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Expert Opinion on Pharmacotherapy Jun 2022Topical pharmacotherapy is often practiced in the treatment of adults with phimosis or Lichen Sclerosus (LS). However, it is unclear if it is effective. (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Topical pharmacotherapy is often practiced in the treatment of adults with phimosis or Lichen Sclerosus (LS). However, it is unclear if it is effective.
AREAS COVERED
The authors review pharmacological treatments in adults with phimosis or LS using the Preferred Reporting of Items for Systematic Reviews and Meta-analysis (PRISMA) methodology. They searched seven databases using key words phimosis, drug treatment, medical, treatment, lichen sclerosis, pharmacological treatment, medications, comparison study for all English language articles from 1962 to 2021. Inclusion criteria were patients >18 yr., and the use of topical medical treatment with outcome data. The article includes the authors' expert opinion and their perspectives for the future.
EXPERT OPINION
There is limited research, with significant heterogeneity, which suggests the probable safety of topical steroids with some potential to reduce the signs and symptoms of LS. However, good quality research, with patient reported outcome data, is required to establish its true role and effectiveness.
Topics: Administration, Topical; Adult; Humans; Lichen Sclerosus et Atrophicus; Male; Phimosis; Steroids
PubMed: 35536559
DOI: 10.1080/14656566.2022.2075697 -
Scientific Reports Aug 2017The true HPV prevalence in the foreskins of infants and children has been little documented, but reporting on this prevalence is of great importance given its impact on... (Meta-Analysis)
Meta-Analysis
The true HPV prevalence in the foreskins of infants and children has been little documented, but reporting on this prevalence is of great importance given its impact on the rationale for treating asymptomatic boys. We searched multiple databases from 1960 to 2016 for observational or prospective studies that reported on HPV prevalence in foreskins. We conducted a meta-analysis using a random-effects model to pool for HPV prevalence in the foreskins of infants and children. Eight studies, with a total of 556 infants and children with phimosis, were eligible for the meta-analysis. The pooled overall prevalence of general HPV, high-risk HPV, low-risk HPV, HPV 16/18, HPV 16, and HPV 18 were 17.3 (95%CI: 0.8-46.3), 12.1 (95% CI: 0.9-31.5), 2.4 (95% CI: 0.0-11.2), 4.8 (95% CI: 0.0-16.8), 1.7 (95% CI: 0.0-5.1), and 0 (95% CI: 0-0.5), respectively. The estimated HPV prevalence in foreskins was not zero among infants and children, which implies HPV transmission other than by sexual contact. Considering that high-risk HPV is detected in asymptomatic infants and children, future studies are warranted to determine whether preventive treatments in asymptomatic infants and children could be effective in preventing persistence or transmission of high-risk HPV.
Topics: Adolescent; Asymptomatic Diseases; Carrier State; Child; Child, Preschool; Foreskin; Genotype; Humans; Infant; Male; Papillomaviridae; Papillomavirus Infections; Phimosis; Prevalence; Prospective Studies
PubMed: 28765591
DOI: 10.1038/s41598-017-07506-z -
Current Urology Reports May 2024Phimosis is a common condition of the urinary system in children and often requires surgical treatment. However, the optimal method of circumcision for children has not... (Review)
Review
PURPOSE
Phimosis is a common condition of the urinary system in children and often requires surgical treatment. However, the optimal method of circumcision for children has not been determined. We conducted a systematic review and meta-analysis to compare the safety and effectiveness of plastic clamp with conventional surgical circumcision in pediatric circumcision.
METHODS
A literature search was carried out to compare the plastic clamp and conventional dissection technique in the pediatric population. The following search terms were used: "circumcision", "plastic clamp", "conventional", "plastibell", "children" and etc. Meta-analysis was used to pool and evaluate variables such as operative time, blood loss, wound infection, bleeding, edema, and total postoperative complications.
