varied considerably among studies. Compared with placebo or no treatment, topical corticosteroids may increase the complete resolution of phimosis after four to eight weeks of treatment (RR 2.73, 95% CI 1.79 to 4.16; I² = 72%; 10 trials, 834 participants; low-certainty evidence). Based on 252 complete resolutions per 1000 boys in the control group, this corresponds to 436 more complete resolutions per 1000 boys (95% CI 199 more to 796 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. Topical corticosteroids may also increase the partial resolution of phimosis at four to eight weeks of treatment compared with placebo or no treatment (RR 1.68, 95% CI 1.17 to 2.40; I² = 44%; 7 trials, 745 participants; low-certainty evidence). Based on 297 partial resolutions per 1000 boys in the control group, this corresponds to 202 more partial resolutions per 1000 boys (95% CI 50 more to 416 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious inconsistency. We are uncertain of the effect of topical corticosteroids compared to placebo on change in retractability score (standardized mean difference [SMD] -1.48, 95% CI -2.93 to -0.03; I²91%; 2 trials, 177 participants; very low-certainty evidence). We downgraded the certainty of the evidence by one level for serious study limitations, one level for serious heterogeneity, and one level for serious imprecision. Compared with placebo, topical corticosteroids may increase the long-term complete resolution of phimosis six or more months after treatment (RR 4.09, 95% CI 2.80 to 5.97; I² = 0%; 2 trials, 280 participants; low-certainty evidence). Based on 171 long-term complete resolutions per 1000 boys in the control group, this corresponds to 528 more complete resolutions per 1000 boys (95% CI 308 more to 850 more). We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision. There may be little or no difference in the risk of adverse effects between topical corticosteroids and placebo or no treatment (RR 0.28, 95% CI 0.03 to 2.62; I² = 22%; 11 trials, 1091 participants; low-certainty evidence). Only two of 11 studies that recorded adverse effects reported any adverse effects; one event occurred in the corticosteroid group and six in the control group. We downgraded the certainty of the evidence by one level for serious study limitations and by one level for serious imprecision.

AUTHORS' CONCLUSIONS

Topical corticosteroids, compared to placebo or no treatment, may increase complete and partial resolution of phimosis when assessed after four to eight weeks of treatment, and may increase long-term complete resolution of phimosis assessed six or more months after treatment. Topical corticosteroids may have few or no adverse effects, and we are uncertain about their effect on retractability scores. The body of evidence is limited by poor reporting of methods in the studies, important clinical heterogeneity, and serious imprecision in the results. Future, higher-quality trials with long-term follow-up would likely improve our understanding of the effects of topical corticoids on phimosis in boys.

Wound healing rates and wound problems of conventional circumcision compared with ring circumcision: A meta-analysis

A meta-analysis investigation was executed to measure the wound healing rates (WHRs) and wound problems (WPs) of conventional circumcision (CC) compared with ring circumcision (RC). A comprehensive literature investigation till March 2023 was applied and 2347 interrelated investigations were reviewed. The 16 chosen investigations enclosed 25 838 individuals, with circumcision, were in the chosen investigations' starting point, 3252 of them were RC, and 2586 were CC. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the WHRs and WPs of CC compared with RC by the dichotomous or continuous approaches and a fixed or random model. RC had a significantly lower wound infection rate (WIR) (OR, 0.58; 95% CI, 0.37-0.91, P = .002) and wound bleeding rate (WBR) (OR, 0.22; 95% CI, 0.12-0.42, P < .001) compared with those with CC. However, RC and CC had no significant difference in WHR (OR, 2.18; 95% CI, -0.73 to 5.09, P = .14), wound edema rate (WER) (OR, 1.11; 95% CI, 0.92-1.33, P = .28), and wound dehiscence rate (WDR) (OR, 0.98; 95% CI, 0.60-1.58, P = .93). RC had significantly lower WIR, and WBR, however, no significant difference in WHR, WER, and WDR compared with those with CC. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta-analysis.

[Precise marking method assisted modified circumcision with a disposable foreskin circumcision device-Preliminary experience and report of 41 cases]

OBJECTIVE

To explore the safety, feasibility, and technical points of the improved circumcision procedure assisted by a precise marking method circumcision device.

METHOD

A retrospective analysis was conducted on 41 cases of modified foreskin circumcision using precise marking method in the urology department of our hospital from February 2021 to January 2023 as the observation group, and 60 cases of traditional foreskin circumcision assisted by traditional foreskin circumcision during the same period as the control group. Compare and analyze indicators such as the distance from the anastomotic margin to the coronal sulcus, postoperative erectile tension, edema, hematoma, postoperative infection, and the presence of sexual intercourse pain between two groups of patients. The number of patients in the observation group who experienced erectile tension at 3 months after surgery was lower than that in the control group (P<0.05), and the number of patients with sexual pain was lower than that in the control group (P<0.05). The distance from the incision edge to the coronal sulcus was closer to 0.5 cm in the observation group (P<0.05).

CONCLUSION

Compared with traditional circumcision, the precise marking method assisted by a modified circumcision device can more accurately control the position of the cutting edge, reduce the incidence of postoperative erectile tension and sexual pain, and is a feasible and safe surgical method.

Accuracy of telemedicine for diagnosis and pre-operative assessment of pediatric penile conditions

INTRODUCTION

Patients with penile conditions comprise a significant proportion of any pediatric urology practice, and physical examination is the mainstay of diagnosis for such conditions. While the rapid adoption of telemedicine (TM) facilitated access to pediatric urology care during the pandemic, the accuracy of TM-based diagnosis for pediatric penile anatomy and pathology has not been studied. Our aim was to characterize the diagnostic accuracy of TM-based evaluation of pediatric penile conditions by comparing diagnosis during the initial virtual visit (VV) with a subsequent in-person visit (IPV). We also sought to assess the agreement between scheduled and actual surgical procedure performed.

METHODS

A single-institution prospective database of male patients less than 21 years of age who presented for evaluation of penile conditions between August 2020 and December 2021 was analyzed. Patients were included if they had an IPV with the same pediatric urologist within 12 months of the initial VV. Diagnostic concordance was based on a surgeon-reported survey of specific penile diagnoses, completed at both initial VV and follow-up IPV. Surgical concordance was assessed based on the proposed versus billed CPT code(s).

RESULTS

Median age among 158 patients was 10.6 months. The most frequent VV diagnoses were penile adhesions (n = 37), phimosis (n = 26), "other" (n = 24), post-circumcision redundancy (n = 18), and buried penis (n = 14). Initial VV and subsequent IPV diagnoses were concordant in 40.5% (64/158); 40/158 (25%) had partial concordance (at least one diagnosis matched). There was no difference in age, race, ethnicity, median time between visits, or device type between patients with concordant vs. discordant diagnoses. Of 102 patients who underwent surgery, 44 had VV only while 58 had IPV prior to surgery. Concordance of scheduled versus actual penile surgery was 90.9% in those patients who only had a VV prior to surgery. Overall, surgery concordance was lower among those with hypospadias repairs vs. non-hypospadias surgery (79.4% vs. 92.6%, p = 0.05).

CONCLUSION

Among pediatric patients being evaluated by TM for penile conditions, there was poor agreement between VV-based and IPV-based diagnoses. However, besides hypospadias repairs, agreement between planned and actual surgical procedures performed was high, suggesting that TM-based assessment is generally adequate for surgical planning in this population. These findings leave open the possibility that, among patients not scheduled for surgery or IPV, certain conditions might be misdiagnosed or missed entirely.

Comparative study of mechanical vs. manual circumcision in the pediatric population: An alternative to the conventional technique?

OBJECTIVE

Circumcision is one of the most common surgical procedures in pediatric surgery. Even though manual suture (MANS) is regarded as the gold standard technique, easy-to-use mechanical suture (MECS) devices have been recently developed, with better postoperative results in the adult population. The objective of our study was to compare the operating time and incidence of postoperative complications between both techniques in our environment.

MATERIALS AND METHODS

A retrospective study of patients undergoing circumcision in our institution from October 2021 to December 2022 was carried out. Operating time and complications observed in the first 14 postoperative days (edema, hematoma, dehiscence) were analyzed according to the technique used (MANS vs. MECS) and patient age (< 12 and ≥ 12 years old).

RESULTS

173 patients (147 MANS, 26 MECS) were included. Mean operating time was significantly lower in MECS patients, both in patients < 12 years old (16 min vs. 10 min, p= 0.002) and in patients ≥ 12 years old (23 min vs. 12 min, p< 0.001). Regarding complications, MECS patients ≥ 12 years old had a lower rate of suture dehiscence (23.5% vs. 0%, p< 0.001), with no significant differences in the younger group.

CONCLUSIONS

MECS circumcision is a simple and effective technique involving shorter operating times than MANS circumcision, regardless of age. It has a lower rate of complications in older children (≥ 12 years), which means it stands as a valid alternative to the conventional technique.

