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The Surgeon : Journal of the Royal... Jun 2020Symptomatic phimosis is a common childhood urology complaint. Circumcision was traditionally the treatment of choice, but its popularity in cases of non-scarred phimosis...
BACKGROUND
Symptomatic phimosis is a common childhood urology complaint. Circumcision was traditionally the treatment of choice, but its popularity in cases of non-scarred phimosis has been superseded by more conservative methods like preputioplasty. We sought to examine outcomes of preputioplasty for the treatment of non-scarred pathological phimosis in two UK paediatric surgery tertiary centres.
METHODS
Retrospective case series selecting cases performed in both departments over a 4 year period (January 2012-December 2015).
INCLUSION CRITERIA
non-scarred pathological phimosis treated with preputioplasty.
EXCLUSION CRITERIA
diffuse scarring of foreskin or presence of balanitis xerotica obliterans (BXO), preputioplasty performed as part of hypospadias repair. Outcome measure was treatment success as evidenced by fully retractile prepuce at follow up. Follow up occurred between 3 and 24 months.
RESULTS
We identified 126 patients, 6 were excluded due to the above criteria. Median age was 13.4 years (range 10 months-18 years). Median follow up was 13 months (range 3-24 months). 115 patients (96%) had successful treatment as evidenced by satisfactory post-operative cosmesis and complete resolution of phimosis at follow up. Recurrence of phimosis occurred in 5 patients (4%). Mean time of recurrence was 6 months, with a median age of recurrence of 15.3 years (range 10.7-16.7 years). All patients with recurrence were successfully treated with circumcision.
CONCLUSION
Foreskin conserving methods like preputioplasty are a valid option in the treatment of non-scarred pathological phimosis.
Topics: Adolescent; Child; Child, Preschool; Circumcision, Male; Humans; Infant; Male; Patient Satisfaction; Phimosis; Plastic Surgery Procedures; Recurrence; Retrospective Studies; Treatment Outcome
PubMed: 31548120
DOI: 10.1016/j.surge.2019.08.004 -
Urology Jul 2020We present an unusual case of isolated urethral tuberculosis. The patient had a history of urethral strictures and persistent discharge from two peno-scrotal fistulas...
We present an unusual case of isolated urethral tuberculosis. The patient had a history of urethral strictures and persistent discharge from two peno-scrotal fistulas which was confirmed on urethrogram. He was treated with antitubercular treatment and a two stage urethroplasty.
Topics: Balanitis Xerotica Obliterans; Cutaneous Fistula; Humans; Male; Middle Aged; Tuberculosis, Urogenital; Urethral Diseases; Urinary Fistula
PubMed: 32325139
DOI: 10.1016/j.urology.2020.04.035 -
Journal of Pediatric Surgery May 2024We describe meatal outcomes for boys undergoing circumcision to treat Lichen Sclerosus (LS/BXO) with a focus on those who underwent meatotomy/meatoplasty at circumcision...
PURPOSE
We describe meatal outcomes for boys undergoing circumcision to treat Lichen Sclerosus (LS/BXO) with a focus on those who underwent meatotomy/meatoplasty at circumcision and factors associated with post-circumcision meatal intervention.
METHODS
Retrospective review of patients undergoing circumcision for histologically confirmed LS between 2011 and 2020. Statistical testing was by Chi2 and multivariate analysis.
RESULTS
382 patients underwent circumcision at a mean of 9.1 years (SD 2.9). At circumcision, LS on the glans was documented in 213/365 (58%). Meatal involvement was documented in 74/382 (19%); 25/382 (6.5%) had a meatotomy, 94/382 (25%) had meatal calibration/dilatation and 234/367 (64%) were prescribed post-operative topical steroids. Patients with LS glans or meatal involvement were more likely to have a meatotomy (p = 0.0013) and to receive post-operative steroids (OR 5, p = 0.0001). Post circumcision, 40/382 (10%) required a median of 1 subsequent procedure (range 1-5), 10 (2.6%) underwent dilatation, 30 (7.4%) had a meatotomy. Patients undergoing meatotomy at circumcision had an odds ratio (OR) of 1.2 for subsequent meatotomy (p = 0.027). Analysis based on requirement for any subsequent procedure identified an OR of 3.1 for having had a meatotomy at circumcision (p = 0.022) and an OR of 6.0 of receiving post-operative steroids (p=<0.001).
CONCLUSIONS
Meatal stenosis following circumcision for LS requiring meatal intervention affected 10% of boys. Meatotomy at circumcision increased the likelihood of subsequent meatal intervention and is therefore not recommended.
LEVEL OF EVIDENCE
Level III.
