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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[A case of urinary retention caused by true phimosis]

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

[Analysis of treatment results of boys referred to outpatient paediatric surgery centre with recognition of phimosis]

The problem with prepuce retraction is caused not only by its narrowing, called phimosis, but also frequently by the inner prepuce adhesion to glans. The spontaneous prepuce retraction is received in 80% cases of boys up to the age of two, whereas in remaining cases, after the age of two it is necessary to take up the medical treatment. The purpose of the research was to estimate the effectiveness of conservative therapy using steroid ointments which was undertaken in boys referred to Outpatient Paediatric Surgery Centre with recognition of phimosis.

MATERIAL AND METHODS

Cases of 315 boys referred to Outpatient Paediatric Surgery Centre due to phimosis were analyzed between April 2004 and May 2007. At the first appointment the boys were divided into 3 main groups: I--children with foreskin adhesion without visible stenosis (near 20%), who had the prepuce adhesion released in a local anaesthetic with Emla cream; II--children with narrowed foreskin (phimosis) who were treated with the use of conservative therapy by means of topical steroids (about 70%); III--children with stenosed prepuce (phimosis) developed to a large extent, who were immediately qualified to a surgery therapy without trying the conservative therapy (near 10%).

RESULTS

Among all patients about 1/5 needed the prepuce adhesion releasing with the use of Emla ointment only. High efficiency of conservative treatment with topical steroids was revealed both in primary and acquired phimosis. Reduction of the therapy time of children treated with topical steroids because of primary phimosis in relation to those treated surgically was taken into account.

CONCLUSION

Conservative treatment of phimosis is highly effective and safe method which may also be an initial stage to operative treatment or to cure scarring after surgical treatment as well.

Penile oleogranuloma among Wisconsin Hmong

Injection of viscous or semisolid materials into the penile shaft to increase its size, to correct erectile dysfunction, and/or to satisfy a sexual partner has only been sporadically reported in Eastern and Western European and American men. However, this practice appears to be more widespread in the countries of Southeast Asia. We present 3 cases of Hmong patients seen in a urology clinic in Wausau, Wis. We describe the presentation, correction, and difficulties experienced in convincing patients to undergo adequate treatment.

Frenular Grafting: An Alternative to Circumcision in Men with a Combination of Tight Frenulum and Phimosis

INTRODUCTION

Men suffering from frenular scarring and stricturing with associated phimosis are traditionally treated with circumcision. In men wishing to retain their foreskin, the treatment options are limited by this dual pathology. Frenuloplasty alone is contraindicated in this clinical setting.

AIM

To demonstrate the utility of frenular grafting in patients with a tight frenulum and concomitant phimosis who wish to retain their foreskin.

METHODS

Six men were included in the study. Presenting symptoms included bleeding (N = 2) and pain/phimosis (N = 6). Median age is 27 years (25-34 years). All men were healthy and sexually active. We describe a refined technique involving the excision of scarred and redundant frenular tissue and the insertion of a skin graft to the area.

MAIN OUTCOME MEASURES

All patients were assessed for graft viability, functional/symptom improvement, time to penetrative intercourse, and overall satisfaction.

RESULTS

All men received an interposition skin graft with 100% viability, with no revision surgery required. Postoperatively, all men were sexually active and able to retract their foreskin.

CONCLUSIONS

Cosmetic outcomes are encouraging and painless sexual intercourse is attainable in this difficult group of patients.

[Scalpel circumcision by inserting a piece of gauze between the inner prepuce and superficial fascia]

OBJECTIVE

To introduce the advantages of the circumcision with a scalpel by inserting a piece of gauze between the inner prepuce and superficial fascia.

METHODS

From November 2000 to March 2006, 2 100 patients with redundant prepuce, aged 6-78 years, averaging 23, were circumcised with a scalpel by inserting a piece of gauze between the inner prepuce and superficial fascia. Of all the cases, 1 799 (85.7%) were classified as Type I, 237 (11.3%) as Type II and 64 (3.0%) as Type III redundant prepuce. The mean operation time was 20 minutes (15-35 min).

RESULTS

The incisions were all healed in one stage, with good appearance, no infection and no disruption. Bleeding occurred in 12 cases 648 hours after the operation and delayed bleeding in 3 cases.

CONCLUSION

The circumcision with a scalpel by inserting a piece of gauze between the inner prepuce and superficial fascia, with easier performance, fewer complications and less bleeding, and capable of preserving more and continuous superficial fascia and giving a better appearance, well deserves to be popularized in clinical practice.

[Penile squamous carcinoma in circumcised patients: a report 17 cases]

OBJECTIVE

To discuss the diagnosis and treatment of penile carcinoma in circumcised men.

METHODS

We reviewed 17 cases of penile carcinoma detected 1 month to 16 years after circumcision performed in our hospital from January, 1997 to December, 2004.

