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Journal of Pediatric Urology Apr 2017
Topics: Balanitis; Balanitis Xerotica Obliterans; Child; Circumcision, Male; Hemorrhage; Humans; Lichen Sclerosus et Atrophicus; Male
PubMed: 28089293
DOI: 10.1016/j.jpurol.2016.11.013 -
Journal of Pediatric Urology Apr 2017We review outcomes after management of meatal balanitis xerotica obliterans (BXO). The primary outcome was recurrent meatal BXO.
INTRODUCTION
We review outcomes after management of meatal balanitis xerotica obliterans (BXO). The primary outcome was recurrent meatal BXO.
METHODS
A database comprising mostly hypospadias patients was queried for meatal BXO. The disease was confirmed histologically in all cases. Management included topical steroids and/or immunosuppressants, and/or surgical excision of BXO with two-stage oral mucosa graft circumferential replacement urethroplasty.
RESULTS
A total of 12 patients had meatal BXO (8 boys and 4 adults). Of these, 10 had hypospadias, two presenting without prior surgery and eight returning 5-30 years after one or multiple (n = 2) repairs. Another two boys did not have hypospadias: one developing BXO 10 years after newborn circumcision and the other having persistent meatal BXO following therapeutic circumcision. Topical and intraluminal steroids (1% betamethasone or clobetasol) and tacrolimus were used for ≥12 weeks each as primary therapy or for meatal recurrence in a total of six cases. Complete response with resolution of white discoloration and relief of stranguria only occurred in two of the three receiving clobetasol, with follow up ≤12 weeks. BXO excision and urethroplasty was done in 11 patients, 10 using oral mucosa grafts; one with a focal lesion and a negative frozen section had reoperative TIP. Of the 10 undergoing excision with two-stage replacement urethroplasty, six remain disease free at a mean follow-up of 23 months (8-48 months), and four had recurrent stranguria and visible meatal BXO at a median of 26 months (22-105 months). Three of the four with recurrences had additional treatment and one was lost to follow-up. All initially had topical steroids, and two also used tacrolimus, without clinical resolution. These three then underwent a second BXO excision and two-stage oral graft replacement urethroplasty. In two recurrences, BXO was found invading from the meatus proximally within oral mucosa (Figure). Of these three with secondary urethroplasties, two are free of disease at 6 and 18 months, and the third had another meatal recurrence 6 months after the second stage.
DISCUSSION
We found topical steroids and immunosuppressants to have limited efficacy, with two clinical complete responses achieved only with clobetasol in patients with short follow-up. Forty percent of patients recurred at 2-9 years after visually complete BXO excision and two-stage oral mucosa graft replacement urethroplasty, and in two cases disease invaded into oral mucosa, the first well-documented cases of this occurrence.
Topics: Adult; Age Factors; Balanitis Xerotica Obliterans; Child; Child, Preschool; Databases, Factual; Follow-Up Studies; Humans; Hypospadias; Infant, Newborn; Male; Mouth Mucosa; Plastic Surgery Procedures; Recurrence; Reoperation; Retrospective Studies; Risk Assessment; Severity of Illness Index; Steroids; Surgical Flaps; Treatment Outcome; Urologic Surgical Procedures, Male; Young Adult
PubMed: 28089110
DOI: 10.1016/j.jpurol.2016.10.014 -
Journal of Pediatric Urology Apr 2017Over 27,000 circumcisions were performed in England in 2012-13. The complication rate is generally perceived to be low, although published figures vary widely. Balanitis...
INTRODUCTION
Over 27,000 circumcisions were performed in England in 2012-13. The complication rate is generally perceived to be low, although published figures vary widely. Balanitis xerotica obliterans, more correctly termed Lichen Sclerosus et atrophicus (LS), is one of the commonest indications for medical circumcision. To test the hypothesis that children undergoing circumcision for LS have a higher rate of postoperative bleeding than those undergoing the procedure for other reasons, we retrospectively reviewed records for patients undergoing circumcision.
METHODS
The disease and procedure coding system was used to identify patients who underwent circumcision (ICD10 code N303) between 2000-2010. Cases with a diagnosis unrelated to circumcision and children circumcised during hypospadias repair were excluded. Bleeding which required return to theatre for surgical arrest was considered significant. Cases were identified by review of medical records if there was: a second procedure during the same admission, or readmission coded for circumcision within 2 weeks. Only cases with histologically confirmed LS were included in the LS cohort. GraphPad online calculator was used for statistical analysis (two tailed Fisher's exact test.