[Research progress and application status of circumcision]

Circumcision is the simplest, most commonly used and most effective treatment for male prepuce overlength, phimosis and other diseases. There has also been a shift from traditional circumcision to simpler, faster, less invasive, instrument-based methods. This paper reviews the surgical methods of circumcision(Traditional circumcision、Electrosurgical circumcision、Laser circumcision、Sleeve circumcision, Dermotomy at the base of penis, Shangring, Gomco, Mogen, PlastiBell, PrePex, Alisklamp and Disposable circumcision suture apparatus), hoping to provide reference for clinicians to choose the appropriate circumcision methods for patients.

Referrals from primary care with foreskin symptoms: Room for improvement

AIMS

Referrals to secondary care for boys with foreskin symptoms require face-to-face review, resulting in time out of school / work and costs to the family. This study aimed to review outcomes of referrals to ascertain if there was scope to reduce referrals.

METHODS

New patients referred to a UK regional paediatric surgery clinic during 2019 were identified and screened retrospectively. Medical records for boys over one year of age referred due to foreskin symptoms were reviewed.

RESULTS

Of 2598 referrals, 1939 (75%) were boys & 1094 were > 1 yr; 398 (21%) were referred with foreskin symptoms at median age 7.2 yrs (IQR 4-10). 307 (77%) were diagnosed with physiological phimosis, 67 (18%) with pathological phimosis, 9 (2%) with balanitis (the remainder had 'smegma' retention cysts, preputial adhesions, tight frenulum or anatomical abnormalities). 211 (53%) were discharged at the initial appointment, this was significantly more likely for younger boys, and those with physiological phimosis (p<0.001). 62 (16%) were prescribed topical steroids (more likely in older boys, p<0.001). 70 (18%) were offered surgery: circumcisions (n = 51), preputioplasties (n = 13), other (n = 4). The circumcision rate was therefore 12%. Age at referral was positively correlated with GP trial of steroid (older more likely), diagnosis (physiological phimosis more likely if younger) and outcome (topical steroids or surgery more likely if older): Spearman's rank correlation p<0.001.

CONCLUSIONS

Over 75% of boys referred had a normal foreskin, over half were discharged at their first review. Improved knowledge amongst parents and primary care providers could reduce referrals and save money and resources.

LEVEL OF EVIDENCE

Level IV - Case series with no comparison group.

[Knot-free suture and frenulum positioning combined with application positioning using a disposable circumcision suture device in circumcision]

OBJECTIVE

To explore the effect of knot-free suture and frenulum positioning combined with application positioning (KFS-FP + AP) in circumcision using a disposable circumcision suture device.

METHODS

We retrospectively analyzed the clinical data on 160 cases of circumcision for phimosis or redundant prepuce by KFS-FP + AP (the observation group, n = 80) or by routine circumcision (the control group, n = 80) with a disposable circumcision suture device from February 2021 to December 2021. We recorded the operation time, incidence of frenulum breve, incidence of frenulum dislocation, and Visual Analog Scale (VAS) scores at 6 hours after surgery, and compared them between the two groups of patients.

RESULTS

The operation time was longer in the observation than in the control group (8.00 ［8.00, 9.00］ min vs 5.00 ［5.00, 5.00］ min), and the incidence rates of frenulum breve (0 vs 8.75%, P < 0.05) and frenulum dislocation (0 vs 7.5%, P < 0.05) significantly lower in the former than in the latter group. There were no statistically significant difference in the VAS scores between the observation and the control groups (2.60 ［2.00, 3.00］ vs 2.55 ［2.00, 3.00］, P > 0.05).

CONCLUSION

KFS-FP + AP with a disposable circumcision suture device is a safe and effective method of circumcision, with high satisfaction of the patients and worthy of clinical promotion.

[Functional phimosis: prevalence, diagnosis and treatment in outpatient practice]

AIM

To study the prevalence of functional phimosis determined during erection in patients over 18 years of age, as well as the features of its diagnosis and treatment in outpatient practice.

MATERIALS AND METHODS

A retrospective study that included 201 patients who underwent circumcision at a mean age of 42.7 years, was carried out. Complaints, history, initial examination and autophotography of the penis during erection were evaluated. The subjects were divided into 2 groups. The group I (n=38) included patients complaining of the inability to reveal the glans penis during erection, while in group II (n=163) men with similar complaints in a f laccid state of the penis were included. All patients underwent circumcision under local anesthesia.

RESULTS

The proportion of functional phimosis was 18.9%. The mean age in groups I and II was significantly different (29.47+/-8.82 and 45.6+/-19.4 years, respectively, p<0.01). In 14 (36.8%) patients of group I, a short frenulum was also diagnosed. Primary phimosis was detected in 26.3% and 14.1% of patients in groups I and II (p<0.05), respectively. The acquired phimosis was diagnosed in 73.7% and 85.9% (p<0.05) of cases, respectively. There were no concomitant diseases in patients with "functional" phimosis, while in men with "pathological" phimosis, 22.7% of patients had various comorbidities, such as diabetes mellitus, coronary heart disease, hypertension, etc. CONCLUSIONS: Among patients who visit a urologist with a diagnosis of phimosis, almost every fifth man has functional form (18.9%). For the diagnosis of the phimosis, the history taking and autophotography of the penis during erection have an important role. In this category of patients, surgical treatment can be performed on an outpatient basis.

Incidence of circumcision among insured adults in the United States

Purpose

Although circumcision is the most commonly performed surgery in males, less is known about the incidence and indications of adult circumcision. In this study, we aim to present the incidence of adult circumcision across the United States.

Methods

Using IBM MarketScan^® Commercial Database from 2015 to 2018, we obtained claims for circumcision in men between 18 and 64 years of age. We calculated the incidence of adult circumcision over the study period and across the United States. We also collected data on indications for surgery using International Classification of Diseases codes.

Results

We identified a total of 12,298 claims for adult circumcisions. The mean age was 39 (±12.9) years. The average incidence rates remained relatively constant from 98.1 per 100,000 person-years in 2015 to 98.2 per 100,000 person-years in 2018 (Δ+0.1%). The age-standardized incidence rates varied significantly across the United States (from 0 to 194.8 per 100,000 person-years) with South Dakota having the highest rate. The most common indications for adult circumcision were phimosis (52.5%), routine/ritual circumcision (28.7%), phimosis + balanitis/balanoposthitis (6.8%), balanitis (3.8%) and balanoposthitis (2.6%), and significantly varied by age groups.

Conclusion

This study suggested a wide geographic variation in rates of adult circumcision between states with highest incidences in the Northeast United States. Future studies can identify the underlying causes for the observed variations.

Frequency of lichen sclerosus in children presenting with phimosis: A systematic histological study

BACKGROUND

The incidence of preputial lichen sclerosus (PLS) among children presenting with phimosis varies from 10 to 95%, depending on the age, the protocol for the treatment of pediatric phimosis, the method of diagnosis (clinical versus histological), and case mix (congenital versus acquired phimosis).

OBJECTIVE

PLS may not be clinically obvious. Our aim is to show that a systematic histological examination of the prepuce may diagnose PLS in clinically unsuspected cases.

METHODS

Prospective observational study of the histology of all prepuces resected from boys undergoing circumcision for phimosis but not clinically suspected to have PLS.

RESULTS

PLS was diagnosed histologically in 22 boys (32%). Boys with PLS were significantly older (mean 8.4 versus 4.7 years old). Diagnosis of PLS was not related to the degree of phimosis (summary figure). In three patients (grade 4 phimosis) glans discoloration was observed during surgery, and all had PLS. Follow up for boys found to have PLS ranged from 1 to 10 years. One patient developed recurrent phimosis, attributed to inappropriate conservative resection, and required further surgery. There were no cases of meatal stenosis.

DISCUSSION

Subtle cases of PLS may be difficult to detect clinically. Children are frequently asymptomatic, except for being unable to retract the prepuce. Physical examination has a low negative predictive value for the diagnosis of PLS. Complete removal of the prepuce with permanent glans exposure is regarded as essential to cure PLS and to avoid recurrent phimosis, but our patients were treated with partial circumcisions for cultural reasons. Only one needed reoperation for recurrent phimosis.

CONCLUSION

Histological PLS was present in approximately 1/3 of boys with phimosis, frequently without typical manifestations. Those patients may be cured with partial circumcisions.

Heineke-Mikulicz Preputioplasty: Surgical Technique and Outcomes

OBJECTIVE

To provide a summary of surgical technique and outcomes for Heineke-Mikulicz preputioplasty (HMP), a foreskin-preserving surgical treatment for phimosis in the adult population.

METHODS

We retrospectively reviewed 7 patients who underwent HMP by a single surgeon from May 2017 to May 2021. Variables included patient demographics, intraoperative considerations, and post-operative course. HMP is performed using a 2-3 cm vertical incision over the phimotic band on the dorsal surface to just above Buck's fascia. Additional incisions are made on the ventral surface if phimosis remains persistent after dorsal release. The incision is closed horizontally in 2 layers.

