儿童隐匿阴茎手术治疗82例

目的：探讨手术治疗儿童隐匿阴茎的疗效。方法回顾性分析2009年1月至2011年12月在本院接受手术治疗的82例隐匿阴茎患儿临床资料。术前检查显示阴茎外观短小,严重者仅见包皮堆而无阴茎体显露,用拇指和食指将阴茎周围皮肤后推可显露发育及长度基本正常的阴茎体,松手后阴茎体迅速回缩。患儿均有包皮口狭窄,阴茎头不外露。手术操作包括：松解包皮狭窄环、脱套阴茎皮肤、转移阴囊皮肤增加阴茎体皮肤覆盖、固定海绵体白膜和阴茎根部皮下组织,重建阴茎阴囊角。结果82例均获随访,平均手术年龄为5（1～13）岁,平均手术时间为40（30～70）min,平均随访时间为6（3～24）个月。术后阴茎体显露良好,阴茎体无明显回缩。结论手术可有效矫正隐匿阴茎外观,改善阴茎体显露。     

经阴茎根部腹侧阴茎阴囊整形术治疗先天性隐匿阴茎

目的 探讨经阴茎根部腹侧入路的阴茎阴囊整形术治疗先天性隐匿阴茎的临床疗效.方法 针对本病的包茎、阴茎皮肤缺乏、阴茎周围肉膜肌的异常附着、特别是阴茎阴囊交界处皮肤的蹼状改变等,采用不但可使阴茎阴囊蹼状改变得到整形,也利于阴茎的充分松解和固定,还可达到延长阴茎皮肤目的的楔形皮肤切口.同时还采用包皮口横切后外板纵形剪开,背侧楔形切除多余内板的的方法,不但解除了包茎,也避免了过多的内板使用.结果 近10年间用此术式治疗先天性隐匿阴茎359例,年龄最小3岁,最大14岁,其中5～7岁224例(62.4％).术后获半年以上随访者265例(73.8％),其中阴茎显露良好,无退缩现象、无包茎、阴囊皮肤无臃肿现象、切口无瘢痕形成和排尿通畅者共247例(93.2％).术后早期出现阴囊血肿7例.远期并发症包括:腹侧切口瘢痕形成3例,后经瘢痕切除治愈.包皮口出现瘢痕环形狭窄并影响阴茎头外露5例,门诊经瘢痕切除治愈.外观仍显阴茎短小10例(4.6％),但经外用睾酮霜2个月后外观明显改善毋需进一步治疗.结论 结果显示此方法简单,效果显著,且并发症多可预防,是一种治疗先天性隐匿阴茎的好术式.     

Epispadias in boys with an intact prepuce

ObjectiveTo present an overview of the clinical presentation and pathological anatomy, and the results of surgical correction of 7 cases of epispadias with intact prepuce; a rare condition that has only occasionally been reported in literature.Patients and methodsA retrospective search was performed in the surgical and diagnoses database between 1991 and 2011. Seven cases of epispadias with intact prepuce were identified. Five presented as a webbed and buried penis, 1 as phimosis and 1 with suspicion for congenital anomaly of the genitalia.ResultsIn 3 of 7 cases, epispadias was suspected or diagnosed at first presentation and could be surgically corrected in the first intervention. In the other 4 cases, epispadias was discovered during surgery, requiring an additional intervention to perform epispadias repair in 3 cases. One boy was diagnosed with glandular, 3 with coronal, 1 with shaft and 2 with penopubic epispadias. Epispadias repair was successful with regard to cosmesis and erectile function. Five patients developed normal continence after surgery, 1 after intensive urotherapy. An under average penile length was the main reported problem during follow-up.ConclusionIn the diagnostic process for a concealed penis, the possibility of epispadias should be considered. If epispadias is suspected or confirmed, epispadias repair can occur in the first intervention, reducing the number of additional interventions. Epispadias with intact prepuce appears to have a better prognosis concerning urinary continence compared to classical epispadias.     