RESULTS
The plastic clamp technique (PCT) was used in 10,412 of the 17,325 participants in the nine studies, while the conventional surgical dissection technique (CST) was used on 6913 patients. When compared to the CST approach, the PCT approach resulted in shorter operative times (mean difference (MD) -17.48, 95% CI -22 to -12.96; P < 0.001), less blood loss (MD -4.25, 95% CI -7.75 to -0.77; P = 0.02), and a higher incidence of postoperative edema (OR 2.33, 95% CI 1.34 to 4.08; P = 0.003). However, no significant difference was found in the incidence of postoperative complications, including wound infection and bleeding between PCT and CST.
CONCLUSIONS
PCT is a safe and time-saving option in the pediatric population. However, this method appeared to have a significant greater rate of postoperative edema.
PubMed: 38769228
DOI: 10.1007/s11934-024-01209-5 -
Pediatric Surgery International Jun 2021Megaprepuce (MP) is a rare and challenging condition characterised by an excessive inner prepuce, paucity of penile skin and an extremely narrow phimotic ring. The...
Megaprepuce (MP) is a rare and challenging condition characterised by an excessive inner prepuce, paucity of penile skin and an extremely narrow phimotic ring. The aetiological factors leading to its development are poorly understood. A variety of surgical techniques have been described in the last 26 years mostly with small number of patients and short follow-up. It is also highly likely that some series have in the past included different variants of inconspicuous penis combining concealed penis, MP and webbed penis. This article is a systematic review of the literature on Megaprepuce; in particular the embryology, history, aetiology, and the surgical techniques available for the correction of this unique penile anomaly will be presented and discussed in this study.
Topics: Foreskin; Humans; Male; Penile Diseases; Penis; Phimosis; Rare Diseases; Urologic Surgical Procedures, Male
PubMed: 33760967
DOI: 10.1007/s00383-021-04883-5 -
Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions.The Cochrane Database of Systematic... Mar 2021Medical circumcisions are among the most common surgical procedures performed in males. The usual indications are phimosis (inability to completely retract the foreskin... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Medical circumcisions are among the most common surgical procedures performed in males. The usual indications are phimosis (inability to completely retract the foreskin and expose the glans due to a congenital or acquired constriction of the prepuce), paraphimosis (when the foreskin is not pulled back over the glans after retraction resulting in a tight constricting band which causes swelling of the distal penis and acute discomfort), balanoposthitis (erythema and edema of the prepuce and glans) and balanitis (inflammation is confined to the glans; the foreskin is usually non-retractile). Circumcision devices have been developed to shorten the operative time, simplify techniques, and improve safety and cosmetic outcomes. The devices generally aim to crush the foreskin while simultaneously creating hemostasis, the foreskin is then excised or allowed to slough off. Their use is supposedly safer and easier to replicate than the standard dissection techniques. There are at least 20 devices for male circumcision on the market, yet their effectiveness has not been reviewed to date.
OBJECTIVES
To assess the effects of device-based circumcisions compared with standard surgical techniques in adolescent and adult males (10 years old and above).
SEARCH METHODS
We performed a comprehensive search with no restrictions to the language of publication or publication status. We searched the Cochrane Library, MEDLINE (PubMed), Embase, Web of Science, trials registries, grey literature sources and conference proceedings up to 16 April 2020.
SELECTION CRITERIA
We included randomized controlled trials of device-based circumcisions (crush or ligature circumcision devices) compared to standard surgical dissection-based circumcision conducted by health professionals in a medical setting.
DATA COLLECTION AND ANALYSIS
At least two review authors independently assessed study eligibility and extracted data from the included studies. We classified adverse events into serious, moderate or mild. We reported study results as risk ratios (RR) or mean differences (MD) using 95% confidence intervals (CI) and a random-effects model. We used the GRADE approach to evaluate the overall certainty of the evidence for each outcome.
