A new treatment of concealed penis: symmetrical pterygoid flap surgery.

PURPOSE: Considerable controversy exists regarding the surgery for concealed penis. We describe a new technique for repairing concealed penis by symmetrical pterygoid flap surgery. METHODS: From January 2016 to July 2022, we evaluated 181 cases of concealed penis that were surgically treated using the symmetrical pterygoid flap surgery. We measured the penile size preoperative and 2, 4, 12 weeks, and 1 year postoperative to confirm the improvement. A questionnaire was administered to the patients and parents to assess satisfaction regarding penile size, morphology, and hygiene. RESULT: The perpendicular penile length was1.59±0.32cm preoperative and 3.82±1.02 cm after the procedure (p < 0.05), and 4.21±1.91cm after one year of postoperative (p < 0.05). The overall satisfaction of patients was 97.89%, while the overall satisfaction of older children patients (age>7) was 75.24%. Parents focus more on the penile exposure size, while patients focus more on the penile morphology. Almost every patient had postoperative penile foreskin edema. However, this symptom had spontaneously resolved by 4-6 weeks. The complications such as skin necrosis, tissue contracture, or wound infection were 4.42%. CONCLUSION: The symmetrical pterygoid flap surgery is an effective surgical technique for the management of concealed penis in children producing predictable results and excellent satisfaction of the parents and patients.

Attitude towards donation of the excised foreskin after circumcision surgery for research: A study from Madinah, Saudi Arabia.

Studies have shown the possibility of using the part of the foreskin removed after circumcision in the field of scientific and therapeutic research. Donations of tissues and organs are always associated with ethical challenges posed by bioethicists and societies to ensure the appropriate use of these tissues/organs. The purpose of this study was to understand the attitudes and awareness of parents/guardians regarding donation of excised foreskin to research and medical use. The study was based on a questionnaire and included 133 parents/guardians who visited Uhud Children's Hospital in Madinah, Saudi Arabia for newborn male circumcision. The results showed a high willingness (61.7%) to donate the extracted foreskin to research. The willingness to donate the extracted foreskin to research associated with undergraduate degree (P = 0.018), male sex (P = 0.011), high income (P = 0.029), and participation in previous research studies (P = 0.002). About 41.8% were convinced that written informed consent should be obtained before circumcision surgery, 38.1% (n = 51) were convinced that written informed consent should be taken after surgery, while the remaining 19.4% reported that the timing of written informed consent is unimportant. Finally, fear of excision of excess tissue (74.5%), lack of confidence in the research (68.6%), and potential for commercial use (64.7%) were the main barriers to unwillingness to donate the excised foreskin for research. In conclusion, a reasonable portion of Saudis agreed to donate their foreskin for research purposes. There is an urgent need to enhance awareness and attitudes towards tissue donation for research and therapeutic use.

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

Objetivos: La circuncisión es una de las intervenciones quirúrgicas más realizadas en cirugía pediátrica. Aunque la técnica con suturamanual (SMAN) se considera el gold standard, recientemente se handesarrollado dispositivos de sutura mecánica (SMEC) de fácil manejo ycon mejores resultados postoperatorios en la población adulta. El objetivo de nuestro estudio es comparar el tiempo quirúrgico y la incidencia decomplicaciones postoperatorias entre ambas técnicas en nuestro ámbito.Material y métodos: Estudio retrospectivo de pacientes circuncidados en nuestro centro entre octubre 2021 y diciembre 2022. Se analizóel tiempo quirúrgico y las complicaciones observadas en los primeros14 días postoperatorios (edema, hematoma, dehiscencia), en funciónde 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) comoen ≥ 12 años (23 min vs 12 min, p< 0,001). En cuanto a las complicaciones, los pacientes con SMEC del grupo ≥ 12 años presentaron menortasa de dehiscencia de sutura (23,5% vs 0%, p< 0,001), sin observarsediferencias significativas en el grupo de menor edad. Conclusiones: La circuncisión con SMEC es una técnica sencillay eficaz, que precisa un tiempo quirúrgico más reducido que la suturamanual, independientemente de la edad. Presenta menor tasa de complicaciones en los niños de mayor edad (≥ 12 años), por lo que se planteacomo una alternativa válida a la técnica clásica.(AU)