Preputial flaps to correct buried penis

The authors developed a preputial skin flap technique to correct the buried penis which was simple and practical. This simple procedure can be applied to most boys with buried penis. In the last 3 years, we have seen 12 boys with buried penis and have been treated by using preputial flaps. The mean age is about 5.1 (from 3 to 12). By making a longitudinal incision on the ventral side of penis, the tightness of the foreskin is released and leave a diamond-shaped skin defect. It allows the penile shaft to extend out. A circumferential incision is made about 5 mm proximal to the coronal sulcus. Pedicled preputial flaps are obtained leaving optimal penile skin on the dorsal side. The preputial skin flaps are rotated onto the ventral side and tailored to cover the defect. All patients are followed for at least 3 months. Edema and swelling on the flaps are common, but improves with time. None of our patients need a second operation. The preputial flaps technique is a simple technique which allows surgeons to deal with most cases of buried penis by tailoring the flaps providing good cosmetic and functional results.     

Penoplasty for buried penis in infants and children: report of 100 cases

Purpose  The aim of this study is to report single surgeon’s experience in treatment of buried penis in children and describe the surgical technique which was developed by the senior author. Methods  Described surgical technique avoids circumferential incision at the base of the penis and thus prevents formation of post-operative lymphedema. Repair is based on a vertical incision in median raphe, complete degloving of penis and tacking its base to prepubic fascia. Shaft skin is attached to base of penis with vertical mattress sutures. Results  Patient age varied from 1 month to 11.4 years (mean 1.9 years). All patients had good to excellent outcome with uniformly improved visualization of penile shaft post-operatively. There was one case of wound infection successfully treated with oral antibiotics. Revisions were needed in 4% patients. Conclusion  Surgical correction of buried penis in infants and children is safe and effective. Described technique is applicable for essentially all cases of congenital buried penis as well as for iatrogenically entrapped penis after circumcision. In our experience there were no additional procedures required to assure skin coverage of penile shaft. An erratum to this article can be found at     

Circumcision--criticism of the routine

Circumcision is one of the most frequent operative procedures done in males. About 120 circumcisions are performed every 5 minutes over the world [14]. Three different reasons lead to circumcision: 1) Medical reasons in present of a pathologic phimosis. 2) Circumcisions done due to religious, social or cultural rea-reasons. 3) Finally in many countries circumcision is performed as "routine-circumcision" in the newborn period. While in the United States the number of routine-circumcisions decreases (about 60% of all male newborns) South-Korea has a rate near to 100%. Even with no religious or cultural background in Germany circumcision often is performed without scrutinizing medical indication. Circumcision is regarded as an procedure with no complications and no disadvantage for the patient. In general circumcision has no medical benefit neither in decreasing the incidence of urinary tract infections nor of sexual transmitted diseases nor of neoplasias. Medical indication for circumcision is given in present of pathologic phimosis in 4% of all males. Postoperative complications range up to 2% and "circumcision is the amputation of the prepuce from the rest of the penis, resulting in permanent alteration of the anatomy, histology and function of the penis...". There are many reports about having discomfort and disadvantages after circumcision as well to the males as to the sexual partners. This challenge the legality of neonatal involuntary circumcision because legality is based on saving the children's best interests.     

Y-V plasty of the foreskin as an alternative to circumcision for surgical treatment of phimosis during childhood

PurposeTo evaluate the result of Y-V preputioplasty and to compare this with an earlier technique of prepuce-sparing phimosis treatment.Materials and methodsA total of 65 boys were treated surgically for phimosis without removing the foreskin. Indications were the failure of conservative ointment treatment, congenital uropathies (to prevent infections and to make proper cleaning of the glans and the inner preputium possible to ensure clean urine sampling), recurrent balanitis or painful ballooning of the prepuce, and/or the need for urethral instrumentation. Forty-seven patients were treated with one or two Y-V plasties to widen the narrow preputial ring; 18 were treated using transverse closure of longitudinal incisions of the narrow preputial ring.ResultsOf the 47 Y-V plasties, two patients had recurring complaints and needed further treatment (4.3%), and of the 18 patients treated by transversely closed longitudinal incisions, two patients had recurring complaints (11%). Recurrences occurred regardless of age and premedication with topical therapy. Cosmesis was considered to be excellent in all cases of Y-V plasty. Few patients complained about skin tags after longitudinal incisions.ConclusionY-V plasty of the preputial skin as an alternative to circumcision in the treatment of phimosis has good functional and cosmetic results. It is a minor operation with less impact on the penis than partial or total circumcision. The cosmetic results are superior to those after transversely closed longitudinal incisions.     

