Pigmentary complications after non-medical male circumcision.

BACKGROUND: A wide spectrum of complications are reported after male circumcision (MC), the non-aesthetic complications are well known, but the pigmentary complications scale are not reported precisely. METHODS: This is a prospective cohort study of 550 circumcised boys; aged from 6 months to 14 years (62% aged 5 years) who were examined and appropriately investigated for the incidence of pigmentary complications after circumcision. Most diagnoses were clinically, but dermoscopy was done for 17 case and a skin biopsy for 14 cases. Patients with personal or family history of vitiligo, or congenital nevi were excluded. Available hospital records details and parents' statements were revised. The main outcome measures are the incidence of different pigmentary complications and circumcision details; data were analyzed by a non-parametric tests including the Mann-Whitney U test. RESULTS: 69 cases had 72 confirmed pigmentary complications discovered at 2-36 months after commencement of circumcision (mean 18). 48 cases had pigmentary complications directly related to MC, 11 cases were probably related and 10 unrelated to MC. The most common lesion is the circular hyperpigmented scar (29 cases); liner hyperpigmented scar in 13, spotted exogenous melanosis in 18 cases, melanocytic nevi (7), hypopigmentation diagnosed in 3 cases, but kissing nevus is the rarest finding (2). Topical corticosteroid was tried in 15 cases, surgical excision of pigmented scar were done for 19 cases, local laser used for 4 resistant cases and reassurance with follow up for the rest. CONCLUSION: Pigmentary complications after male circumcision are not rare and its management is challenging.

Penile Median Raphe Anomalies as an Indicator of Megameatus Intact Prepuce Anomaly in Children Undergoing Routine Circumcision.

OBJECTIVE: To arouse the suspicious for early diagnosis and hence, proper management of megameatus with an intact prepuce (MIP), as there is no external clue for detection of such cases, which usually come to light for the first time in a boy who is about to retract his prepuce or during neonatal circumcision. MATERIALS AND METHODS: Examination of neonates and infants coming to circumcision clinic to detect congenital genitourinary anomalies. Evaluation of 12,518 neonates and infants coming for ritual circumcision from 2006-2017, who were examined thoroughly to detect any incidental congenital genitourinary anomalies. Fifteen of them were diagnosed to have a MIP anomaly. They were investigated to perceive any associated median raphe (MR) anomalies. Sensitivity, positive predictive value, specificity, and negative predictive value of MR anomalies in cases of MIP were estimated and compared with other children who had a normally positioned meatus. RESULTS: Overall incidence of MIP in this group of babies was 0.12%. Twelve of 15 cases (80%) with MIP had 19 forms of MR anomalies; mainly raphe deviation in 6 cases, hyperpigmented raphe in 6, prominent raphe in 4, and bifurcation in 3 cases. Three cases had a redundant long prepuce, and 1 had paraphimosis after preputial retraction, otherwise no other genitourinary anomalies could be detected in those cases. CONCLUSION: MR anomalies, mainly deviation and hyperpigmented prominent raphe, are significant indictors for the presence of an invisible MIP anomaly. Abnormally redundant long prepuce may be seen in such cases, but this is not common.

Efficacy and safety of continent anal urinary diversion for complicated bladder exstrophy in children by using modified Duhamel's procedure.

BACKGROUND: A high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence and a miserable life even after a well-performed staged reconstruction in specialized centers. Most of those children usually have a normal anal sphincter allowing construction of a neobladder from the rectum, so they are continent without an abdominal stoma, and do not require frequent catheterization, which greatly contribute to a favorable body image. OBJECTIVE: In this study a modified Duhamel's rectal pouch done for 19 children, with implication of suitable stapler adopted to construct a rectal bladder with a non-refluxing urterorectostomy, there is a theoretical advantage in our procedure of avoiding a mix of urine and feces. All patients were followed for up to 6 years (2-8 years) for efficacy, safety, subsequent renal complications, and surveillance for any rectal neoplastic changes in this new diversion. STUDY DESIGN: Assessment of electrolytes, acid base balance, and renal function were carried out regularly and all data were analyzed using the SPSS 9.0.1 statistical package and compared using a paired t test; data were considered significant if p < 0.05. Proctoscopy was performed 6 monthly in the first year then annually thereafter, and at any time if there was any rectal bleeding. RESULTS: In this group of patients, follow-up revealed no neoplastic changes in the rectal bladder, deterioration in renal function, or major electrolytes disturbance. They can hold up to 400 mL (350-550 mL) of urine and all are continent during the daytime with an emptying frequency of 3-5 h; three patients had infrequent (4 episodes/month) nocturnal enuresis; and four cases developed pyelonephritis controlled with medical treatment. CONCLUSION: The continent rectal bladder created by using the principles of the Duhamel pull-through is feasible, easy to perform, successful in the immediate short term with low complications after 6 years of follow-up and appropriately accepted by the children and their families with marked improvement in quality of life regarding continence; longer-term follow-up is requested to rule out rectal neoplastic changes. A comparative review of the complications, patient's acceptance, and longer-term follow-up with other well-known procedures, such as Mainz II, is required.

Spectrum of penoscrotal positional anomalies in children.