Objective: Circumcision is one of the most common surgical procedures in pediatric surgery. Even though manual suture (MANS) isregarded 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 tocompare the operating time and incidence of postoperative complicationsbetween both techniques in our environment.Materials and methods: A retrospective study of patients undergoing circumcision in our institution from October 2021 to December 2022was carried out. Operating time and complications observed in the first14 postoperative days (edema, hematoma, dehiscence) were analyzedaccording 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, bothin 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 youngergroup. 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 (≥12years), which means it stands as a valid alternative to the conventionaltechnique.(AU)

Are there anatomical limiting factors to foreskin reconstruction at the time of single-stage hypospadias repair?

INTRODUCTION: Foreskin reconstruction (FR) at the time of primary hypospadias repair is a truly anatomically complete reconstruction of the hypospadic penis. We prospectively collected penile and preputial measurement of children undergoing single-stage hypospadias repair and FR with the aim to identify possible relations between penile and preputial anatomy and the likelihood to develop complications. MATERIALS AND METHODS: We prospectively studied children who underwent single stage hypospadias repair associated with FR from 2016 to 2019. We recorded intra-operative foreskin and penile measurements and post-operative outcomes. Logistic Regression analysis was performed to explore independent factors affecting urethroplasty and skin complications. Chi square test was used to compare outcomes in different groups based on ventral foreskin defect (VFD) width, Glans size, age at surgery and meatal location. RESULTS: From a total of 181 consecutive patients, 86 boys who underwent a single stage hypospadias repair combined with FR were included in the study. Patients were excluded because they were either lost at follow up (n = 10), required a 2-stage repair (n = 2), were circumcised at birth (n = 3) or parents requested a circumcision (n = 78); in 2 patients, a decision to perform circumcision was made intraoperatively due to aesthetic reasons (monk-hood deformity of the prepuce). Median age at surgery was 17 months. Mean glans width was 14.4 mm. Mean unstretched and stretched foreskin circumference were 29.5 mm and 40.9 mm, respectively. Mean VFD (the distance between the proximal insertion of the foreskin hood on either side of the midline at the level of the coronal sulcus) was 7.2 mm (Fig. 1). At median follow-up of 8 months (6-23), 9 complications were recorded (10.4%): foreskin dehiscence occurred in 1% (1/86), a foreskin fistula was noted in 4.6% (4/86), tight, non-retractile, foreskin in 1% (1/86); urethrocutaneous fistula in 2.3% (2/86) and complete dehiscence of the glans and foreskin in 1 (1.2%). Multiple logistic regression analysis demonstrated that none of the measurements obtained was an independent risk factor for developing urethroplasty or skin complications. There was no significant difference in complications between wide VFD (>7 mm) vs. narrow VFD (≤7 mm), large glans (>14 mm) vs. small glans (≤14 mm), age at surgery ≤24 months vs. > 24 month and meatal location distal (glanular, coronal, subcoronal and distal penile) vs. proximal (midpenile, proximal penile and penoscrotal). CONCLUSION: To the best of our knowledge, this is the first study reporting a prospective and objective assessment of the foreskin in the context of single stage hypospadias repair. Individual anatomical differences in preputial and penile anatomy do not seem to affect the likelihood of skin and urethroplasty complications. FR can, therefore, be offered to all boys undergoing primary single stage hypospadias repair . Further studies on larger numbers and external validation of these measurements is necessary.

Hormone receptor expression in hypospadias.