RESULTS

Of the total number, 11 cases were diagnosed as penile carcinoma 1 - 12 months and the others 3 - 16 years after the circumcision. Sixteen of them were treated by partial penectomy, anti 1 first by extensive circumcision and later by partial and total penectomy successively after recurrence. Cloquet nodes biopsy showed 16 cases to be pathologically well-differentiated and I case moderately differentiated penile squamous carcinoma. One died of extensive metastasis, but the other 16 remained disease-free survivals.

CONCLUSION

Circumcised adult men, especially those over 40 years of age, are likely to develop penile carcinoma. Patients with inflammation, plaque or ulcer in the prepuce should be checked by pathological biopsy and followed up closely. For Stage-I penile squamous carcinoma, partial penectomy is shown to be an effective therapeutic option, and Cloquet's nodes biopsy is necessary for all patients.

Ectopic modified sebaceous glands in human penis

The balanopreputial sulcus is believed to be the most frequent site of the so-called Tyson's glands. The intriguing feature of these anatomical structures is their mere existence, which has been doubted. Herein, the authors present a case of a 24-year-old man who underwent surgical treatment of his phimosis. On microscopic examination of the specimen, glands with morphological features similar to those described by Tyson were noted.

[Sleeve circumcision and preputioplasty with modified incision]

OBJECTIVE

To evaluate the sleeve circumcision and preputioplasty with modified incision for the treatment of patients with phimosis or redundant prepuce.

METHODS

Five hundred and seventy-six patients with phimosis or redundant prepuce underwent operations of sleeve circumcision or preputioplasty with modified incision. The conventional incision was modified and changed into two opposite tortuous incisions.

RESULTS

The operation with modified incision had the following advantages: less blood loss, slight postoperative edema, no secondary bleeding or infection, quick recovery and good appearance of the penis.

CONCLUSION

The sleeve circumcision and preputioplasty with modified incision is an excellent therapeutic option for phimosis and redundant prepuce.

Trends in paediatric circumcision and its complications in England between 1997 and 2003

BACKGROUND

It has been suggested that too many English boys undergo circumcision. This report describes how circumcision rates have changed in England between 1997 and 2003, including data on complication rates and on how age, medical indication and surgical specialty affect postoperative haemorrhage rates.

METHODS

Data were extracted from the Hospital Episode Statistics database of admissions to National Health Service hospitals in England. Patients were included in the study if an Office of Population Censuses and Surveys version 4 code for circumcision was present in any of the operative procedure fields of the database; 75 868 boys below 15 years of age were included in the study.

RESULTS

Circumcision rates declined by about 20 per cent, from 2.6 per 1000 boys per year in 1997 to 2.1 in 2003. Between 2000 and 2003, circumcision rates remained static at 2.1 per 1000 boys per year. Circumcision rates fell by 31.2 per cent for boys aged 0-4 years, 9.3 per cent for boys aged 5-9 years and increased by 7.7 per cent in boys aged 10-14 years; 90.2 per cent of circumcisions were done for phimosis and 1.2 per cent of boys experienced a complication.

CONCLUSION

Circumcision rates in England continued to fall up until 2000, particularly in those aged under 5 years, in whom pathological phimosis is rare. The circumcision rate remains five times higher than the reported incidence of Phimosis.

[Preputioplasty in the treatment of phimosis in pediatric age. Indications and results]

AIM

Phimosis is a common condition in the pediatric age. Circumcision has been the technique of choice for the surgical correction of this condition. As an alternative to circumcision different techniques of preputioplasty have been described in the last years. The aim of this paper was to report our experience with the preputioplasty technique in the treatment of phimosis in pediatric age.

METHODS

A preputioplasty is performed for phimosis correction in 109 patients aged between 4 and 16 years. Patients with a sclerotic phimosis were not treated with preputioplasty. All the patients underwent frenulotomy with dorsal preputial plasty using a single dorsal incision. Only in 3 patients a double lateral incision was necessary. Patients were operated under general anesthesia with an average time of 8 min.

RESULTS

Patients were followed-up at 8 days, 30 and 90 days postoperatively. The cosmetic result has been excellent in 90% of cases and good in 10%. The functional result has been excellent in all the patients. We observed 3 cases of infection and 8 cases of edema of the prepuce. These postoperative complications were all resolved with medical therapy. No recurrences have been observed.

CONCLUSIONS

Preputioplasty is a safe and rapid technique that allows to obtain excellent cosmetic and functional results. In our opinion, preputioplasty should be the first choice technique for the treatment of phimosis in pediatric and adolescent age.

[Treatment of phimosis without circumcision and reconstruction of the prepuce following circumcision]

Phimosis of the prepuce can be treated without performing a circumcision. The most common and most effective treatment option is the local application ofcorticosteroid ointment. Should this be insufficiently effective, then the constricted ring can be interrupted with two Z-plasties, which is sufficient to expose the glans penis painlessly. No skin is removed. The intervention may be performed under regional anaesthesia on an outpatient basis. In cases where reconstruction of the prepuce is indicated, this can be accomplished with a distally inverted flap of penile shaft skin combined with the application of free skin grafts.