Long standing balanitis xerotica obliterans resulting in renal impairment in a child

Balanitis xerotica obliterans (BXO) is the most common cause of pathological phimosis in boys. Presented here is the case of a previously well 13-year-old boy who developed obstructive renal impairment (serum creatinine = 190 mumol/l) at least in part from phimosis due to BXO. A circumcision and, 2.5 months later, meatal dilatation were done. Nine months after his initial presentation, his serum creatinine returned to a permanently elevated nadir of 119 mumol/l. Presentation with the complications of phimosis can be delayed in teenage boys because they may feel embarrassed to come forward. Circumcision remains the definitive treatment of BXO induced phimosis though if the penile meatus is involved, more complex surgery is sometimes required. Topical steroids are useful for residual disease. Follow-up is very important due to the frequent involvement of the skin of the glans. In the very long term there is an increased chance of penile malignancy, which can occur even after circumcision.     

Outcome of surgical management of concealed penis

ObjectiveTo review the etiological factors, clinical presentations and outcome of our surgical technique to correct the anomaly of concealed penis.Patients and methodsThirty consecutive patients were treated in 2000–2004. Mean age at operation was 6.7 years (range 13 months–15.4 years). They underwent penoplasty alone (22 patients) or penoplasty with liposuction of prominent prepubic fat pad (eight patients). The medical records of all the patients were retrospectively reviewed, and 23 patients were interviewed, examined clinically and questioned about their initial complaint and the results of our technique. Mean follow up was 28 months (range 6 months–5 years).ResultsThe patients most commonly presented with cosmetic (60.0%), voiding (56.6%) and psychosocial (50.5%) concerns. Three underlying anatomic defects contributing to concealment were observed: fibrotic dartos fascia with poor skin attachment at the base of the penis (93%), prominent prepubic fat pad (40%) and postoperative phimosis leading to trapped penis (26%). Early postoperative complications occurred in 4 patients (13.3%) and all were treated conservatively and successfully. Fourteen patients (46.6%) underwent secondary minor day-case operations, the majority for excision of redundant subcoronal preputial collar. Clinical examination of 23 patients showed very good results in terms of general appearance and accessibility. The older boys were generally more satisfied with the results of surgery than the parents of younger children, whose main source of dissatisfaction was the final circumcised appearance of the penis.ConclusionThe surgical approach used to correct concealed penis alleviates the initial complaint and provides good cosmetic and functional results with greater satisfaction in older patients. Our technique had a low early complication rate but a significant number of patients needed a secondary procedure to improve the final cosmetic results.     

Alternativen zur Zirkumzision

Apart from the reduced incidence of urinary tract infections in the first year of life, there are currently no medical arguments firmly in favour of circumcision and against sparing the prepuce –– with the sole exception of lichen sclerosus et atrophicans, which is rare in children. Not infrequently, parents and child prefer the phimosis to be corrected without removal of the prepuce, in order to preserve the “natural” appearance of the penis. Various investigations have shown a lesser postoperative requirement for analgesics and a better subjective cosmetic outcome after reconstruction of the prepuce. In mild phimosis, “foreskin training”, possibly together with antiphlogistic ointment, may be successful. In the case of persistent phimosis, we recommend giving the family all available information on the potential surgical procedures with and without preservation of the prepuce. In the absence of convincing medical arguments for or against, the decision may be based on individual aesthetic preferences. In our opinion the triple incision technique, a swift, simple and safe operation, represents a good alternative to circumcision.     

小儿埋藏性阴茎的诊断与外科治疗

为了探讨埋藏阴茎的最佳的手术治疗方法，对近１２年中收治的年龄４～１３岁８５例患儿，应用包括包皮外板多处小切口纵切横缝包茎、耻骨联合前上方皮下组织切除、阴茎筋膜分离和阴茎根部皮肤与耻骨骨膜缝合的方法进行手术。术后半年以上获得随访共６７例，其中效果满意５９例（８８．１％），尚有轻度阴茎埋藏８例（１１．９％）。提示本术式是治疗埋藏阴茎简单有效的方法。     

Preputial adhesions — A misunderstood entity

Objective

To assess the trends and outcomes in referrals of ‘phimosis for circumcision’ to a tertiary care pediatric surgical department.

Methods

This is a prospective study of 100 consecutive children of presumed phimosis referred for circumcision. They were assessed and classified by the senior author as having either preputial adhesions or phimosis. The patients in the former group underwent outpatient preputial adhesiolysis while those in the latter group were offered circumcision primarily. All were followed up till resolution.

