Re: Cultural background, non-therapeutic circumcision and the risk of meatal stenosis and other urethral stricture disease: Two nationwide register-based cohort studies in Denmark 1977-2013

Infant Circumcision for Sexually Transmitted Infection Risk Reduction Globally

Population-based studies in high-income countries have failed to find that male circumcision protects against sexually transmitted infections. Using evidence from several sources, we show that male circumcision does protect against HIV during insertive intercourse for men who have sex with men.

Wedge urethral meatotomy in meatal stenosis secondary to web formation

INTRODUCTION

Meatal stenosis is a common acquired urological problem facing pediatric surgeons and urologists. It can affect both the circumcised and non-circumcised boys with a higher incidence in the non-circumcised boys because of the increased risk of penile inflammatory conditions, most commonly lichen sclerosis and urinary tract infection, and in the most recent meta-analysis study, the incidence of meatal stenosis following circumcision is only 0.65%. Urethral meatal web is a common cause of meatal stenosis after circumcision (Fig. 1). Symptoms of meatal stenosis are not evident in non-toilet trained infants. However, in older boys, an abnormal upward direction of urine stream while urinating with a long narrow stream, dysuria, burning at the meatus, blood spot at the meatus, frequency, prolonged urination and recurrent urinary tract infection are the common presenting symptoms. Surgical correction of meatal stenosis is done by either meatotomy or meatoplasty.

OBJECTIVE

We describe a novel modification in the classical urethral meatotomy technique, which is wedge urethral meatotomy, and assess the outcome of this procedure in managing meatal stenosis secondary to a meatal web.

PATIENTS AND METHOD

A prospective study was conducted on 60 cases of symptomatic meatal stenosis due to a thin ventral web treated in the pediatric surgical centre in Mosul city from October 2018 until April 2021.

EXCLUSION CRITERIA

Patients with meatal stenosis not accompanied by web, patients with a thick ventral web (requiring suturing technique), and those with hypospadias or other associated urinary disorders (like VUR) were excluded from the study.

SURGICAL TECHNIQUE

In all cases, the procedure was performed under general anaesthesia and by a single surgeon (the author). A wedge (V-shaped) 2-3 mm long excision of the thin ventral meatal web made after applying a hemostat in three directions (ventral midline and two lateral crushes) (Figs. 2 and 3). The procedure did not require suturing or Foley catheterization. The operative time was ranged from 4 to 6 min (mean 5 min). Postoperatively, The parents were instructed to separate both edges of the meatus three times daily for ten days, together with applying Fucidin cream locally with oral cefixime and paracetamol.

RESULTS

The age of the 60 patients ranged between 6 months and 10 years old (median age 38 months) (Fig. 4). Two (3%) patients developed mild meatal stricture, which did not require further intervention as their urine stream remained straight with accepted calibre. The remaining 58 (97%) cases did well postoperatively apart from temporary dysuria in 23 (38%) patients, evident in the first 2-3 days postoperatively. They had a single straight urinary stream while urinating with a good calibre meatus (Figs. 2(D), 3(D) and 5), and during short term follow up, there is a substantial reduction in the frequency of urinary tract infections.

DISCUSSION

Although two (3%) cases developed mild postoperative meatal stricture, none of them required redo surgery compared with a study done by Godley SP in 2015, which showed a reoperation rate after formal meatotomy of 2%. Cartwright in 1996 had a 2% reoperation rate after office meatotomy. Another study in 2018 also reported a reoperation rate of 2.2%. The reason for restenosis that necessitates revision surgery in the above studies may be refusion of the cut edge of the web after meatotomy, which was not a concern in wedge urethral meatotomy in which the web excised and not incised. In 2017, Özen MA applied the same procedure on 13 boys complaining from meatal web after circumcision. The technique involved excision of the web, and two stitches were inserted at 5 and 7 o'clock using 7/0 Polydiaxonone suture with excellent final results. In our study, suturing was not applied, so spraying or divided urinary stream (although temporary) was not observed in the postoperative period as seen in meatoplasty or in cases of meatotomy that require suturing technique. This point was satisfactory for patients and parents.

CONCLUSION

Wedge urethral meatotomy represents a novel modification in the formal meatotomy technique, which can be applied in meatal stenosis secondary to a thin ventral web with satisfactory results, as reoperation after this procedure was not recorded.

Is there a correlation between meatal stenosis severity, lower urinary tract symptoms and uroflowmetry?

INTRODUCTION

We have recently validated a meatal Stenosis (MS) severity grading system that is based on physical examination.

OBJECTIVES

The study objective was to examine the correlation between this grading system, patients' urinary symptoms, uroflowmetry and postvoid residual parameters.

STUDY DESIGN

Patients referred for our clinic for urinary and non-urinary complaints, were prospectively enrolled. Urinary symptoms questionnaire, uroflowmetry parameters and post-voiding residuals (PVR) were assessed, and photographs of the urethral meatus were taken for each patient. The photographs were graded blindly according to the previously validated grading system and correlated with urinary symptoms, uroflowmetry parameters and PVR.