RESULTS

Seven patients underwent HMP. Median age was 47.3 and median BMI was 24.3. Five patients reported bothersome phimosis and 1 each reported paraphimosis and frenular tethering. Six patients requested foreskin sparing surgery as a personal preference and 1 patient was an intraoperative consult. Topical betamethasone was attempted in 3 of 7 patients. The median time from diagnosis to surgery was 2 months. Median operative time was 45.5 minutes and median estimated blood loss was 5 mL. Two patients required both dorsal and ventral incisions. No intraoperative complications were reported and all patients were discharged the same day. At median follow-up of 1.8 months, 1 patient reported bothersome phimosis secondary to scar formation treated successfully with triamcinolone.

CONCLUSION

HMP is a safe and effective method of treating even very significant phimosis in patients trying to avoid circumcision or intraoperative consults where preferences may be unclear. Our method takes less time than traditional circumcision with a comparable recovery and complication profile.

A Modified Disposable Circumcision Suture Device with Application of Plastic Sheet to Avoid Severe Bleeding After Circumcision

PURPOSE

To evaluate the effectiveness of a modified disposable circumcision suture device (DCSD) with application of plastic sheet to avoid severe bleeding after circumcision and compare the surgical effects and other postoperative complications of two DCSDs.

MATERIALS AND METHODS

A total of 943 excess foreskin patients from January 2018 to January 2020 who underwent circumcision using two different DCSDs were recruited. Preoperative characteristics (patient age, height and weight), main surgical outcomes (surgical time, intraoperative blood loss, incision healing time) and postoperative complications (postoperative hemorrhage and hematoma rate, edema rate, incision infection rate, residual staples rate) were collected and analyzed. Patients' "satisfaction" or "dissatisfaction" was also investigated.

RESULTS

Preoperative characteristics showed no significant statistical difference. The modified DCSD group has a lower intraoperative bleeding, postoperative hemorrhage or hematoma rate and residual staples rate compared with the conventional group. Incision healing time and incision infection rate between the two groups were similar. Nevertheless, conventional group has a shorter surgical time, a lower edema rate and a higher satisfaction rate.

CONCLUSION

The modified DCSD with application of plastic sheet can avoid severe bleeding after circumcision effectively and can be served as a new choice for circumcision.

Differential diagnosis of congenital megaprepuce: therapeutic and prognostic relevance

Congenital megaprepuce is a urological pathology typical of childhood. It can be easily mistaken for other clinical entities such as physiological phimosis or buried penis. Owing to the risk of associated complications - primarily infectious and obstructive complications, with upper urinary tract involvement -, achieving an accurate diagnosis proves particularly significant for early treatment initiation. We present three cases of congenital megaprepuce diagnosed and operated on at our department from January 2019 to May 2020. Diagnosis, therapy, and clinical progression are described.

[A comparative study of three different circumcision devices for redundant prepuce and phimosis]

OBJECTIVE

To compare the clinical effects of disposable titanium nail circumcision stapler (TNCS), one-off circumcision stapler (Shang Ring) and disposable double-handle circumcision suture device (DHCSD) in the treatment of redundant prepuce and phimosis.

METHODS

We reviewed the clinical data on 150 cases of redundant prepuce or phimosis treated with the TNCS (n = 50), DHCSD (n = 50) or Shang Ring (n = 50) from September 2018 to July 2020. We compared the operation time, intraoperative blood loss, wound healing time, Visual Analogue Scale (VAS) scores during and at 1 hour and 7 days after operation, postoperative complications and the patients' satisfaction with postoperative penile appearance among the three groups.

RESULTS

The operation time was significantly longer (P < 0.05) but the wound healing time remarkably shorter (P < 0.05) in the TNCS and DHCSD groups than in the Shang Ring group. The intraoperative blood loss was markedly less in the TNCS and Shang Ring groups than in the DHCSD group (P < 0.05). No statistically significant difference was observed in the patients' satisfaction with postoperative penile appearance among the three groups (P > 0.05). The VAS scores during and at 1 hour and 7 days after operation and the incidence rate of postoperative complications were significantly higher in the Shang Ring and DHCSD groups than in the TNCS group (P < 0.05).

CONCLUSIONS

The disposable titanium nail circumcision stapler is superior to disposable double-handle circumcision suture device and Shang Ring in the treatment of redundant prepuce and phimosis and deserves clinical promotion and application.?

[Application of preputial endoscopy in the treatment of phimosis]

OBJECTIVE

To explore the application value of preputial endoscopy in the treatment of phimosis.

METHODS

The clinical data were obtained on 58 cases of phimosis with an obvious narrow ring at the prepuce mouth and unable to reveal the glans penis when pushed up, which were treated in hour department from October 2018 to May 2020. The patients underwent preputial endoscopic examination followed by circumcision (group A, n = 30) or simple circumcision (group B, n = 28). A ureteroscope was used for preputial endoscopy, and the foreign matter removed with forceps to prepare for later circumcision. Under surface anesthesia, the ureteroscope was entered into the preputial cavity to observe the intactness and smoothness of the right, left and anterior walls and the frenulum side, as well as possible bleeding, tumor or hypospadias.

RESULTS

Preputial endoscopy was successfully performed in all the 30 cases, which revealed 1 case of adhesive integration of the inner preputial lamina to the glans, 1 case of hypospadias, 2 cases of preputial adhesion and 2 cases of glans hemorrhage. Pathological biopsy confirmed penile cancer in 1 of the 6 cases. Lateral wall hemorrhage was found in 4 cases, preputial stones in 3, which was removed with foreign matter forceps, and preputial infection in 5 cases, which was treated by intrapreputial irrigation and antibiotic anti-inflammation therapy. The preputial endoscopic examinations lasted (6.52 ± 2.03) min. The operation time was significantly shorter in group A than in B (［37.81 ± 4.09］ vs ［48.04 ± 5.48］ min, P < 0.01), and so were the postoperative pain duration (［110.74 ± 22.09］ vs ［121.43 ± 26.80］ min, P < 0.01) and postoperative recovery time (［7.96 ± 1.83］ vs ［12.04 ± 3.28］ d, P < 0.01).

CONCLUSIONS

Preputial endoscopy is a safe and efficient method for the diagnosis and treatment of phimosis, with the advantages of simple operation, short examination time and less intraoperative pain, making essential preparations for subsequent circumcision.

[Single- versus double-suture knot for positioning the cutting plane in circumcision with a stapler]

OBJECTIVE

To observe the clinical effect of single-suture versus that of double-suture knot in positioning the cutting plane in circumcision with a stapler.

METHODS

We randomly assigned 120 patients with redundant prepuce or phimosis into three groups of an equal number to receive traditional circumcision without suture knot (group 1), circumcision with single-suture knot (group 2), and circumcision with double-suture knot (group 3) for positioning of the cutting plane. We recorded and compared the operation time, intraoperative blood loss, the rates of frenulum sewing, non-frenulum sewing, poor frenulum sewing and surgical conversion, intraoperative anxiety of the doctors, postoperative ecchymosis, and satisfaction with the retained ventral and dorsal prepuce and postoperative penile appearance among the three groups.

RESULTS

There were statistically significant differences among the three groups in the surgery time, intraoperative blood loss, the rates of frenulum sewing, non-frenulum sewing, poor frenulum sewing and surgical conversion, intraoperative anxiety of the doctors, and satisfaction with the retained ventral and dorsal prepuce and postoperative penile appearance, (P < 0.05), but not in postoperative ecchymosis (P = 0.849). The rate of satisfaction with the retained dorsal prepuce was remarkably higher in group 3 than in group 2 (P = 0.003), and the intraoperative anxiety rate of the doctors was lower in the former than in the latter group (P = 0.003).

CONCLUSIONS

Both single- and double-suture knots for positioning the cutting plane in circumcision with a stapler can help reduce the operation time, intraoperative blood loss, the rates of frenulum sewing, non-frenulum sewing, poor frenulum sewing and surgical conversion, intraoperative anxiety of the doctors, and satisfaction with the retained ventral and dorsal prepuce and postoperative penile appearance, and double-suture knot positioning has an even higher application value in decreasing the intraoperative anxiety of the doctors and increasing the satisfaction with the retained dorsal prepuce.

Circumferential dissection of deep fascia as ancillary technique in circumcision: is it possible to correct phimosis increasing penis size?

BACKGROUND

Phimosis is the inability to retract the preputium downward over the glans penis. Despite the various techniques of preputial plasty described in literature, the most performed surgical treatment is still the conventional circumcision.

METHODS

In this paper we retrospectively reviewed data of a homogeneous population of 36 consecutive adult patients who underwent phimosis correction by circumcsion with dissection of the Deep Fascia. Patients were followed up by one independent plastic surgeon that measured penis length and circumference in nonerected state preoperatively and at 6 month time postoperatively.

RESULTS

The Wilcoxon Signed Rank Test showed a significant (p < 0.0001) difference between the two groups both in terms of length and circumference.

CONCLUSIONS

In conclusion, the ancillary technique we described leads to an increase of penis size, is safe and easy to perform and does not increase significantly operative time nor complication rate to the conventional procedure.