INTRODUCTION: Sex hormone imbalance in utero is hypothesized to play an important role in the pathogenesis of hypospadias. Due to its easy accessibility, foreskin samples have been used to describe hormone receptor expression in rodents, and both adult and pediatric patients. In this study we conducted a systematic approach to assess hormone receptor expression in pediatric patients with hypospadias compared to healthy controls with a focus on age-matching and differences in severity and degree of hypospadias. METHODS: Foreskin samples were collected from 35 children during hypospadias operations (18 distal and 17 proximal hypospadias) and compared with ventral foreskin samples of a control group of 32 children during circumcision (15 age-matched and 17 older boys). The samples were stained with H/E, androgen (AR), estrogen (ER) and progesterone receptors (PR). The receptor stainings were blindly evaluated. An Allred score was used to evaluate receptor expression in both the epithelium as well as stroma. RESULTS: AR was detected in all cases. AR expression in the stroma was more evident than in the epithelium. AR expression in the hypospadias groups was significantly less than the age matched controls (p < 0.05). There was no significant difference between the two hypospadias groups nor between the two control groups. Older control group showed significantly elevated levels of AR expression compared to the hypospadias group (p < 0.05). ER was also detected in all cases. The stroma showed more ER than in epithelium. PR was minimal or negative in all samples. CONCLUSION: Boys with hypospadias showed significantly weaker expression of androgen receptors than age matched controls. The severity of hypospadias did not influence hormone receptor distribution. AR expression is better observed in the stroma than in the epithelium. There was no difference in ER expression between the hypospadias group (distal or proximal) and age matched normal controls. ER was expressed in larger numbers in normal older preputial tissue. The foreskin of prepubertal boys shows little to no expression of PR.

Novel single-stage preputial spiral graft for panurethral stricture: a step-by-step description of the technique.

PURPOSE: To report the 12-month results of a novel urethroplasty technique relying on a spiral preputial graft for panurethral stricture disease. MATERIALS AND METHODS: Twenty consecutive patients were treated between May and October 2021 at our center. A spiral preputial mucocutaneous graft is a foreskin-based graft, developed from a 5-cm-wide preputial skin, which is harvested using a helicoidal shape and can reach up to 20 cm in length. Stricture characteristics were assessed through preoperative retrograde and voiding cystourethrogram and maximum uroflowmetry data (Qmax). Complications were collected up to 30 days after surgery and graded using the Clavien-Dindo (C-D) classification. The patients were followed up to 12 months. RESULTS: Preoperative median Qmax was 6.5 ml/s [interquartile range (IQR): 4.0-8.7]. After a median follow-up of 12 months (IQR 12-13), six patients experienced at least one complication. Of them, two patients had grade 2 C-D complications, while only one developed a grade 3a C-D complication. The median postoperative Qmax was 16 ml/s (IQR: 13-18). Only one patient had early urethral stricture recurrence treated with dilatation after catheter removal. At one-year follow-up, no other patients had urethral stricture recurrence with an overall median Qmax of 15.1 ml/s (IQR 13.5-16.4). CONCLUSIONS: Our novel single-stage spiral preputial graft urethroplasty for panurethral stricture treatment appears to be safe and could be used as a valid alternative to two-stage procedures or even to single-stage buccal mucosa graft augmentation.

Foreskin restorers: insights into motivations, successes, challenges, and experiences with medical and mental health professionals - An abridged summary of key findings.

Demographically diverse surveys in the United States suggest that 5-10% of non-voluntarily circumcised American males wish that they had not been circumcised. Similar data are unavailable in other countries. An unknown proportion of circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth investigation into foreskin restorers' lived experiences. An online survey containing 49 qualitative and 10 demographic questions was developed to identify restorers' motivations, successes, challenges, and experiences with health professionals. Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust. Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by medical and mental health professionals.

[Anthropometric assessment on prepubertal boys with hypospadias: a multicenter case series].

