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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 -
Cirugia Pediatrica : Organo Oficial de... Oct 2017Balanitis xerotica obliterans (BXO) is a disease of the skin and mucosa of male genitals of unknown etiology that may affect children of any age. It has a low incidence...
AIM
Balanitis xerotica obliterans (BXO) is a disease of the skin and mucosa of male genitals of unknown etiology that may affect children of any age. It has a low incidence (9-19%) and in adults is considered a potential premalignant lesion. The aim of our study is to establish the incidence of BXO in our center and to determine its correlation between the clinical and immunohistochemical (IHC) findings.
METHODS
Prospective cohort including all children < 14 years with foreskin pathology that required a circumcision between 2014-2016. Statistical analysis of the clinical characteristics, histological and IHC findings searching for inflammatory response, premalignant lesions and microbiological findings.
RESULTS
A total of 176 boys with phimosis had circumcision with a mean age of 7 ± 3 years (Range 2-14). Presurgical diagnosis of BXO was suspected in 28.4% (n= 50) whereas the AP confirmed a total of 29.5% (n= 53) with a very good interobserver concordance (kappa= 0.81: p< 0.01). Previous treatment with corticoids in BXO was found in 63.5% (n= 33/52). Meatal stenosis was found in 7.69% (n= 4/52) requiring meatal/urethral dilations. Patients with BXO had a T-Lymphocytes CD3+ mediated inflammatory response with a positive correlation between tumor suppressing protein (p53) expression and chronic inflammation.
CONCLUSIONS
BXO is a chronic inflammatory disease mediated by T-lymphocytes with an incidence greater than previously reported. Surgeons' criterion has a very good concordance with the AP findings. The elevation of p53 in children with BXO may indicate a plausible malignant potential that may require a surgical treatment (circumcision) and an adequate follow-up.
Topics: Adolescent; Balanitis Xerotica Obliterans; Child; Child, Preschool; Circumcision, Male; Cohort Studies; Foreskin; Humans; Incidence; Inflammation; Male; Phimosis; Prospective Studies; T-Lymphocytes; Tumor Suppressor Protein p53
PubMed: 29266891
DOI: No ID Found -
Arab Journal of Urology Dec 2017To evaluate the presence of balanitis xerotica obliterans (BXO), clinically and pathologically, in the urethra of boys with failed previous hypospadias repair and where...
OBJECTIVES
To evaluate the presence of balanitis xerotica obliterans (BXO), clinically and pathologically, in the urethra of boys with failed previous hypospadias repair and where surgical management was planned.
PATIENTS AND METHODS
Between February 2010 and March 2015, boys with failed distal penile hypospadias repair who were planned for surgical management were evaluated for the presence of clinical and pathological evidence of BXO. Samples were obtained from the urethral plate and fossa navicularis, after obtaining informed consent and ethical approval. The samples were fixed, sectioned, and haematoxylin and eosin stained for light microscopic examination.
RESULTS
In all, 157 boys were enrolled in our study, with a mean (SD) age of 6.4 (2.8) years. All the boys had a history of failed hypospadias repair surgeries (once or more). The presentation was fistula in 34 boys (21.7%), meatal stenosis in 45 (28.7%), urethral stricture in 28 (17.8%), and total dehiscence in 50 (31.8%). BXO was detected clinically in 46 boys (29.3%). The total number of biopsies taken was 314, of which 124 (39.5%) were pathologically BXO-positive samples. Of the 157 boys, BXO-positive cases were clinically associated with fistula in seven boys (4.5%), meatal stenosis in 18 (10.8%), urethral stricture in seven (4.5%), and total dehiscence in 15 (9.6%). Of the 314 pathological samples, pathologically BXO-positive samples were associated with fistula in 20 samples (6.4%), meatal stenosis in 40 (12.7%), urethral stricture in 22 (7%), and total dehiscence in 42 (13.4%).
CONCLUSIONS
In failed hypospadias cases BXO should be considered, especially for cases with multiple failures, meatal stenosis, and total dehiscence. Urethral plate and fossa navicularis biopsies are important in planning a proper approach for subsequent repair.