Results

All 100 were referred with a non-retractile prepuce and an additional reason — preputial ballooning at voiding, dysuria or suspect UTI. Eight (mean age ?58 months, referred for preputial ballooning at voiding ?6/8 and dysuria ?2/8) had phimosis and were primarily offered circumcision. The remaining 92 (mean age — 22 months, referred for preputial ballooning at voiding ?52/92, dysuria ?28/92 and suspect UTI ?12/92) had preputial adhesions. In the latter group, none has a documented urinary infection on specific investigations. These 92 underwent outpatient preputial adhesiolysis. Seventy three (79 %) required a single sitting, 11 (12%) required 2 ?4 sittings and 4(4.5%) required 5?8 sittings over a follow up period of 1 ?24 months (median ?3 weeks). 4/92(4.5%) were deemed non-responders to adhesiolysis and were circumcised later.

Conclusion

The majority of children referred with ‘phimosis for circumcision’ to this tertiary pediatric surgical centre were actually physiologic preputial adhesions that were managed with outpatient preputial adhesiolysis. This study underscores a lack of awareness amongst referring primary care physicians regarding preputial adhesions and the potential for an erroneous diagnosis of phimosis translating into unnecessary circumcisions in many young boys.     

Lichen sclerosus et atrophicus in children with phimosis and hypospadias

 This prospective study was designed to evaluate the incidence of lichen sclerosus et atrophicus (LSA) in a pediatric population with hypospadias and phimosis in order to discuss the indications for circumcision and utilization of preputial skin for urethral surgery. All 115 boys, 55 with congenital phimosis, 45 with acquired phimosis, 13 with hypospadias, and 2 with recurrent chronic balanitis, underwent full-thickness biopsies of the foreskin that were examined by a single pathologist. Of the patients with acquired phimosis, 88% showed inflammatory features in the foreskin; 60% had LSA. Of the patients with congenital phimosis, 82% showed inflammatory disease in the prepuce; 30% had LSA. Of the patients operated upon for hypospadias, 61% showed histologic findings of chronic inflammation of the foreskin and LSA was evident in 15%. The high incidence of LSA in the prepuce of patients with phimosis suggests that circumcision should be performed to correct this disease. The frequent presence of chronic inflammation is a possible cause of stenosis when the foreskin is used to perform a urethroplasty in patients with hypospadias. Accepted: 30 April 2001     

Surgical correction of congenital megaprepuce

Congenital megaprepuce (CMP) is a rare entity. Two infant boys presented with a tight congenital phimosis resulting in an excessively baggy, urine-filled prepuce and a swollen scrotum. Compression of the scrotum resulted in drainage of urine. We feel this to be a separate entity from a buried penis and recommend early surgery. The phimotic tip of the foreskin was excised and the inner layer preserved to cover the full length of the penile shaft. The outer layer of the foreskin, in reality the penoscrotal junction, was anchored to the base of the penile shaft. A V-shaped edge of ventral skin was excised and the edges approximated, giving the appearance of median raphe. The final appearance was that of a circumcised penis. A third patient awaits operation. Accepted: 25 November 1998     

The response of phimosis to local steroid application

The effectiveness of topical steroid application in relieving phimosis was studied in 63 boys treated with local application of steroid ointment to the foreskin. Betamethasone valerate 0.05% (42 patients), hydrocortisone 1% (18 patients), or hydrocortisone 2% (3 patients) was applied three times daily for 4 weeks. Thirty-seven of the patients treated with 0.05% betamethasone valerate ointment (half-strength Betnovate) showed an initial improvement and circumcision was performed on 5 non-responders. Six patients showed initial improvement but later redeveloped phimosis: they were given a further course of treatment, resulting in 2 satisfactory responses and 4 failures requiring circumcision. Two patients using 2% hydrocortisone and 16 using 1% hydrocortisone ointment showed improvement, but 2 of the latter group ultimately required circumcision. Overall, a permanent improvement was achieved in 51 of the 63 patients, with the ability to retract the foreskin after one or more treatments. The remaining 12 boys required circumcision. Local application of steroid ointment to the foreskin results in resolution of phimosis in the majority of cases, but if the foreskin has a circumferential white scar, it is slightly less likely to respond. Following cessation of steriods, phimosis redevelops in a proportion of patients. Correspondence to: S. W. Beasley     

Circumcision using the Mogen clamp

The purpose of this study was to analyze the results of 313 circumcisions using the Mogen clamp. This procedure was done between 1 day and 2 years of age in all but four patients. The complication rate was low (1.6%). Two patients had local infection, one mild hemorrhage, one concealed penis, and one postcircumcision phimosis. Circumcision using the Mogen clamp is a simple, quick, and safe procedure.     