Objective: Anthropometric variants in prepubertal boys with hypospadias were assigned and assessed to illustrate anatomical malformation. Methods: A total of 516 prepubertal (Tanner grade Ⅰ) boys with hypospadias who were admitted to three medical centers between March 2021 and December 2021 and met the selection criteria for primary surgery were selected. The age of the boys ranged from 10 to 111 months, with an average of 32.6 months. Hypospadias were classified according to the location of the urethral defect, 47 cases (9.11%) of the distal type (the urethral defect is in the coronal groove or beyond), 208 cases (40.31%) of the middle type (the urethral defect is in the penis body), and 261 cases (50.58%) of the proximal type (the urethral defect is at the junction or proximal side of the penis and scrotum). The following indexes were measured: penis length before and immediately after operation, reconstructed urethral length, and total urethral length. Morphological indicators of the glans area, including preoperative height and width of glans, AB, BC, AE, AD, effective AD, CC, BB, the urethral plate width of the coronal sulcus, and postoperative height and width of glans, AB, BE, and AD. In which point A is the distal endpoint of navicular groove, point B is the protuberance lateral to the navicular groove, point C is the ventrolateral protuberance of the glans corona, point D is the dorsal midline point of the glans corona, and point E is the ventral midline point of the coronal sulcus. The foreskin morphological indicators, including the foreskin width, inner foreskin length, and outer foreskin length. The scrotal morphological indicators, including the left, right, and front penile to scrotum distance. The anogenital distances, including anoscrotal distance 1 (ASD1), ASD2, anogenital distance 1 (AGD1), and AGD2. Results: The penis length of the distal, middle, and proximal types decreased successively before operation, the reconstructed urethral length increased successively and the total urethral length decreased successively, these differences were all significant ( P<0.05). The height and width of the glans of the distal, middle, and proximal types significantly decreased successively ( P<0.05), but the height/width of the glans was generally close; AB value, AD value, and effective AD value significantly decreased successively ( P<0.05); there was no significant difference in BB value, urethral plate width of the coronary sulcus, and (AB+BC)/AD value between the groups ( P>0.05). There was no significant difference in the width of glans between the groups after operation ( P>0.05); AB value and AB/BE value increased successively, and AD value decreased successively, these differences were all significant ( P<0.05). The inner foreskin length in the 3 groups significantly decreased successively ( P<0.05), while the outer foreskin length had no significant difference ( P>0.05). The left penile to scrotum distance of middle, distal, and proximal types significantly increased successively ( P<0.05). ASD1, AGD1, and AGD2 significantly decreased from distal type to proximal type successively ( P<0.05). The other indicators' differences were significant only between some groups ( P<0.05). Conclusion: The anatomic abnormalities of hypospadias can be described by anthropometric indicators, which can be used as the basis for further standardized surgical guidance.

Psychological, psychosocial, and psychosexual aspects of penile circumcision.

Policy statements on penile circumcision have focused primarily on disease, dysfunction, or sensation, with relatively little consideration of psychological and psychosocial implications of the procedure. There has also been minimal consideration of potential qualitative changes in the subjective experience of sexual activity following changes in penile anatomy (foreskin removal) or associated sexual biomechanics. We present a critical overview of literature on the psychological, psychosocial, and psychosexual implications of penile circumcision. We give consideration to differences among circumcisions performed in infancy, childhood, or adulthood. We also discuss potential psychosocial effects on parents electing, or failing to elect, circumcision for their children. We propose a framework for policy considerations and future research, recognizing that cultural context is particularly salient for the narratives individuals construct around penile circumcision, including both affected individuals and medical professionals who perform the surgeries. We argue that additional attention should be paid to the potential for long-term effects of the procedure that may not be properly considered when the patient is an infant or child.

What is the medical evidence on non-therapeutic child circumcision?

Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and children.

Immunohistological study of the density and distribution of human penile neural tissue: gradient hypothesis.

Immunohistological patterns of density and distribution of neural tissue in the human penis, including the prepuce, are not fully characterized, and effects of circumcision (partial or total removal of the penile prepuce) on penile sexual sensation are controversial. This study analyzed extra- and intracavernosal innervation patterns on the main penile axes using formalin-fixed, paraffin-embedded human adult and fetal penile tissues, single- and double-staining immunohistochemistry and a variety of neural and non-neural markers, with a special emphasis on the prepuce and potential sexual effects of circumcision. Immunohistochemical profiles of neural structures were determined and the most detailed immunohistological characterizations to date of preputial nerve supply are provided. The penile prepuce has a highly organized, dense, afferent innervation pattern that is manifest early in fetal development. Autonomically, it receives noradrenergic sympathetic and nitrergic parasympathetic innervation. Cholinergic nerves are also present. We observed cutaneous and subcutaneous neural density distribution biases across our specimens towards the ventral prepuce, including a region corresponding in the adult anatomical position (penis erect) to the distal third of the ventral penile aspect. We also describe a concept of innervation gradients across the longitudinal and transverse penile axes. Results are discussed in relation to the specialized literature. An argument is made that neuroanatomic substrates underlying unusual permanent penile sensory disturbances post-circumcision are related to heightened neural levels in the distal third of the ventral penile aspect, which could potentially be compromised by deep incisions during circumcision.

Potentially under-recognized late-stage physical and psychosexual complications of non-therapeutic neonatal penile circumcision: a qualitative and quantitative analysis of self-reports from an online community forum.