MAIN RESULTS
Eighteen trials met the inclusion criteria. Trials were conducted in China, South Africa, Kenya and Zambia, Mozambique, Rwanda, Uganda and Zimbabwe. Primary outcomes Serious adverse events: there were no serious adverse events in either treatment arm (11 trials, 3472 participants). Moderate adverse events: there may be a slight increase in moderate adverse events when devices are used compared to standard surgical techniques (RR 1.31, 95% CI 0.55 to 3.10; I²= 68%; 10 trials, 3370 participants; low-certainty evidence); this corresponds to 8 more (ranging from 15 fewer to 84 more) moderate adverse events per 1000 participants. We downgraded the certainty of the evidence for study limitations and imprecision. Secondary outcomes Mild adverse events: we are uncertain about the difference in mild adverse events between groups when devices are used compared to standard surgical techniques (RR 1.09, 95% CI 0.44 to 2.72; I² = 91%; 10 trials, 3370 participants; very low-certainty evidence). We downgraded the certainty of the evidence for study limitations, imprecision and unexplained inconsistency. Operative time: operative time is probably about 17 minutes shorter when using a device rather than standard surgical techniques, which constitutes a clinically meaningful decrease in a procedure (MD -17.26 minutes, 95% CI -19.96 to -14.57; I² = 99%; 14 trials, 4812 participants; moderate-certainty evidence). We downgraded the certainty of the evidence for serious study limitations. The standard surgical technique generally takes about 24 minutes. There may be less postoperative pain during the first 24 hours when circumcision devices are used compared to standard surgical techniques (measured using a visual analog scale [VAS]; MD 1.30 cm lower, 95% CI 2.37 lower to 0.22 lower; I² = 99%; 9 trials, 3022 participants; low-certainty evidence). We downgraded the certainty of the evidence for study limitations and unexplained heterogeneity. There may be little or no difference in postoperative pain experienced during the first seven days when compared with standard surgical techniques (measured using a VAS; MD 0.11 cm higher, 95% CI 0.89 lower to 1.11 higher; I² = 94%; 4 trials, 1430 participants; low-certainty evidence). We downgraded the certainty of the evidence for study limitations and unexplained inconsistency. A higher score on the VAS indicates greater pain. Participants may slightly prefer circumcision devices compared to standard surgical techniques (RR 1.19, 95% CI 1.04 to 1.37; I² = 97%; 15 trials, 4501 participants; low-certainty evidence). We downgraded the certainty of the evidence for study limitations and unexplained inconsistency. We recorded satisfaction as a dichotomous outcome. Higher rates reflected greater satisfaction.
AUTHORS' CONCLUSIONS
We found that there were no serious adverse events reported when using a circumcision device compared to standard surgical techniques, but they may slightly increase moderate adverse effects, and it is unclear whether there is a difference in mild adverse effects. Use of circumcision devices probably reduces the time of the procedure by about 17 minutes, a clinically meaningful time saving. For patients, use of the circumcision device may result in lower pain scores during the first 24 hours and patients may be slightly more satisfied with it compared with standard surgical techniques. Clinicians, patients and policymakers can use these results in conjunction with their own contextual factors to inform the approach that best suits their healthcare settings. High-quality trials evaluating this intervention are needed to provide further certainty regarding the rates of adverse effects and postoperative pain of using devices compared to standard approaches.
Topics: Adolescent; Adult; Bias; Child; Circumcision, Male; Humans; Male; Middle Aged; Operative Time; Pain, Postoperative; Patient Preference; Randomized Controlled Trials as Topic; Young Adult
PubMed: 33786810
DOI: 10.1002/14651858.CD012250.pub2 -
Frontiers in Pediatrics 2016We performed a systematic review of the literature on preputial reconstruction (PR) during hypospadias repair to determine the cumulative risk of preputial skin...
INTRODUCTION
We performed a systematic review of the literature on preputial reconstruction (PR) during hypospadias repair to determine the cumulative risk of preputial skin complications and the influence of PR on urethroplasty complications, namely, fistula formation and overall reoperation rate of the repair.
MATERIALS AND METHODS
A systematic search of the literature published after 06/1995 was performed in 06/2015 using the keyword "hypospadias." Only studies on the outcome of PR in children, defined as dehiscence of the reconstructed prepuce or secondary phimosis needing circumcision, were selected. A meta-analysis of studies comparing PR vs. circumcision was performed for the outcomes "hypospadias fistula formation" and "reoperation rate."