[Comparison of the disposable circumcision stapler, disposable prepuce ligator and traditional surgical method in circumcision]

OBJECTIVE

To compare the effects and complications of the disposable circumcision stapler, disposable prepuce ligator and traditional surgical method in circumcision.

METHODS

This retrospective study included 327 cases of phimosis or redundant prepuce treated by circumcision with the disposable circumcision stapler (the DCS group, n = 133), disposable prepuce ligator (the DPL group, n = 105) or traditional surgical method (the TS group, n = 89) in our hospital from June 2019 to June 2020. We compared the three surgical methods in terms of operation time, intraoperative blood loss, pain score, satisfaction of the patients with the penile appearance and incidence rates of incision edema, hematoma, infection and dehiscence.

RESULTS

The DCS and DPL groups, compared with the TS group, showed significantly shorter operation time (［9.72 ± 2.17］ and ［10.57 ± 2.31］ vs ［36.13 ± 6.85］ min, P < 0.01), less intraoperative blood loss (［2.07 ± 0.96］ and ［2.53 ± 1.46］ vs ［14.33 ± 4.92］ ml, P < 0.01) and higher appearance satisfaction score (4.07 ± 0.80 and 3.93 ± 0.96 vs 3.13 ± 1.06, P < 0.05). The DCS and TS groups, in comparison with the DPL group, exhibited markedly lower pain score (1.87 ± 0.99 and 2.27 ± 1.16 vs 3.87 ± 1.30, P < 0.01) and the rates of postoperative incision hematoma (3.01% and 2.25% vs 9.52%, P < 0.05), and infection and dehiscence (2.45% and 2.04% vs 8.07%, P < 0.05). The postoperative rate of incision edema was remarkably lower in the DCS than in the DPL and CS groups (10.2% vs 20.2% and 23.5%, P < 0.05).

CONCLUSIONS

Circumcision with the disposable circumcision stapler, with the advantages of simple operation, short operation time, less bleeding, less pain, satisfactory appearance, and lower incidence of complications, deserves clinical application and promotion.

[Abnormally short frenulum induced by circumcision with the disposable circumcision suture device: Causes and improvement of the surgical method]

OBJECTIVE

To investigate the causes of abnormally short frenulum induced by circumcision with disposable circumcision suture device and the improvement of the surgical method.

METHODS

We retrospectively analyzed the clinical data on 320 cases of phimosis or redundant prepuce treated from January 2020 to September 2020, including 160 children (group A) and 160 adults (group B), each further divided into an observation group (n = 80, groups A1 and B1) and a control group (n = 80, groups A2 and B2). The patients in groups A1 and B1 underwent circumcision by suture positioning at the frenulum with the disposable circumcision suture device, and those in groups A2 and B2 received conventional circumcision with the disposable circumcision suture device. We compared the operation time, incidence rate of abnormally short frenulum and Visual Analogue Scale (VAS) score at 6 hours after surgery among the four groups of patients.

RESULTS

Statistically significant differences were observed between groups A1 and A2 in the operation time (12.00 ［11.00, 13.00］ vs 8.50 ［8.50, 9.00］ min, P < 0.05) and the incidence rate of abnormally short frenulum (0 vs 10%, P < 0.05) but not in the VAS score (3.00 ［3.00, 4.00］ vs 3.00 ［3.00, 3.75］, P > 0.05). Statistically significant differences were also found between groups B1 and B2 in the operation time (12.00 ［11.00, 12.00］ vs 6.25 ［6.00, 7.00］ min, P < 0.05) and the incidence rate of abnormally short frenulum (0 vs 7.5%, P < 0.05) but not in the VAS score (2.00 ［2.00, 3.00］ vs 2.00 ［2.00, 3.00］, P > 0.05).

CONCLUSIONS

Abnormally short frenulum induced by circumcision with the disposable circumcision suture device is mainly attributed to ligation and fixation of the prepuce with the fixation band. Circumcision with the disposable circumcision suture device by suture positioning at the frenulum is a safe and effective method worthy of clinical promotion.

A Comparative Study on the Clinical Efficacy of Modified Circumcision and Two Other Types of Circumcision

PURPOSE

To compare the clinical effects of three methods of circumcision: modified circumcision, traditional circumcision, and disposable suturing device circumcision.

MATERIALS AND METHODS

Male patients (n = 241) with redundant prepuce and/or phimosis were included in a clinical trial from January 2019 to March 2020. Patients were divided into 3 groups based on the surgical method: group A, traditional circumcision (n = 79); group B, modified circumcision (n = 80); and group C, disposable suturing device circumcision (n = 82).

RESULTS

The operation times in groups A, B, and C were 25.2 ± 3.3 min, 10.2 ± 2.7 min, and 6.7 ± 1.4 min, respectively. The volumes of intraoperative blood loss in groups A, B, and C were 12.7 ± 2.3 mL, 8.1 ± 3.4 mL, and 2.2 ± 0.8 mL, respectively (P < 0.05). Groups A and B were superior to group C in terms of the 6-h postoperative visual analog scale score and appearance satisfaction (P < 0.05). There were no obvious differences in the 7-day postoperative pain score and total healing time (P > 0.05). The operating expenses in groups A and B were lower than that in group C (P < 0.05).

CONCLUSION

Modified circumcision, with its advantages of shorter operation time, less blood loss and pain, lower cost, and better postoperative penile appearance, is easily accepted by patients and deserves wide clinical application.

Clinical characteristics, classification, and surgical outcome for kittens with phimosis: 8 cases (2009-2017)

OBJECTIVE

To describe clinical characteristics and surgical outcomes for kittens with phimosis and to develop a system to classify phimosis on the basis of gross pathological lesions.

ANIMALS

8 kittens with phimosis.

PROCEDURES

Medical record databases of 2 veterinary teaching hospitals were searched to identify records of cats ≤ 20 weeks old (ie, kittens) with phimosis that underwent surgical intervention between 2009 and 2017. For each kitten, information extracted from the record included signalment, history, clinical signs, physical examination findings, treatments, and details regarding the surgical procedure performed, postoperative complications, and outcome.

RESULTS

The most common clinical signs were stranguria (n = 6), marked preputial swelling (5), and a small (6) or inevident (2) preputial orifice. Six kittens had type 1 phimosis (generalized preputial swelling owing to urine pooling without penile-preputial adhesions) and underwent circumferential preputioplasty. Two kittens had type 2 phimosis (focal preputial swelling and urine pooling in the presence of penile-preputial adhesions) and underwent preputial urethrostomy. No postoperative complications were recorded for kittens that underwent preputial urethrostomy. All 6 kittens that underwent circumferential preputioplasty had some exposure of the tip of the penis immediately after surgery, which typically resolved over time. At the time of last follow-up (mean, 1.4 years after surgery), all 8 patients were able to urinate and had no signs of phimosis recurrence.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that circumferential preputioplasty and preputial urethrostomy could be used to successfully manage kittens with type 1 and type 2 phimosis, respectively.

Treatment of balanitis xerotica obliterans in pediatric patients

OBJECTIVES

Balanitis xerotica obliterans (BXO) is a chronic inflammatory disease with a little known incidence in pediatric population. The objective of this work was to describe our experience in the treatment of BXO.

MATERIALS AND METHODS

Retrospective study carried out in 419 patients undergoing circumcision surgery between January 2014 and January 2017. Demographic, clinical, therapeutic, and anatomical and pathological variables, as well as complications during follow-up, were analyzed.

RESULTS

Of the 419 patients, 41 (9.78%) were diagnosed with BXO. 6 patients were excluded owing to lack of follow-up, so 35 patients were analyzed. Mean age at diagnosis was 8.6 years. Suspicion diagnosis was clinical at physical exploration in 17 patients (48.6%), and at surgery in 18 patients (51.4%). Anatomical and pathological confirmation was performed in a total 35 patients (100%). During follow-up, 6 patients (17.14%) had lesions in the glans, 3 (8.57%) in the urethra, and 9 (25.71%) in both. 6 meatotomies (17.14%) and 5 new circumcisions (14.28%) had to be carried out. Mean recurrence time was 32.43 months. In 19 patients (54.28%), topical corticoids - ointment - were applied, and 1 patient (2.85%) received topical immunosuppressants.

CONCLUSIONS

A close follow-up of patients with clinical or anatomical and pathological diagnosis of BXO is required given its high morbidity. The complications described in pediatric population include meatal and urethral stenosis, as well as recurrent phimosis, unless a sufficient amount of foreskin is resected.

Limited Dorsal Slit Preputialplasty for Management of Phimosis in Children

OBJECTIVE

To evaluate the functional and cosmetic result of limited dorsal slit preputialplasty for surgical management of phimosis in children.

METHODS

This is a prospective cohort study (Jan 2010 to Dec 2019) of 246 children (age >5 y) who were unable to retract the foreskin and were symptomatic.