BACKGROUND: The normal relationship between the scrotum and penis during fetal development is controlled by several genetic and hormonal factors, and impairment of this positional relation results in a wide spectrum of positional congenital anomalies. OBJECTIVE: This a cohort study analysing 63 cases of penoscrotal anomalies (PSAs) according to severity and other associated malformations to provide a simple classification for recognising, describing and categorizing cases that may require surgical correction. DESIGN AND SETTING: Between 2005 and 2013, 63 diverse cases of penoscrotal positional anomaly were detected and analysed based on their hormonal profile and other associated anomaly. RESULTS: A wide variety of PSAs were included in the study, 11 cases were of major PST with complete penoscrotal transposition in three, incomplete in eight, and minor degree in 45 cases, which are symmetrical (bilateral) in 29, sixteen are asymmetrical, 4 had midline scrotlisation, and 3 had wide penoscrotal distance. Associated genitourinary anomalies were detected in 29 babies. Sex hormonal assays showed no significant differences between the PSA patients and controls (P < .05), and no gross chromosomal anomalies were detected in any cases. CONCLUSION: Penoscrotal positional anomalies include the previously described penoscrotal transposition, and the variants of a central penile scrotalisation, and wide penoscrotal distance. A simple classification for these anomalies adopted herein.

Versatility of tissue expansion in abdominal wall reconstruction after removal of vascular malformations in children.

BACKGROUND: Children who have had extensive abdominal wall vascular anomalies (VAs) face 3 common reconstructive options: either tolerating the complications of these lesions, exposure to repeated laser therapy session with its sequelae, or excision followed by a color-matched skin graft. The use of serial tissue expansion and excision of the affected skin offers a potentially better option under the right circumstances. Tissue expanders (TEs) have broad applicability but are not without complications. OBJECTIVE: To study the versatility of use of TEs in the management of children who had extensive VAs in their abdominal wall with special emphasis to the complications and children and parental satisfaction. MATERIALS AND METHODS: Retrospective data collection of 12 patients' charts, operative data of 84 operative procedures, and follow-up visits. Statistical analysis done using Student t test significance and P<0.05 was considered statistically significant. RESULTS: Using 35 different sizes of TEs and 84 operative procedures in 9 boys and 3 girls aged from 2 to 12 years with different types of abdominal wall VAs revealed an overall complications rate of 20%. Child and parental satisfaction was found to be good overall. CONCLUSIONS: Tissue expander is a useful and feasible tool for reconstruction of the abdominal wall with extensive VAs in children; parents and children were satisfied and body image is acceptable.

The feasibility of tissue expanders in reconstruction of giant congenital melanocytic nevi in children.

BACKGROUND: Children with giant congenital melanocytic nevi (GCMN) pose a great challenge to pediatric and reconstructive surgeons because they have to cover the widely exposed area after its excision. A variety of treatment options exist for the management of such cases. In this retrospective review of a selected group of children who had a GCMN of their abdominal walls managed with implantation of tissue expanders (TEs) for staged reconstruction, patients were evaluated with respect to complications and general and esthetic criteria for patient and parent satisfaction. OBJECTIVE: The purpose was to study the feasibility of use of TEs in the management of children who had GCMN, with special emphasis on the complications and children's and parents' satisfaction. MATERIAL AND METHODS: Retrospective data from the 12 patients' charts, operative data of 86 surgical procedures, and follow up visits were analyzed using the Student's t test, and P < .05 was considered statistically significant. RESULTS: In a period of 4 years, from 2004 to 2008, the results of using 37 different sizes of TEs and 86 operative procedures in 12 children (9 boys and 3 girls) aged from 2 to 12 years with different types of abdominal wall GCMN are discussed. CONCLUSION: The TE is a useful and feasible tool for reconstruction of the abdominal wall in cases of GCMN in children. Parents and children are satisfied in general and also with the body image.

Ureterorectostomy as a continent urinary diversion for complicated bladder exstrophy in children by using a modified Duhamel procedure: a case series.

INTRODUCTION: Whatever the method and timing of surgery, a high proportion of children with bladder exstrophy will continue to suffer from urinary incontinence. They face the options of urinary diversion to an external stoma or construction of a neobladder from bowel. This study describes a modified Duhamel's rectal pouch with a ureterorectostomy was carried out on 11 children who had a failed repair of bladder exstrophy. MATERIALS AND METHODS: Ten boys and one girl, aged from 4 to 7 years (mean 5.5), had several unsuccessful operations for bladder exstrophy. All selected to have good renal function and no other anomalies, but were incontinent of urine and had a small contracted or prolapsed bladder. They underwent urinary diversion to the rectum using the Duhamel pullthrough technique, where the sigmoid colon was opened into the back of the anal canal above the dentate line, creating a rectal bladder and making use of the anal sphincter to control urine and stool. All were followed up for 24 months (18-27 months). RESULTS: In this selected group of patients there were no major operative or postoperative complications. Follow-up for 2 years revealed no deterioration in renal function, or electrolytes disturbance. They can hold up to 300 ml of urine and all patients are continent during the daytime with an emptying frequency of 3-5 times. Nocturnal wetting occur some 4-8 times per month with significant decrease with time. Two cases developed pyelonephritis but this was controlled with medical treatment. CONCLUSION: Eleven children achieved effective urinary continence by ureteric diversion to the rectum using a modified Duhamel pullthrough technique. Two years follow up showed no complications, except bed wetting, but long term assessment is warranted.