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.

Comparative study of mechanical vs. manual circumcision in the pediatric population: An alternative to the conventional technique? / Estudio comparativo entre circuncisión mecánica y manual en población pediátrica: ¿una alternativa a la técnica convencional?

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.

OBJETIVOS: La circuncisión es una de las intervenciones quirúrgicas más realizadas en cirugía pediátrica. Aunque la técnica con sutura manual (SMAN) se considera el gold standard, recientemente se han desarrollado dispositivos de sutura mecánica (SMEC) de fácil manejo y con mejores resultados postoperatorios en la población adulta. El objetivo de nuestro estudio es comparar el tiempo quirúrgico y la incidencia de complicaciones postoperatorias entre ambas técnicas en nuestro ámbito. MATERIAL Y METODOS: Estudio retrospectivo de pacientes circuncidados en nuestro centro entre octubre 2021 y diciembre 2022. Se analizó el tiempo quirúrgico y las complicaciones observadas en los primeros 14 días postoperatorios (edema, hematoma, dehiscencia), en función de la técnica empleada (SMAN vs SMEC) y la edad de los pacientes (< 12 y ≥ 12 años). RESULTADOS: Se incluyeron 173 pacientes (147 SMAN, 26 SMEC). El tiempo quirúrgico medio fue significativamente menor en los pacientes con SMEC, tanto en < 12 años (16 min vs. 10 min, p= 0,002) como en ≥ 12 años (23 min vs 12 min, p< 0,001). En cuanto a las complicaciones, los pacientes con SMEC del grupo ≥ 12 años presentaron menor tasa de dehiscencia de sutura (23,5% vs 0%, p< 0,001), sin observarse diferencias significativas en el grupo de menor edad. CONCLUSIONES: La circuncisión con SMEC es una técnica sencilla y eficaz, que precisa un tiempo quirúrgico más reducido que la sutura manual, independientemente de la edad. Presenta menor tasa de complicaciones en los niños de mayor edad (≥ 12 años), por lo que se plantea como una alternativa válida a la técnica clásica.

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.

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.

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.

[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.

[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.

Comparative analysis on the outcomes in circumcising children using modified Chinese ShangRing and conventional surgical circumcision.

OBJECTIVE: To compare the differences and outcomes of surgical procedures, clinical effect, complications and patients' satisfaction between disposable oval-shaped circumcision device (Modified Chinese ShangRing series, Kiddie love®) and conventional circumcision in the treatment of children with phimosis or redundant prepuce. METHODS: The clinical data were retrospectively analyzed in 114 children with phimosis or redundant foreskin undergone circumcision using a disposable oval-shaped circumcision device, a modified Chinese ShangRing series, Kiddie Love® (Kiddie Love group) in our hospital between January 2018 and February 2020, and another 114 children with similar conditions circumcised by conventional surgical procedure before January 2018 (conventional group). The two groups were compared regarding the operative time, intraoperative blood loss, postoperative pain scores, healing time, the incidence of complications and guardian's satisfaction. RESULTS: Circumcision was successfully completed in children in both groups. The operative time, intraoperative blood loss, postoperative pain scoring in 24 h by VAS, pain at the removal of the device or stitches and wound healing were (6.4 ± 1.6) min, (34.1 ± 6.4) min; (0.7 ± 0.2) ml, (2.6 ± 0.6) ml; (2.2 ± 1.0) points, (1.3 ± 0.5) points; (23.7 ± 3.9)day, (15.9 ± 2.8)day, respectively for Kiddie Love group and conventional group(either P < 0.05 or P > 0.05). The two groups were significantly different in the incidence of hematoma, edema and incision dehiscenceyet were insignificant in incision infection. Children in both groups were followed up from 6 to 31 months (mean: 23 months), and the satisfaction rate was 94.7% (108/114) in parents of the children circumcised by the ShangRing and 83.3% (95/114) in those of children treated by conventional circumcision (P < 0.05). CONCLUSION: Modified Chinese ShangRing, Kiddie Love®, has superiorities, including simpler procedure, shorter operative time, less blood loss, fewer complications, better cosmetic results and higher satisfaction of patients over conventional circumcision in the treatment of children with phimosis or redundant foreskin, and worthy of wider clinical recommendation.

[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.

Analysis of related factors between the occurrence of secondary epidermoid cyst of penis and circumcision.