PubMed: 29234536
DOI: 10.1016/j.aju.2017.08.002 -
Global Pediatric Health 2017This study investigated whether boys with balanitis xerotica obliterans (BXO) have increased rates of obesity compared with boys with no concern for BXO (NCB). Boys...
This study investigated whether boys with balanitis xerotica obliterans (BXO) have increased rates of obesity compared with boys with no concern for BXO (NCB). Boys ≤18 years old with circumcision pathology-confirmed BXO were compared with an age-matched group who had NCB during circumcision. Boys with BXO were found to have a mean body mass index of 70.64 percentile for age compared with 52.43 percentile in age-matched controls ( = .0005). The rate of obesity was significantly higher in boys with BXO (42%) compared with 12.4% in boys with NCB (odds ratio = 5.12; 95% CI = 2.6 to 10.06). Given the increasing rates of childhood obesity and the long-term health consequences of both BXO and obesity, special attention should be paid to this population. Further research is needed to determine if BXO in obese children may represent an early indicator of a systemic disease process where intervention may be warranted.
PubMed: 29204461
DOI: 10.1177/2333794X17742749 -
American Journal of Men's Health Mar 2018Squamous cell carcinoma (SCC) of the bulbar urethra accompanied by lichen sclerosus (LS) is rarely reported. This study reports the case of a 56-year-old man with...
Squamous cell carcinoma (SCC) of the bulbar urethra accompanied by lichen sclerosus (LS) is rarely reported. This study reports the case of a 56-year-old man with urethral squamous cell carcinoma (USCC) accompanied by a long history of genital LS. The man presented with a painful perineal mass and had a long-term history of urethral strictures and urethral dilatation. The patient developed a periurethral abscess that expanded to the perineum and formed an urethrocutaneousperineal fistula. An organ-sparing perineal resection and fistulectomy was performed according to the patient's wishes. During the operation, residue-like pus mixed with necrotic tissues drained out. A section of the prepuce and the necrotic tissues were sent for histological analysis. Hematoxylin and eosin (HE) staining of the excised prepuce revealed classical LS. HE and immunohistochemical (IHC) staining of the necrotic tissues showed well-differentiated USCC. IHC staining showed the USCC to be positive for P53 and Ki-67 and negative for P16, suggesting the USCC was probably associated with LS. The patient received high-dose chemotherapy and radiation therapy and died 10 months after surgery.
Topics: Carcinoma, Squamous Cell; Comorbidity; Fatal Outcome; Humans; Lichen Sclerosus et Atrophicus; Male; Middle Aged; Urethra
PubMed: 29182032
DOI: 10.1177/1557988317743386 -
Journal of Pediatric Urology Feb 2018Balanitis xerotica obliterans (BXO) is a common condition that can affect the foreskin, glans, meatus, and urethra, and rarely can also involve urethra leading to...
INTRODUCTION
Balanitis xerotica obliterans (BXO) is a common condition that can affect the foreskin, glans, meatus, and urethra, and rarely can also involve urethra leading to stricture. Numerous procedures have been suggested to treat urethral stricture secondary to BXO but these have had variable results.
OBJECTIVE
We describe the first prospective study of a single stage buccal mucosal inlay grafting in children with urethral strictures resistant to existing remedies.
MATERIALS AND METHODS
We treated five boys with resistant urethral strictures secondary to BXO with a single stage buccal mucosal inlay graft (BMIG, Figure). Uroflowmetry was performed both pre- and post-operatively. Functional outcome was the prime measure determining success.
RESULT
All the boys had a successful functional outcome and all expressed satisfaction with cosmetic outcome as well. Uroflow parameters improved remarkably, with maximum and mean urinary flow rates significantly improved from 4.2 mL/s to 26 mL/s (p = 0.0002) and from 1.6 mL/s to 12.2 mL/s (p = 0.003), respectively. Median follow-up was 34 months (range 30-42 months).