RESULTS

Overall, 75 patients were assessed (20 grade 0, 23 grade 1 and 32 grade 2). When using grade 0 as a reference, the odds ratio (OR) for reporting narrow stream was 6.4 (95%CI 1.65-24.77) and 4 (95%CI 1.18-14.16) for grade 1 and 2 respectively. OR for prolonged urination was 6 (95% CI 1.47-24.89) for Grade 1 and 2; OR for upward stream deviation was10.08 (95%CI -2.43-41.82) for grade 1 and 15.12 (95%CI - 3.74-61.17) for grade 2. Uroflowmetry results showed lower Qmax from 16.8(SD ± 8.0) ml/sec in grade 0-9.6 ml/s on grade 1 and 2 (p < 0.001) (Figure 1). PVR was not statistically different in the three groups.

DISCUSSION

Our main findings were that meatal stenosis severity grade is associated with narrow stream as reported by parent, prolonged urination, and upward deviation of urinary stream, with increasing severity with worsening stenosis. MS grade was also associated with significant worsening of uroflow measures: a lower Qmax, Qmean and a longer time-to-Qmax. Post-void residual volume was not significantly different between the different severity grades. This study showed the clinical significance of the grading system. With subjective and objective measures. The implementation of this grading system in clinics, may aid in decision making regarding surgical intervention in the appropriate patients, and avoid unnecessary procedures.

CONCLUSION

The Severity of MS seen on physical examination correlates well with obstructive symptoms and decrease of urine stream seen on uroflowmetry. These findings confirm the importance of the grading system in the evaluation of patients with MS and may be additional measure that assist in consulting parents on the indications to meatotomy.

Nomogram of paediatric male urethral size: A systematic review

INTRODUCTION

Knowledge of the normal size of the urethral meatus in boys is important for safely performing urethral catheterization and fundamental to the diagnosis and treatment of paediatric urological conditions. However, clinicians often rely subjectively on previous experience and clinical judgement, rather than a robust evidence-base. A systematic review of the literature was undertaken to define the calibre of the male urethral meatus in paediatric age-groups.

METHODS

The MEDLINE and EMBASE databases were systematically searched from inception to December 2020 for studies measuring meatal calibre in boys up to 16 years of age. Google Scholar searches along with forward and backward citation tracking identified additional studies. Studies of subjects >16 years, females, or patients with urethral diseases were excluded.

RESULTS

Nine articles (2084 paediatric subjects) were included in the final review. Mean meatal calibre increases non-linearly with age, with accelerated growth occurring during infancy (mini-puberty) and adolescence (puberty). Meatal calibre can be approximately grouped by age as follows: neonate (6-10Fr); infant (10-12Fr); child (12-14Fr); and adolescent (14-18Fr). There is substantial individual variability for same-aged children. Meatal calibre has been independently related to height, weight, and penile size, but the effects of ethnicity and circumcision remain unclear.

CONCLUSIONS

The evidence-base for this fundamental aspect of paediatric urology includes only a few low-quality studies and is largely derived from one early study of circumcised American boys. Further studies are warranted to establish normative urethral size values based on rigorous, contemporary data with known dependent variables also included.

Formulation and validation of meatal stenosis grading system

INTRODUCTION

Meatal stenosis (MS) is a common finding in circumcised children. Indication for surgical correction is based on urinary symptoms such as strength and direction of urine stream as well as physical examination, including direction and caliber of the urinary stream. There is no objective grading of MS severity, and therefore indications for surgery and management protocols are vague.

OBJECTIVE

We aimed to formulate a standardized, validated, and reliable grading system for MS severity based on the physical examination finding.

STUDY DESIGN

Photographs of the urethral meatus were taken in patients scheduled for meatotomy due to MS, whereas patients without this condition served as control. The photographs were rated by three experienced fellowship trained pediatric urologists. The study was conducted in two phases: 1) development of a grading system by the expert panel and 2) testing of the proposed grading system for inter- and intra-rater reliability. To estimate the correlation between different rates, the intra-class correlation coefficient (ICC) was calculated.

RESULTS

Three grades were generated: Grade 0 (wide open meatus, visible mucosa), Grade 1 (minimal mucosa/fibrotic tissue visible), and Grade 2 (pinpoint meatus/no mucosa visible/large fibrotic layer). A panel of 51 raters (pediatric urologist, community urologist, pediatricians) participated in the survey evaluating the representative photos from 86 patients. Inter-rater reliability was high ICC = 0.99 (95% confidence interval [CI] of 0.983-0.996, P < 0.0001) Cronbach's alpha = 0.992. In total, 18 raters participated in the same survey two weeks later for intra-rater reliability. An identical grading was obtained in 83.3% of photographs (kappa = 0.455 [P < 0.05]).

CONCLUSION

We propose a grading system that is a valid, reliable, and reproducible method to classify the severity of MS on physical exam. This grading system could improve the healthcare provider's and parent's communication and can be a building block for further research in this field. A further research should assess the correlation with clinical signs and symptoms.

Critical evaluation of arguments opposing male circumcision: A systematic review

OBJECTIVE

To systematically evaluate evidence against male circumcision (MC).

METHODS

We searched PubMed, Google Scholar, EMBASE and Cochrane databases.

RESULTS

Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems.

CONCLUSIONS

Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.