Secondary epidermoid cyst of the penis is a very rare epidermoid cyst that occurs in the penis. The purpose of this study was to investigate the relationship between the occurrence of secondary epidermoid cyst of penis and circumcision-related factors, and to provide possible reasonable and effective suggestions for circumcision. The data of all patients who visited the clinic for epidermoid cysts of the penis from September 2000 to September 2021 in Xiangya Hospital were collected. A retrospective study was carried out on whether the patients had been circumcised and the surgical method, anesthesia method, cyst location, surgical age, postoperative wound infection, whether they were phimosis patients, and the level of the surgeon. Among the 24 patients followed up, 95.8% had a history of circumcision, and only 4.2% had no history of circumcision, and the more traumatic surgical methods developed secondary epidermoid cyst of the penis after surgery the higher the probability. Injecting anesthesia at the base of the penis increases the chances of developing a secondary epidermoid cyst of the penis. Postoperative secondary epidermoid cyst of the penis were mainly located in the anterior segment and posterior segment, and the anterior segment had a higher proportion, followed by the posterior segment. Secondary epidermoid cyst of the penis occur mainly in adults. Postoperative wound infection accelerates the appearance of secondary epidermoid cyst of the penis. Patients with phimosis have an increased probability of developing secondary epidermoid cysts of the penis after surgery. The incidence of secondary epidermoid cysts and postoperative infection after manual circumcision by the attending physician was higher than that of the chief physician. Circumcision, injection of anesthesia at the base of the penis, ligation of the penis, and postoperative wound infection may be the etiologies and triggers of secondary epidermoid cysts of the penis. Adults and phimosis patients may be high-risk groups. Lower-level surgeons may increase the odds of postoperative secondary epidermoid cysts of the penis, and it is recommended that surgery be performed by a clinically-experienced, higher-level surgeon. The indications for circumcision should be strictly evaluated and the operation should be performed as soon as possible, and the less invasive surgical method and anesthesia method should be selected. Reduce irrelevant operations during surgery and avoid wound infection after surgery.

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.

Impact of Florida Medicaid guidelines on frequency and cost of delayed circumcision at Nemours Children's hospital.

INTRODUCTION: In 2003, Florida Medicaid discontinued coverage of routine neonatal circumcision (NC) resulting in an increase in nonneonatal circumcisions. Florida Medicaid is one of 16 state healthcare plans that do not cover NC. Florida Medicaid covers male circumcision in a child ≥3 years for a defined medical indication or persistent phimosis refractory to topical steroid therapy (TST). We sought to assess the economic impact of the evaluation and management of phimosis/circumcision in Florida Medicaid males ≥3 years treated at Nemours Children's Hospital. STUDY DESIGN: We performed an IRB approved retrospective chart review of all male Florida Medicaid patients ≥3 years seen at NCH for phimosis/circumcision from Sept. 2016-Sept. 2019. Data extracted included demographics, age at presentation, prior treatment with TST, response to TST, and surgical interventions. The patients were stratified into three management groups. Total costs for each group were based upon estimated Medicaid reimbursement rates. Data were analyzed using descriptive analysis on SPSS. RESULTS: Seven hundred and sixty-three males were evaluated. Age at presentation ranged from 3 to 17 years and 59% of patients were 3-6 years at initial presentation. Three hundred and forty patients underwent circumcision. The total estimated cost of care for all patients was $1,345,533.90. This compares to an estimated cost of $171,675 if all individuals underwent NC at 2020 costs. CONCLUSIONS: The total estimated cost associated with the evaluation and management of 763 patients ≥3 years for phimosis/circumcision was 7.8 times the estimated cost of NC for all these patients and likely is an underestimation of the true difference in cost as we did not account for additional visits outside of the initial consultation and follow-up, post-operative visits outside of the global period, emergency room visits, and returns to operating room. Of the circumcisions performed, only 18.5% met Florida Medicaid defined medical indications. Success rates for TST range from 53.8 to 95% in the literature, however, our success rate was 34.3%. The reason for the variation in response rate between our results and the literature may reflect that caretakers desiring circumcision may be less compliant with TST use. Only 6.6% of patients had a documented failure of TST prior to initial presentation. Further education of PCPs on current Medicaid/MCG guidelines for the evaluation and management of phimosis, as well as PCP adoption of TST, could reduce the number of unnecessary office visits, healthcare costs, and family burden.