RESULTS
2385 boys with a median age of 4 years (range 0-16) were included in the study. Indication for circumcision included religious (1305, 54.7%), phimosis or redundant prepuce (512, 21.5%), suspected LS (366, 15.4%) and balanoposthitis (202, 8.5%). LS was histologically confirmed in 262 (10.9%) boys. Fourteen (0.6%) patients returned to theatre for surgical arrest of bleeding following circumcision; 6 had LS and 8 did not (Table 1). The bleeding rate was higher in those with LS (2.3%) than in those without (0.3%), P = 0.0003 with a relative risk of 6.08.
CONCLUSION
Post-operative complications are distressing, especially if further surgery is required. Published figures for complications following circumcision vary widely making counseling regarding risk difficult. Since LS includes an inflammatory element and circumcision in widespread LS can be challenging, the observation of more post-operative bleeding in patients with histologically confirmed LS during a previous audit prompted the hypothesis that this may be a significant finding. Thus we reviewed all patients requiring return to theatre within 2 weeks of circumcision, finding that whilst the overall bleeding rate was low, circumcision for LS significantly increased the risk. Although factors such as the severity of LS and surgical technique were not assessed, this is still a notable finding which should be reflected during pre-operative counseling.
Topics: Age Factors; Balanitis Xerotica Obliterans; Child; Child, Preschool; Circumcision, Male; Databases, Factual; Follow-Up Studies; Hemostasis, Surgical; Humans; Infant; Infant, Newborn; Lichen Sclerosus et Atrophicus; Male; Postoperative Hemorrhage; Reoperation; Retrospective Studies; Risk Assessment; Treatment Outcome; United Kingdom
PubMed: 28043767
DOI: 10.1016/j.jpurol.2016.10.023 -
The Urologic Clinics of North America Feb 2017Lichen sclerosis (LS) is a chronic, relapsing disease with a variable presentation. In men, genitourinary LS may affect the penile foreskin, glans, meatus, and urethra.... (Review)
Review
Lichen sclerosis (LS) is a chronic, relapsing disease with a variable presentation. In men, genitourinary LS may affect the penile foreskin, glans, meatus, and urethra. Treatment is multifaceted, ranging from pharmacotherapy to surgery. Urethral reconstruction due to stricture disease from LS is frequently plagued by a high recurrence rate. At the authors' institution, the high recurrence rate has shifted their practice toward potent steroids and minimally invasive surgical techniques. Management of recurrence includes dilation, meatotomy/meatoplasty, 1-stage and 2-stage repairs. Recalcitrant cases may necessitate abandonment of most of the urethra resulting in a perineal urethrostomy.
Topics: Humans; Lichen Sclerosus et Atrophicus; Male; Plastic Surgery Procedures; Treatment Outcome; Urethra; Urethral Stricture; Urologic Surgical Procedures, Male
PubMed: 27908374
DOI: 10.1016/j.ucl.2016.08.004 -
Cirugia Pediatrica : Organo Oficial de... Jul 2015Balanitis xerotica obliterans (BXO) is a chronic inflamatory disease, a genital form of Lichen Sclerosus in males.
OBJECTIVES
Balanitis xerotica obliterans (BXO) is a chronic inflamatory disease, a genital form of Lichen Sclerosus in males.
MATERIAL AND METHODS
This retrospective and descriptive analysis was carried out by rewiew of the medical records of boys who underwent circumcision from April 2013 to April 2014. The study group consisted of boys that were circumcised due it persistant phimosis at 4 years of age, urinary symptoms or painful erection. The histopathological examination was performed only in patients with clinical suspicion of BXO.
RESULTS
339 patients were circumcised. The mean age of surgery was 6.5 years (Median 5, Mode 4). BXO was confirmed in eleven boys (3.9%) out of 16 biopsies (5.7%), with a mean age of 8.2 years (6-12). Of all the biopsies that were analysed for clinical BXO, 9 had scarring phimosis (2 meatal stenosis), 2 had balanitis and 1 had acute urinary retention, 2 presented descamative foreskin or glands, and 1 had recurrent phimosis. The histopathological examination revealed lichen sclerosus in 10 patients. Meatotomy was performed in 3 boys, one of them in during the follow-up period. 10 patients with BXO were treated with topical corticosteroid cream after circumcision.
CONCLUSIONS
Our incidence is low in compared to literature (10-40%) as we did not refer the foreskin routinely to histopathological analysis. The clinical suspicion underestimates the incidence of BXO up to 49%. The circumcision is curative in most cases with BXO. The BXO may produce meatoestenosis and urethral abnormalities, and it is associated with a high incidence of penile carcinoma of the penis.
PubMed: 27775307
DOI: No ID Found -
Journal of Pediatric Urology Feb 2017Repair of severe primary and revision hypospadias is a demanding procedure. Debate continues as to whether a two-stage approach or single-stage technique is superior....