RESULTS
Twenty studies were identified. Nineteen reported the outcome of PR in 2115 patients. Overall, 95% (2016/2115) of patients undergoing PR had distal hypospadias. The cumulative rate of PR complications was 7.7% (163/2115 patients), including 5.7% (121/2115 patients) preputial dehiscences and 1.5% (35/2117 reported patients) secondary phimoses needing circumcision. A meta-analysis of seven studies comparing patients undergoing PR vs. circumcision showed no increased risk of urethral fistula formation associated with PR, odds ratio (OR) (Mantel-Haenszel, Fixed effect, 95% CI), 1.25 (0.80-1.97). Likewise, two studies comparing the overall reoperation rate did not show an increased risk of reoperation associated with PR, OR (Mantel-Haenszel, Random effect, 95% CI), 1.27 (0.45-3.58).
CONCLUSION
PR carries an 8% risk of specific complications (dehiscence of reconstructed prepuce or secondary phimosis needing circumcision), but does not seem to increase the risk of urethroplasty complications, and the overall reoperation rate of hypospadias repair.
PubMed: 27200322
DOI: 10.3389/fped.2016.00041 -
Pediatric Surgery International Nov 2018Previous histological studies have shown a variable incidence of genital lichen sclerosus (LS). However, the results of these studies were inconsistent. To overcome the...
PURPOSE
Previous histological studies have shown a variable incidence of genital lichen sclerosus (LS). However, the results of these studies were inconsistent. To overcome the limitation of individual studies, we performed this systematic review to explore the true incidence of LS.
METHODS
A comprehensive search of Pubmed, Embase, Web of Science and Cochrane Library was performed including cross-referencing independently by two assessors.
RESULTS
A total of 22 articles published from 1980 to 2017 were included in our study. The proportion of LS in those with phimosis had been described in many literature studies, ranging from 2 to 95%. The actual incidence of LS is thought to be clinically underestimated by as much as 50%.
CONCLUSIONS
The true incidence of LS in boys is more common than previously realized. LS may be observed in foreskin with or without phimosis. The presence of acquired phimosis may be an aggravating factor in the incidence of LS. The diagnosis LS must be based on biopsy for acquired phimosis because clinical findings underestimated the incidence of LS.
Topics: Humans; Incidence; Lichen Sclerosus et Atrophicus; Male; Phimosis
PubMed: 30264374
DOI: 10.1007/s00383-018-4357-7 -
Journal of Pediatric Surgery Nov 2018To determine whether treatment of lichen sclerosus et atrophicus (LS), with topical steroids reduces the rate of circumcision.
PURPOSE
To determine whether treatment of lichen sclerosus et atrophicus (LS), with topical steroids reduces the rate of circumcision.
METHODS
Two independent reviewers performed a literature search of studies reporting treatment of LS with topical steroids using EMBASE and MEDLINE database(s).
INCLUSION CRITERIA
boys aged 0-18 years, clinical diagnosis of LS, treatment with topical steroids. Literature reviews, studies of phimosis without LS and adult patients were excluded. Data analysed for each paper included age, duration of treatment, length of follow up and outcome, notably circumcision or no surgery.
RESULTS
The original search identified 26 titles. Application of exclusion criteria left 6 articles for inclusion in the study. Eighty nine patients with LS were treated with topical corticosteroids. Circumcision was avoided in 31/89 (35%; range 0-100%). Median patient age was 6.5 years (1 month-15 years). Median duration of treatment was 2 months (1-23 months); median follow-up 4 months (6 weeks-5 years).
CONCLUSIONS
Treatment of LS with topical steroids reportedly avoided circumcision in 35% of boys. Duration of medical therapy and patient follow up in analysed studies were, however, short. A prospective randomised trial would provide a definitive answer.
TYPE OF STUDY
Systematic review.
LEVEL OF EVIDENCE
III.
Topics: Administration, Topical; Adolescent; Balanitis Xerotica Obliterans; Child; Child, Preschool; Circumcision, Male; Humans; Infant; Infant, Newborn; Lichen Sclerosus et Atrophicus; Male; Steroids
PubMed: 29395150
DOI: 10.1016/j.jpedsurg.2017.12.021