PubMed: 38862295
DOI: 10.1016/j.jpedsurg.2024.05.010 -
Asian Journal of Surgery May 2021
Topics: Balanitis Xerotica Obliterans; Child, Preschool; Foreskin; Hand, Foot and Mouth Disease; Humans; Male
PubMed: 33752984
DOI: 10.1016/j.asjsur.2021.02.014 -
Journal of Pediatric Urology Jun 2024It is estimated that approximately one out of 200 boys has the diagnosis of lichen sclerosus (LS), previously referred to as BXO (balanitis xerotica obliterans). Severe...
INTRODUCTION
It is estimated that approximately one out of 200 boys has the diagnosis of lichen sclerosus (LS), previously referred to as BXO (balanitis xerotica obliterans). Severe progressive disease is rare however, mismanagement of urethral tissues may contribute to progression of LS.
STUDY DESIGN
The current literature regarding the management of severe lichen sclerosus was reviewed alongside our management of seven patients with ages ranging from six to ten years of age with severe lichen sclerosus who required surgical intervention. These patients were identified out of a busy pediatric practice that saw 5507 patients during the four-year span. Based on the pathophysiology of lichen sclerosus, urethral anatomy, and our management an algorithm was developed for medical and surgical management.
RESULTS
All patients received initial medical treatment with topical steroids. Three patients underwent urethral mobilization and serial biopsy. One of these patients with severe disease required a second distal urethral mobilization. Three patients were treated with circumcision, and one is responding well to topical steroids after complex reconstruction. None developed postoperative urethral disease.
DISCUSSION
Lichen sclerosus affects squamous epithelium but can extend to unaffected tissue if traumatized via the Koebner phenomenon. There are no randomized control trials for the management of the disease. Thus, appropriate early management with avoidance of urethral dilation or incision may prevent extension down the urethra that can lead to severe stricture disease. Several authors identified this as one of the worst forms of stricture diseases to manage. Based on the pathophysiology of the disease and our 4-year experience treating patients, we propose an algorithm for management of severe lichen sclerosus in boys. The diagnosis of lichen sclerosus in boys requires a high level of suspicion, and early biopsies should be obtained if suspected. If identified before circumcision or meatotomy, initial treatment should be medical. If the patient fails topical steroid therapy, circumcision and biopsy are the initial recommended surgical approach. Optimally, a biopsy with the first meatotomy establishes the diagnosis. If the disease persists, urethral mobilization may represent a curative treatment as it advances healthy urethra and allows complete removal of distal squamous epithelium instead of traumatic repeated dilations or incisions.
CONCLUSION
This paper summarizes the available literature on the management of severe LS and provides a flow diagram based on the pathophysiology of the disease and our experience sever cases.
PubMed: 38918118
DOI: 10.1016/j.jpurol.2024.06.007 -
Journal of Pediatric Surgery Apr 2020Lichen sclerosus (LS), (balanitis xerotica obliterans), causes pathological phimosis. Many boys present with obstructive symptoms, the cause is usually obvious on...
BACKGROUND
Lichen sclerosus (LS), (balanitis xerotica obliterans), causes pathological phimosis. Many boys present with obstructive symptoms, the cause is usually obvious on examination so ultrasound scans (USS) of the urinary tract are not routinely indicated. We review a series of abnormal USS in boys with LS.
METHODS
Retrospective note review for boys undergoing surgical treatment for LS between 2000 and 2017. Seventy-eight boys had a USS prior to surgery, those with abnormal USS form the study population. Boys with neuropathic bladder or congenital urinary tract abnormalities were excluded.
RESULTS
Nineteen of 78 boys (24%), mean age 9 years, were included. Seventeen had obstructive symptoms, 13 had culture proven UTIs, 12 had new onset incontinence. On USS 3 (17%) had acute retention, 8 (78%) had an isolated post-void residual volume (PVR) >10% of estimated bladder capacity (EBC); 3 had bladder wall thickening +/- PVR >10%, 5 had upper tract changes. Symptoms resolved with successful treatment of LS. Six boys had post treatment USS, abnormalities resolved in 5.
CONCLUSIONS
Clinicians should consider LS in boys presenting with UTIs, new onset incontinence and obstructive urinary tract symptoms. Routine USS are not indicated though should be considered in those with an atypical history or examination.
TYPE OF STUDY
Case Series.
LEVEL OF EVIDENCE
Level 4.
Topics: Adolescent; Balanitis Xerotica Obliterans; Child; Child, Preschool; Humans; Male; Phimosis; Retrospective Studies; Ultrasonography; Urinary Bladder Neck Obstruction; Urinary Incontinence; Urinary Retention
PubMed: 31455543
DOI: 10.1016/j.jpedsurg.2019.07.020