DISCUSSION
This paper is the first to describe the successful use of buccal mucosal inlay grafts to treat refractory BXO stricture in children. Various surgical techniques have been proposed particularly in adults including single vs. staged procedures, preputial and post auricular grafts, circular mucosal buccal grafts, as well as double mucosal grafts placed both ventrally and dorsally. All of these procedures are not without problems, and had variable results and outcome. Most of the procedures have been described in adult urethra and are not suitable for paediatric small calibre urethra. Our technique of dorsal inlay graft gives a robust structure to the distal urethra avoiding diverticula, pooling or urine spraying and can be placed onto proximal urethra as well. We have not seen recurrence of BXO in our buccal grafts, which is reported in other grafts from prepuce and post auricular grafts. The number of patients presented in our study is limited, nonetheless an excellent result in all our cases makes this a compelling approach to manage BXO urethral strictures. An early intervention in such cases is paramount to convert a salvage operation to a pre-emptive procedure.
CONCLUSION
A single stage buccal mucosal inlay grafting in children with BXO stricture can offer an excellent outcome.
Topics: Adolescent; Balanitis Xerotica Obliterans; Biopsy, Needle; Child; Graft Survival; Humans; Immunohistochemistry; Male; Mouth Mucosa; Prognosis; Recovery of Function; Retrospective Studies; Risk Assessment; Sampling Studies; Surgical Flaps; Treatment Outcome; Urethral Stricture; Urologic Surgical Procedures, Male; Young Adult
PubMed: 29150196
DOI: 10.1016/j.jpurol.2017.09.015 -
Journal of Clinical and Diagnostic... Jul 2017Penile carcinoma is considered a delayed sequel of lichen sclerosus. It is important to recognize this not so uncommon complication in time as survival of patients with...
Penile carcinoma is considered a delayed sequel of lichen sclerosus. It is important to recognize this not so uncommon complication in time as survival of patients with Squamous Cell Carcinoma (SCC) depends on early diagnosis and treatment. We describe a case of a 49-year-old male presenting with urethral stricture due to lichen sclerosus. He was treated for stricture disease and later on developed SCC penis after ten years of presentation.
PubMed: 28892974
DOI: 10.7860/JCDR/2017/26330.10254 -
Urology Dec 2017To characterize the physical features and reconstructive outcomes of a series of idiopathic urethral strictures (IUS) in an effort to elucidate the nature of this common...
OBJECTIVE
To characterize the physical features and reconstructive outcomes of a series of idiopathic urethral strictures (IUS) in an effort to elucidate the nature of this common yet poorly understood entity.
PATIENTS AND METHODS
We retrospectively reviewed our urethroplasty database to identify men undergoing initial urethral reconstruction from 2007 to 2014 at 1 of 3 hospitals (N = 514). Patients were stratified by stricture etiology, including IUS, acute trauma, iatrogenic, hypospadias, balanitis xerotica obliterans, and radiation. IUS that had a known history of subacute or repetitive blunt force to the perineum (horseback riding, avid cycling, motocross, etc.) were subclassified as subacute or repetitive perineal trauma (SRPT).
RESULTS
Among 466 men undergoing initial reconstruction with available data, 215 (46%) were IUS cases. The median delay between IUS diagnosis and urethroplasty was 5.2 years, during which time men underwent a median of 2 endoscopic treatments. A total of 51 (24%) IUS cases recalled a distinct history of SRPT. Men with SRPT were slightly younger (median 43 vs 48 years, P = .01) but were remarkably similar in terms of urethral stricture length (2 vs 2 cm, P = .15), location (bulbar 96% vs 89%, P = .41), and treatment success (92% vs 88%; P = .61). Bulbar (-)SRPT and (+)SRPT IUS had similar clinical and morphometric features as those with known acute bulbar trauma with excellent 24-month stricture recurrence-free survival rates (93% vs 92% vs 97%, P = .19).
CONCLUSION
IUS have clinical features suggesting that many may be related to unrecognized or repetitive perineal trauma. Although treatment tends to be delayed, IUS have excellent urethroplasty success because most are short bulbar strictures amenable to anastomotic urethroplasty.
Topics: Adult; Humans; Male; Middle Aged; Perineum; Retrospective Studies; Urethral Stricture; Urologic Surgical Procedures, Male; Wounds and Injuries
PubMed: 28755966
DOI: 10.1016/j.urology.2017.07.022 -
Journal of the European Academy of... Jan 2018Male genital lichen sclerosus (MGLSc) is an acquired, chronic, inflammatory skin disease that is associated with significant morbidity and squamous cell carcinoma of the...