RESULTS

No intraoperative complications were encountered. Preputial edema was the most common (n=45, 18.2%) immediate postoperative occurrence. At one year follow-up, a total cosmetic score of 6 (considered optimal) was seen in 203 (91%) patients. A score of 5 was observed in 13 (5.9%) and the remaining 7 (3.1%) had a score of less than 4. All pubertal children, except one, could retract prepuce freely without discomfort.

CONCLUSIONS

This preputialplasty provides satisfactory cosmetic and functional result in phimosis, and is an acceptable alternative to circumcision.

Circumcision Rates after the Release of Preputial Adhesions

Aim We aim to determine if the release of preputial adhesions (RPA) successfully managed symptoms related to physiological phimosis and prevented the need for circumcision. Methods We performed a retrospective review and analysed data on RPA procedures performed between January 2005 and December 2017. Results 534 RPA’s were performed. Median age at RPA was 52.7 months (range: 3-197 months). Mean follow-up was 108 months (range: 4.7 to 152.4 months). 44 children and 1 child subsequently required a circumcision or preputioplasty respectively (8.4% incidence). There was no statistical difference in the circumcision rates in children who had RPA over 5 years vs those that had RPA under 5 years old (6.6% vs 9.8%; p = 0.21). The histology of the 44 excised foreskins showed BXO in 2 (4.5%) and chronic inflammation in 11 (25%). Conclusion RPA is an effective alternative to circumcision where either reassurance on the benign and self-limiting nature of physiologic phimosis or steroid treatment are unsuccessful in managing symptoms.

Concealed cysts presenting as 'Club' penis: a case report

BACKGROUND

Penile swellings are not very common. They usually present as an obvious lesion visible and palpable either on the penile shaft, glans, or prepuce. Rarely, benign swellings may be concealed by phimosis and can present as "club" penis.

CASE PRESENTATION

We report the case of a 30-year-old Indian male man who presented with the complaint of difficulty in retracting his foreskin and a club-shaped distal penis. There were palpable lumps on either side of the glans penis which were concealed by the foreskin; hence, a proper preoperative clinical diagnosis was not possible. Circumcision revealed the presence of two discrete cystic swellings from inner prepuce which were excised. Histopathology was suggestive of epidermoid cysts.

CONCLUSIONS

Although epidermoid cysts are common cutaneous swellings, they are rarely seen on the penis. They generally present as a small solitary swelling on the penile surface and occurrence at multiple sites is very rare. Epidermoid cysts arising from inner prepuce, hiding within and presenting as club penis have not been reported. Thus, benign lumps should be considered an etiology for phimosis.

Subcutaneous tissue-sparing dorsal slit with new marking technique: A novel circumcision method

Circumcision is a very common surgical procedure that is performed for medical and traditional purposes in the world. However, many technical of circumcision is needed to improve. Thus, this study introduced a novel method of circumcision that is a refined version of the sleeve technique, termed subcutaneous tissue sparing dorsal slit with new marking, and evaluated the safety and efficacy of this novel method of circumcision.The randomized clinical trial included 93 adult patients with redundant foreskin or phimosis treated from May 2015 to March 2017. Patients were randomly divided into the novel circumcision method (n = 45) or conventional dissection (n = 48). The groups were compared regarding rates of intraoperative hemorrhage, operative time, pain, healing, satisfaction with penis appearance, and relevant adverse events.No patient suffered any obvious complication. Compared with the patients given conventional dissection, the patients who underwent the new surgical device experienced significantly less wound healing time, scar width, and recovery time (P <.05). The new method resulted in greater intraoperative bleeding volume and surgical time (P <.05). The rate of satisfaction with appearance of the penis was significantly higher in the group treated with the novel technique. In addition, the cost of surgery of these 2 methods was similar.Based on the above research, we found that subcutaneous tissue-sparing dorsal slit with new marking technique was an effective and safe procedure for circumcision, and deserved further application in clinical practice.

[Free grafting of internal preputial lamina for penile divided nevus in children]

OBJECTIVE

To evaluate the effect of free grafting of internal preputial lamina in the treatment of penile divided nevus in children.

METHODS

This retrospective study included 5 children with penile divided nevus, 4 complicated by redundant prepuce and the other 1 by concealed penis, all treated by free grafting of internal preputial lamina from October 2015 to November 2017. The patients ranged in age from 6 years and 8 months to 10 years and 4 months, averaging 8 years and 6 months. The surgical procedure involved complete excision of the lesions underneath the foreskin with a safety margin of 2 mm, collection of healthy internal preputial lamina for free grafting onto the defected glans, and simultaneously circumcision or concealed penis correction. The removed tissue of the divided nevus was subjected to pathological examination. The patients were followed up for 4－29 (mean 18) months postoperatively.

RESULTS

All incisions healed primarily and the free grafts of internal preputial lamina survived well, similar to the glans in color and with a desirable appearance. The patients lost no protopathic sensibility of the glans and experienced no recurrence. Pathological examination confirmed 1 case of intradermal nevus and 4 cases of compound nevus.

CONCLUSIONS

Free grafting of internal preputial lamina is an ideal method for the treatment of penile divided nevus in children, with the advantages of easy graft collection, little color difference between the graft and surrounding skin, desirable external appearance, and definite clinical effect.

[Surgical plane positioning with a disposable circumcision suture device for the treatment of phimosis and redundant prepuce]

OBJECTIVE

To investigate the clinical effects of circumcision by surgical plane positioning with a disposable circumcision suture device in the treatment of phimosis and redundant prepuce.

METHODS

From September 2016 to June 2017, we treated 250 patients with phimosis or redundant prepuce, 127 by conventional circumcision (the control group) and the other 123 by surgical plane positioning with a disposable circumcision suture device (the observation group). We compared the operation time, intra-operative bleeding, preputial frenulum alignment, postoperative ecchymosis, and postoperative penile appearance between the two groups of patients.

RESULTS

Compared with the controls, the patients in the observation group showed significantly longer operation time (［4.48 ± 1.18］ vs ［7.17 ± 1.42］ min, P<0.05), lower rates of intra-operative frenulum bleeding (15.0% ［19/127］ vs 4.1% ［5/123］, P<0.05) and frenulum misalignment (26.8% ［34/127］ vs 0.8% ［1/123］, P<0.05), higher incidence of postoperative ecchymosis (41.7% ［53/127］ vs 21.1% ［26/123］, P<0.05), and higher satisfaction of the patients with the postoperative penile appearance (92.9% ［18/127］ vs 98.4% ［121/123］, P<0.05). However, no statistically significant difference was found between the control and observation groups in intra-operative non-frenulum bleeding (4.7% ［6/127］ vs 1.6% ［2/123］, P = 0.164).

CONCLUSIONS

Circumcision by surgical plane positioning with a disposable circumcision suture device can effectively avoid preputial frenulum misalignment, reduce intra-operative bleeding, and improve postoperative penile appearance.

[A novel disposable ring versus the suture device in circumcision]

OBJECTIVE

To investigate the clinical effect of a novel disposable ring versus that of the suture device in circumcision for redundant prepuce and phimosis.

METHODS

We randomly assigned 470 male patients with redundant prepuce or phimosis to receive circumcision with a novel disposable ring (the DR group, n = 235) or the suture device (the SD group, n = 235) and compared the operation time, intraoperative blood loss, pain scores, wound healing time, and postoperative complications and penile appearance between the two groups of patients.

RESULTS

All the operations were completed smoothly. Compared with the SD group, the DR group showed significantly shorter operation time (［7.49 ± 1.84］ vs ［3.83 ± 0.42］ min, P <0. 05), less intraoperative blood loss (［3.34 ± 2.59］ vs ［2.41 ± 1.01］ ml, P <0.05), lower intraoperative pain score (0.57 ± 0.76 vs 0.20 ± 0.47, P <0.05) and 6-hour postoperative pain score (3.42 ± 1.12 vs 0.48 ± 0.94, P <0.05), shorter wound healing time (［12.05 ± 2.80］ vs ［7.79 ± 1.65］ d, P <0.05), lower incidence rates of postoperative glans congestion or edema (36.17% ［85/235］ vs 2.56% ［6/235］, P <0.05), dysuria or strenuous urination (34.04% ［80/235］ vs 2.13% ［5/235］, P <0.05) and bleeding or hematoma (5.11% ［12/235］ vs 1.28% ［3/235］, P <0.05), and higher satisfaction with postoperative penile appearance (90.6% ［213/235］ vs 95.8% ［228/235］, P <0.05). There were no statistically significant differences between the SD and DR groups in the pain scores at the sixth night after operation (1.31 ± 0.96 vs 1.34 ± 1.07, P >0.05) or while the staples scraping the underpants or at the ring removal (3.49 ± 1.22 vs 3.36 ± 1.41, P >0.05). No obvious postoperative infection or delayed healing was observed except for 3 cases of wound dehiscence (1 in the DR and 2 in the SD group) and 8 cases of delayed removal of the staples in the SD group.