Lichen sclerosus in pediatric age: A new disease or unknown pathology? Experience of single centre and state of art in literature.

Lichen Sclerosus (LS) is a chronic inflammatory skin disease with unknown etiology. In pediatric age the main disease "lichenlinked" is the phimosis in male. This is a retrospective study that reports the experience of our clinic and review of the literature. We included all patients affected by pathological phimosis, treated by circumcision between January 2015 and May 2020, older than 6 years old and with an histopathological diagnosis of lichen sclerosus. The aim was to identify prognostic factors based on histological report to plan the clinical management of patients. Statistical analysis was done. We included 207 patients. The mean age of children was 9,78 years (5-18 years, DS±3.29). Based on the histological features we divided patients in 2 groups: early lesions (70/207, 34%) and advanced (137/207, 66%). In term of complications lichen linked we considered meatal stenosis that needed of urethral dilatations. We included 7 patients (7/207, 3,4%). We report P value Statistical Significance in many aspects. An early diagnosis of LS and surgical treatment of foreskin are essential to prevent early and late complications in children. The size of sample is a limit of the study but results encourage our management.

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. / Diagnóstico diferencial del megaprepucio congénito: relevancia terapéutica y pronóstica.

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.

El megaprepucio congénito es una patología urológica propia de la infancia que puede ser fácilmente confundida con otras entidades clínicas como la fimosis fisiológica o el pene enterrado. Debido al riesgo de complicaciones asociadas, principalmente de carácter infeccioso u obstructivo con afectación del tracto urinario superior, es importante incidir en su correcto diagnóstico de cara a ofertar un tratamiento precoz. Presentamos tres casos de megaprepucio congénito, diagnosticados e intervenidos en nuestro servicio durante el periodo comprendido entre enero de 2019 y mayo de 2020, describiéndose el diagnóstico, la terapéutica empleada y la evolución clínica.

[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 ï¼»8.00, 9.00ï¼½ min vs 5.00 ï¼»5.00, 5.00ï¼½ 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 ï¼»2.00, 3.00ï¼½ vs 2.55 ï¼»2.00, 3.00ï¼½, 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.

Preputioplasty as a surgical alternative in treatment of phimosis.

Preputioplasty denotes various surgical techniques directed at resolving phimosis without the need for radical or partial circumcision. This narrative review summarizes the best-known surgical techniques of preputioplasty. A MEDLINE and EMBASE-based literature search of original manuscripts and case reports published in English has been carried out using the following key words: "circumcision", "partial circumcision", "phimosis", "paraphimosis", and "preputioplasty". Six different procedures are explored in more detail and illustrated. The complication rates of all surgical procedures presented here are reported to be low. In cases of medical (rather than cultural and religious) indications, foreskin-preserving procedures present useful alternatives to circumcision in the routine clinical practice of urologists and pediatric surgeons.

Cosmetic results of circumcision and scar wrinkling: Do we exaggerate in terms of hemostasis and sutures?

OBJECTIVE: To objective of this study was to investigate poor scar appearance of the circumcision line and scar wrinkling caused by the sutures placed during the circumcision in primary school age circumcised children. METHODS: A total of 455 children aged between 6 and 9 years, circumcised by four different specialists in our hospital between 2009 and 2018 were evaluated. Circumcisions performed due to balanitis, phimosis, secondary phimosis, and paraphimosis were excluded from the study. Only routine religious circumcisions performed on request of the family were included in the study. Children underwent a second procedure and those receiving treatment after the circumcision due to infection were excluded from the study. About 363 patients included the study. Patients were evaluated according to the Fitzpatrick skin type classification, independent observer scale, Stony Brook Scar Evaluation Scale, and Dunn-Bonferroni test. RESULTS: No statistically significant difference was found between distributions of scar wrinkling levels in children according to the circumcision (p > 0.05). There was a statistically significant difference between age of circumcision according to scare wrinkling levels (p = 0.001). According to the Dunn-Bonferroni test; the circumcision age was found to be significantly lower in children with severe scar wrinkling compared to the children with no or mild scar wrinkling (p = 0.001; p = 0.011). CONCLUSION: The tense, short-interval sutures placed away from the wound margin during circumcision in order to control subcutaneous bleeding lead to scar wrinkling and a poor cosmetic appearance. Knowing the risk factors leading to scar wrinkling and taking appropriate measures will provide acceptable cosmetic outcomes after the circumcision.