Décalottage ou circoncision : quelle indication dans le phimosis ?

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.

High incidence of balanitis xerotica obliterans in boys with phimosis: prospective 10-year study

This prospective study was designed to address the incidence and clinical and histologic characteristics of balanitis xerotica obliterans in a large random pediatric population with phimosis. We investigated 1178 boys who presented consecutively with phimosis between 1991 and 2001. All patients who underwent complete circumcision and surgical specimens were typed histologically as early, intermediate, or late forms of this disorder or as nonspecific chronic inflammation. Patients with balanitis xerotica obliterans were controlled at 1, 6, and 12 months postoperatively, then yearly. Balanitis xerotica obliterans was found in 471 of the 1178 patients (40%), with the highest incidence in boys aged 9 to 11 years (76%). Secondary phimosis occurred in 93% of boys with balanitis xerotica obliterans and in 32% of those without the disorder. In six instances of balanitis xerotica obliterans, meatotomy and in one meatoplasty was performed, as well as circumcision. On histologic evaluation, we found 19% had early, 60% intermediate, and 21% late form of balanitis xerotica obliterans. Glanular lesions disappeared completely within 6 months in 229 out of 231 patients. Our data strongly suggest that the true incidence of childhood balanitis xerotica obliterans is higher than previously assumed. Its incidence peaks in the 9 to 11 years age group, in whom secondary phimosis was almost exclusively caused by balanitis xerotica obliterans.

Congenital phimosis in a cat

An 8-week-old domestic shorthair cat was presented with a history of pollakiuria and polydipsia. No abnormalities were detected during the clinical examination other than the penis could not be extruded from the prepuce. Urine culture demonstrated a growth of E. coli, which was treated with a prolonged course of amoxycillin. The polydipsia resolved and the pollakiuria improved but did not completely abate after antibiotic treatment and the cat had occasional bouts of haematuria. Because of the history of pollakiuria and polydipsia and the ongoing, occasional bouts of haematuria, the cat underwent surgical correction of the congenital phimosis. A small wedge of the dorsal prepuce was removed and the ipsilateral edges of the prepuce were apposed using a simple interrupted pattern. The procedure was quick, easy to perform and led to a resolution of the occasional bouts of haematuria and pollakiuria.

A new technique for correction of disproportionate preputial growth with phimosis

A new surgical solution to correct the rare anomaly of asymmetric phimosis is described, with a note on its symptomatology and etiopathogenesis.

Male neonatal circumcision: indications, controversies and complications

The debate about whether to circumcise infants in the neonatal period likely will continue. As the medical and ethical issues are discussed and studied, however, economic factors are beginning to limit the practice in the United States. As the shift in reimbursement occurs, parents who believe that circumcision is a medically necessary practice will need to be reassured that their child may lead a healthy life with an intact foreskin.

Ballooning of the foreskin and physiological phimosis: is there any objective evidence of obstructed voiding?

OBJECTIVES To determine whether physiological phimosis with or without ballooning of the prepuce is associated with noninvasive urodynamic or radiological evidence of bladder outlet obstruction. PATIENTS AND METHODS From August 2001 to October 2002 all boys with a foreskin problem and referred to one paediatric surgeon were assessed in special clinics. Those with physiological phimosis were recruited for the study and had upper tract and bladder ultrasonography (US), followed by uroflowmetry and US-determined postvoid residual urine volumes (PVR). Data were compared between boys with and with no ballooning of the prepuce. The project was approved by the local research ethics committee and informed consent was obtained from all study participants. RESULTS In all, 54 patients were referred for circumcision; 32 boys with physiological phimosis completed the uroflow and US investigations. Ballooning of the foreskin was present in 18 boys (mean age 6.8 years, range 3-12); 14 had physiological phimosis with no ballooning (mean age 6.5 years, range 4-11). Upper tract US and bladder wall thickness were normal in all boys. The mean maximum urinary flow rate (Q(max)) was not significantly different in boys with ballooning and those without (mean 15.3 mL/s, sd 4.4, range 9-24, vs 15.4, sd 2.9, range 10.7-20, P = 0.96). In addition, all Q(max) values were within the normal range when correlated with voided volume and compared with age-related nomograms. Most boys had flow rate patterns showing a normal bell-shaped curve; a few (9%) had subtle changes in the flow-rate profile, with either a plateau-type curve or slow initial increase in flow and prolonged time to achieve Q(max). The two groups had comparable mean PVRs (3.5 mL, sd 5.1, range 0-18 with ballooning vs 6.1, sd 10.7, range 0-38 without, P = 0.37). Only one patient had a marginally abnormal PVR. CONCLUSIONS Physiological phimosis with or without ballooning of the prepuce is not associated with noninvasive objective measures of obstructed voiding. Minor abnormalities in the flow-rate pattern in this patient group deserve further study.