CONCLUSIONS

The novel disposable ring, with its advantages of short operation time, less bleeding and pain, good penile appearance, high safety, and simple operation, is obviously superior to the suture device in circumcision and deserves to be applied and popularized clinically. .

Troubles with the Foreskin: One Hundred Consecutive Referrals to Paediatric Surgeons

To assess the reasons for and outcomes of referrals concerning the foreskin, 100 consecutive patients seen in paediatric clinics were followed to discharge. 18 referrals were for circumcision on religious grounds. Of the other 82, the main reason for referral was non-retractability or phimosis. At clinic, 24 (29%) of these were deemed normal for age, 31 (38%) were treated with topical steroid (successfully in 25), 9 (11%) were listed for preputioplasty, 7 (9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4 were listed for other forms of surgery. 6 patients were identified as having balanitis xerotica obliterans (BXO), a condition that had not been suggested on referral. With the advent of new treatments for foreskin disorders, circumcision is decreasingly necessary. Knowledge of the natural history of the foreskin, and the use of topical steroids, could shift the management of paediatric foreskin problems from the hospital outpatient department to primary care. BXO is not sufficiently recognized as a form of phimosis that requires operation.

[A novel disposable circumcision device versus conventional surgery in the treatment of redundant prepuce and phimosis]

OBJECTIVE

To compare the clinical effect of a novel disposable circumcision device Ring with that of conventional circumcision in the treatment of redundant prepuce and phimosis.

METHODS

Totally, 750 patients with redundant prepuce or phimosis underwent Ring circumcision (group A, n = 450) or conventional circumcision (group B, n = 300). We recorded the operation time, intraoperative blood loss, Visual Analogue Scale (VAS) intraoperative pain scores, postoperative complications, wound healing time, and patients' satisfaction with postoperative penile appearance, followed by comparison of the collected data between the two groups of patients.

RESULTS

All the operations were successfully completed. Group A, as compared with B, showed significantly shorter operation time (［3.78 ± 0.42］ vs ［26.24 ± 3.99］ min, P <0.05), less intraoperative blood loss (［2.39 ± 1.01］ vs ［10.80 ± 3.57］ ml, P <0.05), lower pain scores intraoperatively (0.14 ± 0.36 vs 2.30 ± 1.46, P <0.05), 6 hours postoperatively (0.32 ± 0.78 vs 3.03 ± 1.56, P <0.05) and at the ring removal (3.35 ± 1.42 vs 2.78 ± 1.43, P <0.05), shorter wound healing time (［7.61 ± 1.60］ vs ［8.57 ± 1.37］ d, P <0.05), higher satisfaction with postoperative penile appearance (97.8% ［440/450］ vs 86% ［258/300］, P <0.05), and lower incidence of postoperative bleeding or hematoma (0.89% ［4/450］ vs 3% ［9/300］, P <0.05). No statistically significant differences were observed between groups A and B in the nocturnal pain score before the ring removal (1.45±1.02 vs 1.38 ± 0.92, P >0.05) or the postoperative incidence rate of edema (0.89% ［4/450］ vs 2.33% ［7/300］, P >0.05). There were no significant postoperative infections or delayed incision healing except for 1 case of wound dehiscence in each group.

CONCLUSIONS

Ring circumcision, with its advantages of shorter operation time, less blood loss and pain, higher safety, and better postoperative penile appearance, is easily accepted by the patients and deserves wide clinical application.

[Clinical and immunohistochemical correlation of balanitis xerotica obliterans]

AIM

Balanitis xerotica obliterans (BXO) is a disease of the skin and mucosa of male genitals of unknown etiology that may affect children of any age. It has a low incidence (9-19%) and in adults is considered a potential premalignant lesion. The aim of our study is to establish the incidence of BXO in our center and to determine its correlation between the clinical and immunohistochemical (IHC) findings.

METHODS

Prospective cohort including all children < 14 years with foreskin pathology that required a circumcision between 2014-2016. Statistical analysis of the clinical characteristics, histological and IHC findings searching for inflammatory response, premalignant lesions and microbiological findings.

RESULTS

A total of 176 boys with phimosis had circumcision with a mean age of 7 ± 3 years (Range 2-14). Presurgical diagnosis of BXO was suspected in 28.4% (n= 50) whereas the AP confirmed a total of 29.5% (n= 53) with a very good interobserver concordance (kappa= 0.81: p< 0.01). Previous treatment with corticoids in BXO was found in 63.5% (n= 33/52). Meatal stenosis was found in 7.69% (n= 4/52) requiring meatal/urethral dilations. Patients with BXO had a T-Lymphocytes CD3+ mediated inflammatory response with a positive correlation between tumor suppressing protein (p53) expression and chronic inflammation.

CONCLUSIONS

BXO is a chronic inflammatory disease mediated by T-lymphocytes with an incidence greater than previously reported. Surgeons' criterion has a very good concordance with the AP findings. The elevation of p53 in children with BXO may indicate a plausible malignant potential that may require a surgical treatment (circumcision) and an adequate follow-up.

A Comparative Study on the Clinical Efficacy of Two Different Disposable Circumcision Suture Devices in Adult Males

PURPOSE

We evaluated the safety and efficacy of two different kinds of disposable circumcision suture devices in adult men.

MATERIALS AND METHODS

Adult male patients (n = 179; mean age: 23.7 years) with redundant prepuce and/or phimosis were included in a clinical trial from July 2015 to August 2016. Patients were divided into 2 groups: group A using the Langhe disposable circumcision suture device (n = 89), and group B using the Daming disposable circumcision suture device (n = 94).

RESULTS

Intraoperative and postoperative bleeding were more serious in the group A of disposable circumcision suture device compared with the group B of disposable circumcision suture device (4.21 ± 1.31 ml) versus (2.56 ± 1.45 ml). Patients in the group B of disposable circumcision suture device had a longer swelling time (group A versus group B: 11.7 ± 0.9 days versus 14.5 ± 1.4 days), the postoperative pain score in the 7 days after surgery (group A versus group B: 2.9 ± 0.9 versus 3.8 ± 1.5), and higher postoperative infection rate (group A versus group B: 4.7% versus 13.8%), the differences were statistically significant (p < 0.05).

CONCLUSION

postoperative complications of the two kinds of disposable circumcision suture devices are different. We should pay attention to the risk of postoperative bleeding when the patients use the Langhe disposable circumcision suture device, while the patients who use the Langhe disposable circumcision suture device will have a longer healing time, and postoperative pain and the risk of infection cannot be ignored after the surgery.

Use of a disposable circumcision suture device versus conventional circumcision: a systematic review and meta-analysis

This systematic review assessed the safety and efficacy of the disposable circumcision suture device (DCSD) and conventional circumcision (CC) in the treatment of redundant prepuce and phimosis. Two independent reviewers conducted a literature search for randomized controlled trials (RCTs) using the DCSD and CC for the treatment of redundant prepuce or phimosis in China and abroad. Nine RCTs (1898 cases) were included. Compared with the CC group, the DCSD group had a shorter operative time (standardized mean difference [SMD] = -21.44; 95% confidence intervals [95% CIs] [-25.08, -17.79]; P < 0.00001), shorter wound healing time (SMD = -3.66; 95% CI [-5.46, -1.85]; P < 0.0001), less intraoperative blood loss (SMD = -9.64; 95% CI [-11.37, -7.90]; P < 0.00001), better cosmetic penile appearance (odds ratio [OR] =8.77; 95% CI [5.90, 13.02]; P < 0.00001), lower intraoperative pain score, lower 24-h postoperative pain score, lower incidence of infection, less incision edema, and fewer adverse events. There were no differences between the CC and DCSD groups in the incidences of dehiscence, or hematoma. The results of this meta-analysis indicate that the DCSD appears to be safer and more effective than CC. However, additional high-quality RCTs with larger study populations are needed.

[Frenulum identification positioning with a disposable suture device in circumcision to prevent postoperative penile frenulum malposition]

OBJECTIVE

To investigate the effect of the frenulum identification positioning method with a disposable suture device in circumcision for the prevention of postoperative penile frenulum malposition.

METHODS

Totally 212 patients with phimosis or redundant prepuce underwent circumcision from March 2015 to September 2016, including 109 cases of conventional circumcision (the control group) and 103 cases treated by frenulum identification positioning with a disposable suture device (the observation group). We observed the postoperative position of the penile frenulum and median raphe and compared the deviation angles of the frenulum between the two groups of patients.

RESULTS

The median of penile frenulum deviation angle (interquartile range) was 0 (3.56) in the observation group, significantly smaller than 12.41 (19.59) in the control (P <0.001, P = 0.000). And the rate of frenulum deviation was remarkably lower in the former (8.74% ［9/103］) than in the latter group (66.06% ［72/109］) (P <0.01).

CONCLUSIONS

Circumcision using the frenulum identification positioning method with a disposable suture device can effectively avoid postoperative penile frenulum malposition. With the advantages of safety and easy operation, it deserves clinical application and popularization.