INTRODUCTION
Repair of severe primary and revision hypospadias is a demanding procedure. Debate continues as to whether a two-stage approach or single-stage technique is superior. The two-stage procedure with a free graft involves penile straightening followed by application of a graft for the neourethral plate at stage one; with tubularization at stage two after graft maturation.
OBJECTIVE
To report the outcomes of a single surgeon's experience with the two-stage repair using a free graft for both severe primary and revision hypospadias with long-term follow-up.
MATERIALS AND METHODS
Between July 1998 and January 2010, 301 boys underwent a two-stage reconstruction. The surgical technique is described in the manuscript. Primary repairs (n = 208): indications for a two-stage approach with a free graft included meatal position, presence of corporal chordee, and poor glans development. Median follow-up from completion of the second stage was 75 months. Revision repairs (n = 93): indications included urethral fistula, excessive scarring/meatal stenosis, balanitis xerotica obliterans (BXO), and residual or untreated chordee. Median follow-up from completion of the second stage was 85 months.
RESULTS
For the primary repairs (n = 208), the graft took well in all but one case. Second-stage complications included fistula (7), meatal stenosis (3), partial glans dehiscence (3), and all were re-operated (13). For the revision repairs (n = 93), the graft took well in all but four cases. Second-stage complications included fistula (5), meatal stenosis (3), breakdown (1) and reoperation (8).
DISCUSSION
In a systematic review of 20 years of publications on the repair of primary severe hypospadias, the two-stage procedure with a free graft demonstrated an overall complication rate of 22%; this was a distinct overall benefit when compared with the single-stage procedures in terms of lower complication rates (Castagnetti and El-Ghoneimi, 2010). Our results for the severe primary repairs revealed significantly lower complication rates than those in the literature, with an overall re-operation rate of 6.3%, a fistula rate of 3.4%, and meatal stenosis and partial glans dehiscence at 1.4% each. Several papers have documented outcomes following the single-stage tubularized incised plate urethroplasty for re-operative hypospadias, giving overall complication rates ranging from 15.4 to 30%. Our data show a re-operative rate of 8.6%, a fistula rate of 5.3%, breakdown in 1.1%, and meatal stenosis in 3.2%.
CONCLUSION
The two-stage repair with a free graft for correction of both severe primary and failed primary hypospadias is a safe, viable, and durable procedure offering low morbidity and excellent cosmetic results. The authors advocate the two-stage repair with a free graft as the technique of choice for treatment of both of these challenging groups of the deformity.
Topics: Child; Child, Preschool; Follow-Up Studies; Humans; Hypospadias; Infant; Male; Plastic Surgery Procedures; Reoperation; Retrospective Studies; Surgical Flaps; Time Factors; Treatment Outcome; Urethra; Urodynamics; Urologic Surgical Procedures, Male
PubMed: 27746246
DOI: 10.1016/j.jpurol.2016.08.014 -
Acta Dermato-venereologica Mar 2017Lichen sclerosus is a chronic inflammatory disease associated with substantial morbidity. Knowledge of the aetiology and progression of lichen sclerosus is therefore...
Lichen sclerosus is a chronic inflammatory disease associated with substantial morbidity. Knowledge of the aetiology and progression of lichen sclerosus is therefore needed. In this cross-sectional study, 100 male patients diagnosed with lichen sclerosus were interviewed and examined. Since there is a possible link between lichen sclerosus and autoimmunity, blood tests were analysed for thyroid disease, antinuclear antibodies and antibodies to extracellular matrix protein 1, but autoimmunity was found to be infrequent. In 72 participants active genital lichen sclerosis was observed and complications were common; 27 patients had preputial constriction and 12 meatal engagement. In total, 13 patients needed a referral to the Department of Urology, including 1 patient with suspected penile cancer. In conclusion, despite available treatment with ultra-potent steroids and circumcision, lichen sclerosus in males is frequently complicated by phimosis and meatal stenosis. However, the disease can also go into remission, as seen in 27% of our patients.
Topics: Adult; Aged; Autoantibodies; Autoimmunity; Balanitis Xerotica Obliterans; Biomarkers; Circumcision, Male; Cross-Sectional Studies; Humans; Male; Middle Aged; Penis; Phimosis; Remission Induction; Retrospective Studies; Serologic Tests; Skin; Treatment Outcome; Urethral Stricture
PubMed: 27671756
DOI: 10.2340/00015555-2537 -
International Journal of Molecular... Sep 2016Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder of unclear etiology. The etiology and the exact molecular mechanisms underlying the disease...
Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder of unclear etiology. The etiology and the exact molecular mechanisms underlying the disease are still unknown. The human transglutaminase (TG) family consists of several proteins with catalytic activity essential for biological processes. In the present research we investigated the transcript levels of three TGs in patients operated on for congenital phimosis without or with histologically confirmed BXO; Thirty children with acquired phimosis were enrolled. The removed foreskins were sent both for histological diagnosis and for quantitative real-time PCR to evaluate the transcript levels of keratinocyte (TG1), tissue (TG2), and epidermal (TG3) transglutaminase; We observed a decrease in TG1 and TG3 transcripts by about 70% (p < 0.001) in foreskins from patients with BXO (n = 15) in comparison with patients without BXO (n = 15) and an increase in TG2 mRNA levels by 2.9 folds (p < 0.001); Reduced expression of both TG1 and TG3 was associated with the altered structure of the foreskin in BXO and can be a consequence of damage to keratinocytes. Increased expression of TG2 can be the result of chronic inflammation. TG2 overexpression can play a pivotal role in triggering and maintaining the inflammatory response in BXO patients.
Topics: Adolescent; Balanitis Xerotica Obliterans; Blotting, Western; Cadherins; Child; Child, Preschool; Foreskin; Gene Expression Profiling; Gene Expression Regulation, Enzymologic; Humans; Interferon-gamma; Isoenzymes; Male; Phimosis; Reverse Transcriptase Polymerase Chain Reaction; Transglutaminases
PubMed: 27649154
DOI: 10.3390/ijms17091551 -
Journal of Clinical and Diagnostic... Jul 2016The penile circular fasciocutaneous flap (FCF) is employed in the successful single stage reconstruction of long segment complex anterior urethral strictures especially...
The penile circular fasciocutaneous flap (FCF) is employed in the successful single stage reconstruction of long segment complex anterior urethral strictures especially when buccal mucosa is unavailable due to various reasons. A 65-year-old gentleman, chronic smoker and tobacco chewer, hypertensive on treatment, presented with obstructive lower urinary tract symptoms for 8 months. He had no prior urethral catheterization. On examination, he had circumcised penis, with stenosis of the external urethral meatus. Glans had no changes suggesting balanitis xerotica obliterans. Suprapubic cystostomy was done as he developed acute urinary retention during evaluation. Retrograde urethrogram (RGU) showed pan-anterior urethral stricture. He was planned for substitution urethroplasty. On oral cavity examination, he had moderate trismus with oral submucous fibrosis. As buccal mucosal graft was unavailable, he was planned for FCF. A ventral onlay tubularization FCF urethroplasty from meatus to bulbar urethra based on dartos dorsal pedicle was done. His postoperative recovery was uneventful. Pericatheter RGU did not show extravastion and he voided well with Qmax 14 ml/second. He is doing well at follow-up.
PubMed: 27630900
DOI: 10.7860/JCDR/2016/20404.8117 -
Pediatrics May 2016As a consequence of the discussion on whether the health benefits of newborn male circumcision outweigh the risks and the discrepancies in reported figures of...
OBJECTIVE
As a consequence of the discussion on whether the health benefits of newborn male circumcision outweigh the risks and the discrepancies in reported figures of complications, we evaluated the incidence and morbidity of foreskin surgery due to medical indications in boys from the Capital Region of Denmark in 2014.
METHODS
Medical records from all boys operated on the foreskin due to medical reasons in the Capital Region in 2014 were reviewed. Patients with hypospadias, ritual circumcision, and redo-surgery because of complications to nontherapeutic circumcision were excluded.
RESULTS
A total of 181 patients were included. The cumulative risk of undergoing foreskin operation before 18 years of age was 1.7%. Forty patients had histologic verified balanitis xerotica obliterans (BXO) corresponding to a total risk of 0.37% of developing BXO. Mean age at surgery was 10.1 years (range 1-17). Phimosis was the most frequently reported indication (95.0%). The remaining 5.0% underwent surgery because of frenulum breve causing problems during erection. Before surgery, 27.1% had foreskin-related voiding problems and 17.1% had at least 1 episode of balanitis. Circumcision was initially performed in 44 cases. The remaining 137 patients had a foreskin-preserving operation performed. Nine boys had secondary circumcision after initially having foreskin-preserving operation. Fifty patients initially had preputial histology performed. BXO was verified in 37 patients. Of the 9 patients with redo-surgery due to recurrent phimosis, a further 3 had histologically verified BXO.
CONCLUSIONS
Childhood foreskin-related problems in a region with no tradition of newborn male circumcision should not be neglected.
Topics: Adolescent; Balanitis Xerotica Obliterans; Child; Child, Preschool; Denmark; Foreskin; Humans; Incidence; Infant; Infant, Newborn; Male; Phimosis; Retrospective Studies
PubMed: 27244821
DOI: 10.1542/peds.2015-4340