The removal of non-pathogenic foreskin from the penis of healthy neonates and infants for non-religious reasons is routinely practiced in many parts of the world. High level data from well-designed randomized controlled trials of circumcision in neonates and infants does not guide clinical practice. Reliable counts of immediate and short term circumcision complications are difficult to estimate. Emerging evidence suggests routine neonatal circumcision could lead to long term psychological, physical, and sexual complications in some men. The stigma associated with discussing circumcision complications creates a prevalence paradox where the presence of significant circumcision complications is higher than reported. Prior to the Internet, there were very few forums for men from diverse communities, who were troubled about their circumcision status, to discuss and compare stories. To investigate the long term consequences of circumcision, we reviewed 135 posts from 109 individual users participating in a circumcision grief subsection of Reddit, an internet discussion board. We identified three major categories of complications: physical such as pain during erections and lost sensitivity, psychological such as anxiety and violation of autonomy, and sexual such as feeling that the sexual experience was negatively altered or being unable to complete a sexual experience. We also identified a "discovery process" where some men described coming into awareness of their circumcision status. These findings suggest that neonatal circumcision can have significant adverse consequences for adult men. The removal of normal foreskin tissue should be limited to adult men who choose the procedure for cosmetic reasons or when medically indicated.

Fasciocutaneous foreskin twin flaps in hypospadias repair: Reconstructing a functional penis with freestyle design.

BACKGROUND: Hypospadias is the most common congenital urological deformity in males; however, there is still no perfect solution or surgical method for one-stage operations to fix proximal hypospadias with ventral penile curvature (VPC). We developed a fasciocutaneous foreskin twin flap technique that can provide freestyle flap designs in hypospadias repair. METHODS: A retrospective study including 26 patients was performed between January 2017 and June 2020. The surgical procedures included VPC correction, skin flap design, transfer and reconstruction. The urethra and shaft were reconstructed by twin flaps in one stage. All patients were followed up until 12 months. RESULTS: All VPC cases were corrected after the operation. The fistula rate was 11.5% (3/26). No meatal stenosis, urethral diverticulum, or stricture was observed. A total of 92.3% (24/26) of patients were satisfied with their penis appearance. CONCLUSIONS: The fasciocutaneous foreskin twin flaps provide freestyle designs in hypospadias repair, which can achieve a one-stage operation for proximal hypospadias with low fistula rates.

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.

[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.

Operative techniques and long-term outcomes of hypospadias repair in the absence of preputial skin after neonatal circumcision.

PURPOSE: To present the results of hypospadias repair in the absence of preputial skin following neonatal circumcision, and the analyses of surgical techniques and predictors of procedural success. METHODS: Records of all children who underwent hypospadias repair between 10/1999 and 12/2018 were retrospectively reviewed. All of those who underwent neonatal circumcision prior to surgery were included. Patients with any prior penile reconstruction surgery and those with the megameatus intact prepuce variant were excluded. The primary endpoint was the need for reoperation. RESULTS: A total of 69 patients with a history of neonatal circumcision underwent surgical reconstruction of hypospadias during the study period. Their mean age at surgery was 14 months (interquartile range [IQR] 9,22). Forty-five cases (65%) involved distal hypospadias, and ventral curvature was present in 24 (35%). Dartos flaps were harvested from the dorsal aspect in 37/58 (64%) patients and from the ventral aspect in 21/58 (36%). Twenty-two patients (22/69, 32%) required reoperation after a median follow-up of 9 years (IQR 6,13). Indications for revision surgery included urethral fistula (n = 16, 22%), meatal stenosis (n = 5, 7%), and skin redundancy (n = 1). Ventral curvature (odds ratio [OR] 3.5, p = 0.02) and higher grades of hypospadias. (OR 3.3, p = 0.03) had a higher probability of reoperation (univariate logistic regression). CONCLUSION: Hypospadias repair following neonatal circumcision in the absence of preputial skin is a challenging reconstruction. The reoperation rate in our cohort was 30%, similar to reoperative hypospadias surgery. Parents of newborns diagnosed with hypospadias should be encouraged to refrain from pre surgical neonatal circumcision. LEVEL OF EVIDENCE: Treatment study, level IV.