[Shang Ring scissor circumcision versus electrotome circumcision for redundant prepuce]

OBJECTIVE

To compare the clinical effects of Shang Ring scissor circumcision (SC) and electrotome circumcision (EC) in the treatment of redundant prepuce or phimosis.Methods: Results: Conclusion.

METHODS

This retrospective study included 524 patients with redundant prepuce or phimosis, 422 treated by SC and 120 by EC. We made comparisons between the two groups of patients in the operation time, intra- and post-operative pain scores, pain scores before, at and after ring removal, wound healing time, and incidence rates of postoperative edema and incision dehiscence.

RESULTS

The operation time was longer in the SC than in the EC group (［59.99±5.39］ vs ［39.94±4.94］ sec, P<0.05), but there were no significant differences between the two groups in the intraoperative pain scores (1.02±0.74 vs 1.08±0.59, P>0.05) or the pain scores within 24 h after operation (6.74±1.01 vs 6.56±1.06, P>0.05), 24 h prior to ring removal (1.14±0.69 vs 1.10±0.64, P>0.05), and after ring removal (2.73±0.74 vs 2.85±0.75, P>0.05) except at ring removal, which was remarkably lower in the SC than in the EC group (3.56±0.47 vs 4.77±0.58, P<0.05). The wound healing time was markedly shorter in the former than in the latter (［14.11±1.26］ vs ［39.78±7.55］ d, P<0.05), but the incidence rate of incision dehiscence showed no significant difference between the two groups (4.03% ［17/422］ vs 9.17% ［11/120］, P>0.05). The rate of postoperative satisfaction with the external penile appearance was 100% in both of the two groups.

CONCLUSIONS

Shang Ring scissor circumcision is preferred to electrotome circumcision for its advantages of less pain at ring removal and shorter healing time despite its longer operation time.

[Shang Ring versus disposable circumcision suture device in the treatment of phimosis or redundant prepuce]

OBJECTIVE

To compare the clinical efficiency of Shang Ring with that of the disposable circumcision suture device (DCSD) in the treatment of phimosis or redundant prepuce.

METHODS

From June 2013 to March 2015, we treated 320 patients with phimosis or redundant prepuce using Shang Ring (n=158) or DCSD (n=162). We compared the operation time, intra-operative blood loss, incision healing time, postoperative complications, postoperative satisfaction, and treatment cost between the two groups of patients.

RESULTS

Comparison between the Shang Ring and DCSD groups showed that the operation time was (5.6±1.3) vs (5.4±1.2) min, intra-operative blood loss (1.2±0.8) vs (1.3±0.9) ml, postoperative delayed hemorrhage 3.16% (5/158) vs 4.32% (7/162), incision healing time (16.1±7.2) vs (7.5±2.3) d, wound infection 15.82% (25/158) vs 7.41% (12/162), 1-month postoperative incision edema 29.11% (46/158) vs 9.26% (15/162), overall postoperative satisfaction rate 63.92% (101/158) vs 90.12% (146/162), and treatment cost (1121.2±15.6) vs (2142.6±10.8) RMB ¥. There were statistically significant differences between the two groups in the latter five parameters (P<0.05 ), but not in the first three (P>0.05 ).

CONCLUSIONS

The DSCD has an obvious superiority over Shang Ring for its relatively lower complication rate, shorter incision healing time, and better cosmetic appearance.

Indications for adult circumcision: a contemporary analysis

INTRODUCTION

Circumcision is the most common surgical procedure performed worldwide. However, there is a dearth of literature regarding medical indications for adult circumcisions. Here, we describe our experience with adult circumcision and contemporary demographics, indications and complications.

MATERIALS AND METHODS

We reviewed all circumcisions performed in our institution between July 2008 and January 2015. Patient demographics, procedure indications and postoperative complications were recorded, and patients were grouped by age as either less than 50 years old or 50 years and older.

RESULTS

A total of 202 charts were reviewed. The most common indications for circumcision were phimosis (46.5%), dyspareunia (17.8%), balanitis (14.4%), and concurrent phimosis and balanitis (8.9%). Older patients were more likely to undergo circumcision for concurrent phimosis and balanitis or cancer, whereas younger patients sought circumcision for dyspareunia. The complication rate was 3.5% and there was no significant difference in complication rates between the two age groups.

CONCLUSION

Circumcision is performed in the adult population for a variety of reasons. Circumcision remains a safe surgical option for patient management with a low complication rate.

[Circumcision versus the foreskin-deglove plus shaft-fix procedure for phimosis or redundant prepuce in obese adult patients]

OBJECTIVE

To compare the clinical effects of circumcision and the foreskin-deglove plus shaft-fix (FDSF) procedure in the treatment of phimosis or redundant prepuce in obese adult males (body mass index [BMI] ≥ 28 kg/m²).

METHODS

Forty-four obese adult men with phimosis or redundant prepuce underwent circumcision (n = 24) or FDSF (n = 20) according to their own wishes. The patients in the circumcision and FDSF groups were aged (26.38 ± 4.24) and (26.90 ± 3.14) years, with BMIs of (27.77 ± 0.77) and (28.07 ± 2.28) kg/m² and penis lengths of (3.51 ± 0.46) and (3.50 ± 0.59) cm, respectively. The operations were performed under local anesthesia with lidocaine plus ropivacaine mesylate.

RESULTS

The operation time of circumcision was (28.04 ± 2.65) min and that of FDSF was (45.45 ± 3.49) min. At 6 months after surgery, normal penile erection was found in all the patients, the penis length was significantly longer in the FDSF than in the circumcision group ([5.01 ± 0.73] vs [3.70 ± 0.47] cm) , and the rate of satisfaction with penile appearance was markedly higher in the former than in the latter group (3.25 ± 0.71 vs 2.83 ± 0.56).

CONCLUSION

The foreskin-deglove plus shaft-fix procedure under local anesthesia with lidocaine and ropivacaine mesylate may achieve desirable penile erection and appearance in the treatment of phimosis or redundant prepuce in obese adult patients.

Phimosis with Preputial Fissures as a Predictor of Undiagnosed Type 2 Diabetes in Adults

Diabetes is usually asymptomatic in its early stage. Early diagnosis may improve outcomes by enabling initiation of treatment before end organ damage has progressed. The aim of this study was to determine whether the clinical sign of phimosis with preputial fissures is predictive of type 2 diabetes in patients not previously diagnosed with diabetes. Twenty-eight patients with acquired phimosis and preputial fissures were collected prospectively. Twenty-eight controls with acquired phimosis without preputial fissures were selected. Statistically significant differences were found in body mass index, random plasma glucose, glucosuria and glycosylated haemoglobin levels, but not in age, family history of diabetes, hypertension and classical hyperglycaemic symptoms. Diabetes was confirmed in all 28 patients in the preputial fissures group, but only 2 (7.1%) patients in the non-preputial fissures group (p < 0.0001). In conclusion, phimosis with preputial fissures may be a specific sign of undiagnosed diabetes mellitus.

[Modified circumcision with a disposable suture device]

OBJECTIVE

To improve the methods and reduce the complications of circumcision with a disposable suture device.

METHODS

This study included 325 male patients aged 14-65 (mean 28.9) years, treated for redundant prepuce or phimosis by modified (n = 201) or conventional circumcision with a disposable suture device (n = 124). We compared the incidence of complications and the patients' satisfaction between the two surgical methods.

RESULTS

Compared with conventional circumcision, the modified method showed a significantly lower incidence of postoperative bleeding (14.52% vs 2.49% , P < 0.05) and a lower rate of second surgery for penile hematoma (4.03% vs 0.50%, P < 0.05). The patients' satisfaction was markedly higher with the modified method (91.94%) than with conventional circumcision (97.51%) (P < 0.05).

CONCLUSION

Modified circumcision with the disposable suture device can significantly reduce the incidence of postoperative bleeding and penile hematoma and therefore deserves wide clinical application.

[Penile necrosis resulting from post-circumcision microwave diathermy: A report of 9 cases]

OBJECTIVE

To investigate the pathogenesis and treatment of penile necrosis resulting from microwave diathermy following circumcision.

METHODS

We retrospectively analyzed the clinical data about 9 cases of penile necrosis resulting from postoperative microwave diathermy following circumcision. The 9 males, aged 20 - 39 (mean 26) years, underwent traditional circumcision for redundant prepuce or phimosis in other hospitals, followed by microwave diathermy for 30 - 60 minutes daily, which resulted in penile necrosis. With no response to conservative therapy, the patients were referred to our hospital at 3 -30 days postoperatively. Of the 9 patients, 5 presented with dry gangrene and 4 with moist gangrene. Six of the patients underwent partial penectomy, including 1 that received penis lengthening.3 months later, while the other 3 underwent total penectomy for total penile necrosis followed by penile reconstruction 3 months later, with deep inferior epigastric perforator (DIEP) flaps and by implantation of the 12th costal cartilage in 2 cases and with epigastric groin island flaps and by urethroplasty in the other.