INTRODUCTION
Male genital lichen sclerosus (MGLSc) is an acquired, chronic, inflammatory skin disease that is associated with significant morbidity and squamous cell carcinoma of the penis (PSCC). However, some clinical, diagnostic and management controversies endure, including the relationship with penile intraepithelial neoplasia (PeIN).
OBJECTIVES
To clarify clinical presentations, diagnostic approaches, histological findings, response to treatment and the relationship with PeIN.
METHODS
Retrospective review of patients with a diagnosis of MGLSc who attended a specialist male genital dermatoses clinic.
RESULTS
301 patients were identified: 260 had isolated MGLSc and 41 both MGLSc and PeIN. Referrals were made from the local Urology and Andrology departments (128), primary care (89), GUM (54), other dermatology departments (28) and other specialties (2). In isolated MGLSc, 94.6% were diagnosed clinically with 93.5% accuracy (based on data from subsequent circumcisions). In combined MGLSc/PeIN, 85.4% were diagnosed following diagnostic biopsy and 14.6% retrospectively after circumcision. In isolated MGLSc, 50% were treated topically, and 50% required surgery. In MGLSc/PeIN, 78% required surgical interventions. In isolated MGLSc, 92.2% achieved resolution of symptoms, 3.5% were awaiting procedures, and 4.8% were receiving ongoing topical therapy. In MGLSc/PeIN, 90.2% achieved clearance, 2.4% were waiting surgery, and 7.3% were treated topically. Only 2.7% reported ongoing symptoms, all in patients treated surgically. None progressed to PSCC.
DISCUSSION
MGLSc is generally a disease of the uncircumcised; the majority of cases of MGLSc are accurately diagnosed clinically; suspected PeIN or PSCC requires histological confirmation; circumcision histology can be non-specific; most men are either cured by topical treatment with ultrapotent corticosteroid (53.1%) or by circumcision (46.9%); surgical intervention is required in most cases of concomitant MGLSc and PeIN; the majority of patients with MGLSc alone or with MGLSc and PeIN remit with this approach; effective management appears to negate the risk of malignant transformation to PSCC.
Topics: Administration, Cutaneous; Adrenal Cortex Hormones; Balanitis Xerotica Obliterans; Biopsy; Carcinoma in Situ; Circumcision, Male; Humans; Male; Penile Neoplasms; Penis; Retrospective Studies
PubMed: 28750140
DOI: 10.1111/jdv.14488 -
JRSM Open Jun 2017We observed whether general practitioners are referring more appropriately for balanitis xerotica obliterans in regards to circumcision, especially at a time of clinical...
OBJECTIVES
We observed whether general practitioners are referring more appropriately for balanitis xerotica obliterans in regards to circumcision, especially at a time of clinical concern, and whether their discriminative abilities were affected by age. We also aimed to explore if balanitis xerotica obliterans was over-diagnosed by surgeons potentially leading to unnecessary circumcisions of healthy foreskins.
DESIGN
Cross-sectional descriptive study.
SETTING
Leicester Royal Infirmary.
PARTICIPANTS
All children less than 16 years of age were included and were subsequently split into two categories: those less than or equal to five years and those above five years. Circumcision was justified if surgeon found pathology under foreskin commissioning guidelines set by the Royal College of Surgeons of England. After clinical diagnosis of balanitis xerotica obliterans, the pathological database was searched for histological confirmation.
MAIN OUTCOME MEASURES
Has diagnostic accuracy improved amongst general practitioners for balanitis xerotica obliterans and is there a high clinical to histological confirmation.
RESULTS
Of the total patients, 14.5% were diagnosed clinically with balanitis xerotica obliterans. Only 66.7% of cases were histologically confirmed with chronic inflammation found in the rest; 5.5% of all boys referred had balanitis xerotica obliterans on histology; and 8.2% of children <5 had clinical balanitis xerotica obliterans with 1.7% confirmed histologically. This was in contrast with 18.1% and 9.2% found in the older cohort.
CONCLUSION
There remains a high diagnostic inaccuracy amongst general practitioners when referring for balanitis xerotica obliterans. This is greatest in those under five years. Although balanitis xerotica obliterans was over-diagnosed, no healthy foreskin underwent unnecessary circumcision.
PubMed: 28620502
DOI: 10.1177/2054270417692731