包皮环扎术治疗小儿包皮过长803例

目的 总结运用包皮环扎术治疗小儿包茎包皮过长的治疗经验以及术后并发症的处理方法.方法 回顾性分析2009年7月至2012年6月我科运用包皮环扎术治疗小儿包茎、包皮过长803例病例资料.年龄2～13岁,平均6.9岁.包茎516例,包皮过长287例,包茎与龟头粘连121例,包茎合并内板下积垢217例,尿路感染病史13例,有气囊扩张术治疗病史30例.结果 799例成功完成包皮环扎术,4例转传统包皮环切术.手术时间5～12 min,平均7 min.术中出血1～12 mL.塑料环扎环脱落时间7～14 d,平均10 d.脱落后切缘整齐、美观.塑料环松脱1例,严重水肿22例,内板出血10例,感染3例,龟头嵌顿4例,塑料环不脱落8例.总的并发症发生率为6.01%.结论 包皮环扎术治疗小儿包茎、包皮过长手术简单,手术时间短、出血少、组织创伤小、患儿痛苦小、术后可洗浴、无需拆线等优点,适合基层医院推广应用.     

Penile resurfacing for denuded penis following circumcision

Major loss of penile shaft skin following circumcision has been rarely reported in the paediatric literature and when it occurs is usually due to the injudicious use of monopolar diathermy, infection and poor surgical technique. We report the reconstruction of a penis following complete loss of penile skin due to circumcision. We employed a split-skin graft for the glans and full-thickness graft for the shaft to achieve a more natural cosmetic appearance. This approach has not been described previously in the paediatric literature and should be considered in the unfortunate event of significant penile skin loss.     

Preputial intussusception or acquired megaprepuce

Preputial intussusception, or acquired megaprepuce, is a clinical condition whose incidence is increasing. It results from infolding of the outer preputial skin, obstruction of urinary flow, and the development of a phimosis. With time the process continues, resulting in a distinctive clinical picture. Treatment by early circumcision cures the problem and allows resolution of the sequelae. Accepted: 3 June 1997     

Male circumcision

Male circumcision consists of the surgical removal of some, or all, of the foreskin (or prepuce) from the penis. It is one of the most common procedures in the world. In the United States, the procedure is commonly performed during the newborn period. In 2007, the American Academy of Pediatrics (AAP) convened a multidisciplinary workgroup of AAP members and other stakeholders to evaluate the evidence regarding male circumcision and update the AAP's 1999 recommendations in this area. The Task Force included AAP representatives from specialty areas as well as members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention. The Task Force members identified selected topics relevant to male circumcision and conducted a critical review of peer-reviewed literature by using the American Heart Association's template for evidence evaluation. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks; furthermore, the benefits of newborn male circumcision justify access to this procedure for families who choose it. Specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/sensitivity or sexual satisfaction. It is imperative that those providing circumcision are adequately trained and that both sterile techniques and effective pain management are used. Significant acute complications are rare. In general, untrained providers who perform circumcisions have more complications than well-trained providers who perform the procedure, regardless of whether the former are physicians, nurses, or traditional religious providers. Parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception or early in pregnancy, which is when parents typically make circumcision decisions. Parents should determine what is in the best interest of their child. Physicians who counsel families about this decision should provide assistance by explaining the potential benefits and risks and ensuring that parents understand that circumcision is an elective procedure. The Task Force strongly recommends the creation, revision, and enhancement of educational materials to assist parents of male infants with the care of circumcised and uncircumcised penises. The Task Force also strongly recommends the development of educational materials for providers to enhance practitioners' competency in discussing circumcision's benefits and risks with parents. The Task Force made the following recommendations:Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it. Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child. Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure. Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families. Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not. Elective circumcision should be performed only if the infant's condition is stable and healthy. Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management. Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision. If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns. Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing; Teach the procedure and analgesic techniques during postgraduate training programs; Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents; Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises. The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure. The American College of Obstetricians and Gynecologists has endorsed this technical report.