RESULTS

The patients were followed up for 2 - 8 years, and all could urinate smoothly in the standing position. Of the 6 men treated by partial penectomy, 1 received penis lengthening and achieved a penile length of 7 cm and 5 had the remaining penile length of 3 -5 cm, 4 with erectile function and the other 2 capable of sexual intercourse. The 3 men treated by total penectomy achieved nearly normal external appearance of the penis, with a finalized length of (11.7 ± 1.3) cm, a circumference of (11.4 ± 2.1) cm, and a normal feel of the skin. Of the 3 cases of penile reconstruction, 2 achieved sufficient erectile hardness of the penis (grade 3) for sexual intercourse, while the other 1 remained impotent.

CONCLUSION

Post-circumcision microwave diathermy may result in penile necrosis, for the management of which, early debridement is necessitated and penile lengthening or reconstruction can be performed according to the severity of the lesion and needs of the patient.

[Clinical application of the disposable circumcision suture device in male circumcision]

OBJECTIVE

To investigate the safety and efficiency of the disposable circumcision suture device (DCSD) in the surgical treatment of phimosis and redundant prepuce.

METHODS

We randomly assigned 249 outpatients with phimosis or redundant prepuce to be treated with DCSD (n = 129) and by conventional circumcision (CC, n = 120), respectively. Then we compared the safety and efficiency of the two strategies.

RESULTS

Comparisons between DCSD and CC showed that the operation time was (4.02 +/- 0.69) vs (30.8 +/- 4.05) min, blood loss was (1.07 +/- 1.29) vs (8.72 +/- 2.15) ml, intraoperative pain score was 0.81 +/- 0.81 vs 2.42 +/- 1.15, 24-hour postoperative pain score was 1.84 +/- 1.02 vs 4.99 +/- 1.36, postoperative complication rate was 13. 95% (18/129) vs 9.17% (11/120), wound healing time was (13.99 +/- 9.06) vs (17.48 +/- 3.49) d, satisfaction with the penile appearance was 98.4% (127/129) vs 95% (109/120), and treatment cost was (2215.62 +/- 17.67) vs (576.47 + 15.58) Y RMB. DCSD exhibited obvious superiority over CC for shorter operation time, less blood loss, milder intraoperative pain, sooner wound healing, and better penile appearance, but it also had a higher rate of postoperative complications (P > 0.05) and involved more treatment cost than the latter (P < 0.05).

CONCLUSION

The disposable circumcision suture device affords ideal clinical effects and therefore deserves clinical popularization.

The clinical spectrum of lichen sclerosus in male patients - a retrospective study

Lichen sclerosus (LS) is a chronic dermatosis mainly localised to the anogenital area. The aim of this study was to investigate the clinical features of LS in adult men. A retrospective analysis of records from 771 patients diagnosed with LS was made and a questionnaire was sent to all patients. The results showed that the clinical spectrum was wide. Itch, tenderness and pain were frequently reported and more than half of the patients reported that LS had a negative impact on their sexual health. Phimosis was common and almost 1/3 of the patients were circumcised before or during the study period. Eight cases (1%) of penile squamous cell carcinoma were recorded. This emphasises the need for follow-up of male patients with LS.

[Novel no-flip Shang Ring circumcision for adult males: a clinical application study of 528 cases]

OBJECTIVE

To evaluate the safety and clinical outcomes of the novel simplified no-flip surgical approach to Shang Ring male circumcision in adults.

METHODS

A total of 528 adult males, aged 18 - 58 (mean 35) years, 63 with phimosis and 465 with redundant prepuce, underwent no-flip Shang Ring circumcision with or without removal of the outer ring. The operation time and intraoperative blood loss were recorded and observations were made on such complications as postoperative bleeding, infection, edema, and wound dehiscence.

RESULTS

The operation time, intraoperative blood loss, and 2-hour postoperative pain score were (3.8 +/- 0.3) min, (0.6 +/- 0.1) ml, and 7.3 +/-0.3, respectively. Spontaneous ring detachment occurred at 21.6 +/- 2.1 days postoperatively in 12.7% of the patients (67/528) who had chosen not to remove the rings. Of those who preferred removal of the outer ring (87.3% [461/528]), none experienced any pain at the ring removal 7 days after the operation. Postoperative complications included infection in 3 cases (0.56%) and mild edema in 9 (1.70%), but no bleeding and wound dehiscence. Totally, 518 (98.1%) of the patients felt satisfied with the postoperative penile appearance.

CONCLUSION

No-flip Shang Ring circumcision, with no need for removal of the inner ring, is a safe and simple approach for adult males, which is superior to conventional Shang Ring circumcision for requirement of fewer surgical instruments, shorter operation time, lower incidence of complications, and better satisfaction with the penile appearance. However, these advantages are to be further demonstrated by more randomized controlled trials.

[Outward versus inward placement in Shang Ring circumcision for phimosis and redundant prepuce in adult men: analysis of 527 cases]

OBJECTIVE

To observe the clinical effects of two different circumcision procedures with the Shang Ring and compare their advantages and disadvantages.

METHODS

A total of 527 adult males with phimosis or redundant prepuce underwent Shang Ring circumcision by conventional outward replacement (n = 254) and inward placement (n = 273), respectively. We observed the in-ring nocturnal pain, complications, ring-removal pain, degree of edema, recovery time, and patients' satisfaction after surgery, and compared them between the two groups.

RESULTS

Compared with the conventional outward placement (5.9%) of the Shang Ring, the inward placement method showed the advantages of mild in-ring nocturnal pain, a low complication rate, significantly reduced ring-removal pain, and mild edema, but exhibited longer healing time.

CONCLUSION

In Shang Ring circumcision for phimosis and redundant prepuce in adult males, each of the outward and inward placement methods has advantages and disadvantages of its own, but the latter is more advantageous and feasible.

[Shang Ring circumcision by transverse incision in the distal penis foreskin and pull-up of the interior board for short frenulum praeputii]

OBJECTIVE

To investigate the effectiveness of surgical strategies for Shang Ring circumcision in the treatment of short frenulum praeputii in patients with redundant prepuce or phimosis.

METHODS

Totally, 130 cases of short frenulum praeputii with redundant prepuce or phimosis were randomly assigned to an experimental group and a control group of equal number to receive Shang Ring circumcision, the former by transverse incision in the distal penis foreskin and pull-up of the interior board, and the latter by conventional transverse incision and longitudinal suture of the frenulum praeputii. Comparisons were made between the two groups in the surgical duration, intraoperative blood loss, 24 h postoperative pain visual analog score (VAS), postoperative complications, satisfaction with the penile appearance, and the quality of sexual life.

RESULTS

The surgical duration, intraoperative blood loss, 24 h postoperative VAS, postoperative sexual satisfaction, and satisfaction with penile appearance were (4.60 +/- 1.20) min, (2.61 +/- 1.81) ml, 1.73 +/- 0.76, 98.5%, and 98.5%, respectively, in the experimental group, as compared with (21.60 +/- 6.30) min, (11.10 +/- 3.40) ml, 5.37 +/- 1.84, 70.3% and 69.8% in the control, with statistically significant differences between the two groups (P < 0.05). The incidence rates of such major complications as wound dehiscence, infection, and moderate to severe edema were 1.5% (1/65), 3.1% (2/65), and 4.6% (3/65), respectively, in the experimental group in comparison with 12.3% (8/65), 15.3% (10/65), and 30.7% (20/65) in the control, with statistically significant differences between the two groups (P < 0.05). None of patients had any serious complications.

CONCLUSION

Shang Ring circumcision by transverse incision in the distal penis foreskin and pull-up of the interior board, with its advantages of shorter operation time, less blood loss, mild pain, fewer complications, and higher satisfaction and acceptance of the patients, can be used as an safe and effective approach to the treatment of short frenulum praeputii.

[Circumcision with no-flip Shang Ring technique for adult males: analysis of 168 cases]

OBJECTIVE

To observe the clinical effects of the no-flip procedure with the Chinese Shang Ring when circumcising adult males with redundant prepuce or phimosis, and to discuss its advantages and disadvantages.

METHODS

Using the no-flip Shang Ring technique, we performed circumcision for 167 adult males aged 18 -72 (mean 27.8) years with redundant prepuce or phimosis, and analyzed the clinical data, including the operation time, postoperative complications, ring-removal time, and postoperative appearance of the penis.

RESULTS

Complete follow-up data of 94 cases (56.29%) were obtained. The mean operation time was (5.03 +/- 0.71) minutes and the average ring-removal time was (18.83 +/- 6.70) days. The primary postoperative complications were edema (35 cases [37.23%] at 2 weeks and 9 cases [9.57%] at 4 weeks), including 2 severe cases (2.13%), and infection (3 cases [3.19%]). The pain scores were 2.01 +/- 2.46 during the procedure and 4.52 +/- 2.53 at 24 hours postoperatively. Slipping of the outer ring occurred in 1 case, and delayed removal of the ring in 30 cases (31.91%).

CONCLUSION

Adult male circumcision with the no-flip Shang Ring technique is recommended for its short operation time, simple procedure, fewer postoperative complications, less pain, and better incision appearance.