30th ESPU Congress - Lyon, France - 2019

S17: GENITALIA 1

Moderators: Berk Burgu (Turkey), Pedro Jose López (Chile)

ESPU Meeting on Friday 26, April 2019, 16:12 - 16:58


16:12 - 16:17
S17-1 (LO)

★ RANDOMIZED OPEN LABEL TRIAL COMPARING TRIAMCINOLONE TO HYDROCORTISONE FOR THE TREATMENT OF PHIMOSIS

Joshua CHAMBERLIN 1, Crystal DORGALII 1, Ahmed ABDELHALIM 1, Christina CHALMERS 1, Maryellen KELLY 2, Peter Zhan Tao WANG 3, Kai-Wen CHUANG 1, Irene MCALEER 1, Heidi STEPHANY 1, Elias WEHBI 1 and Antoine KHOURY 1
1) University of California Irvine, Children's Hospital of Orange County, Pediatric Urology, Orange, USA - 2) Duke University, Pediatric Urology, Durham, USA - 3) Western University, Pediatric Urology, London, CANADA

PURPOSE

Phimosis can cause penile infection, inflammatory changes, and urinary retention. Medical treatment for symptomatic phimosis includes topical corticosteroids with manual foreskin retraction. In a randomized controlled fashion we compared prescription triamcinolone to over-the-counter hydrocortisone for the medical management of phimosis.

MATERIAL AND METHODS

We performed a single institution randomized open label trial for the treatment of grades 4-5 physiologic phimosis.  We included boys age 3-13 years, randomizing them to 1% hydrocortisone cream or to 0.1% triamcinolone cream dosed 2-4 times per day for a course of 12 weeks.  Instructions were provided on appropriate application and manual retraction of the foreskin.  Evaluations were performed at 4, 8 and 12 weeks.  Successful completion of the study was determined by reaching phimosis grade 2 or less or after completing 12 weeks of treatment.

RESULTS

A total of 52 boys enrolled in the trial, with a total of 32 boys completing the 12 week duration.  Of the 13 boys in the hydrocortisone arm, there was a 30.8% success at 4 weeks, 53.8% success at 8 weeks and 61.5% success at 12 weeks.  Of the 19 boys in the triamcinolone arm, there was a 31.6% success rate at 4 weeks, 52.6% success rate at 8 weeks and 68.4% success at 12 weeks. There was no statistical difference between the 2 arms at each interval.

CONCLUSIONS

Over-the-counter hydrocortisone 1% cream is not inferior to triamcinolone 0.1% cream when paired with manual retraction for the treatment of grade 4-5 phimosis. Successful treatment response may be seen up to 12 weeks.


16:17 - 16:20
S17-2 (PP)

ANNUAL AUDIT HAS IMPROVED OUTCOMES OF CIRCUMCISIONS WITH DISPOSABLE RINGS IN CHILDREN IN A COMMUNITY CLINIC UNDER LOCAL ANAESTHESIA

Abdul Rauf KHAN, Mohammed AMIN, Darrel GREGORY and Murtaza KHANBHAI
Thornhill Circumcision Clinic, GP Surgery, Luton, UNITED KINGDOM

PURPOSE

To evaluate the early postoperative complications particularly delayed separation/impaction of disposable devices in children’s circumcision procedures under local anaesthesia in a community clinic in this year’s audit versus previous 3 audits

MATERIAL AND METHODS

In our current audit cycle, the outcome of circumcisions (n=1222) was prospectively studied over a 1 year period (May 2017 to April 2018) and were compared with the last 3 audit cycles. Circumcision was performed under local anaesthesia, by trained doctors in a community clinic using Circumplast (CC) (n=310) and Plastibell (PC) (n=912).  Early postoperative complications especially delayed ring separation/impaction were compared among the four audits.  Follow-up was arranged if required.

RESULTS

The mean age was 4.4±0.3 months (median 1.5). Complication rate in this year’s audit was 5.1% (62/1222). There is no significant difference in overall complications rate in CC (6.8% n=21/310) versus PC (4.5% n=41/912) (p>0.5). Delayed ring separation/impaction is significantly lower in CC (0.96% n=3/310) versus PC (2.4% n=22/912) (p<0.05) and has significantly improved from the previous audits (table 1).  In current year, 202(16.5%) children were followed and mean duration of follow up was 10±2.6 days (median 6).

Table 1: 4-year Audit cycles (n=5375)

Year

2015

2016

2017

Current data

Method

Circumplast n=208 (%)

Plastibell n=1179(%)

Circumplast n=569 (%)

Plastibell n=748 (%)

Circumplast n=470 (%)

Plastibell n=979 (%)

Circumplast n=310 (%)

Plastibell n=912 (%)

Complications 

13 (6.3) 

154 (13.1)

55 (9.7)

91 (12.2)

33 (7.0)

64 (6.5)

21 (6.8)

41 (4.5)

Ring delayed separation /impaction

7 (3.4)

102 (8.7)

8 (1.4)

50 (6.7)

2 (0.4)

33 (3.4)

3(0.96)

22 (2.4)

CONCLUSIONS

The annually conducted audit has shown improved outcomes of circumcisions with disposable devices especially delayed ring separation/impaction in children in a community clinic under local anaesthesia over successive years.


16:20 - 16:23
S17-3 (PP)

SKIN FLAP CORRECTION OF CONCEALMENT FOLLOWING CIRCUMCISION INDUCED SKIN LOSS

Gregory DEAN 1, Gregory MCMAHON 2, Nathan PEFFER 3, Zarine BALSARA 4, Charles CONCADORA 3, Jonathan ROTH 3 and Michael PACKER 4
1) St Christopher's Hospital for Children, Pediatric Urology, Philadelphia, USA - 2) Rowan University, Urology, Glassboro, USA - 3) Temple University, Voorhees, USA - 4) Temple University, Urology, Voorhees, USA

PURPOSE

We have previously described correction of penile concealment using scrotal mobilization. Penile skin loss following newborn circumcision can complicate correction of associated concealment. We describe a strategy employing local skin flap to overcome this deficiency in conjunction with scrotal mobilization.

MATERIAL AND METHODS

Between December 2015 and August 2018 twenty-three boys (age 6 months-16 years) underwent circumcision revision and concealment repair requiring skin flap reconstruction. Patients were identified during our standard scrotal mobilization to correct penile concealment. During degloving, a mid-line ventral incision extending to the penoscrotal junction is made. Deep tethering bands are released, and the scrotum retracted toward the anus. Midline scrotal fat is divided, and the scrotum repositioned to correct ventral shaft length deficiency. Inadequate skin coverage secondary to prior aggressive newborn circumcision, was identified and corrected with skin flaps. These were obtained from the scrotum, mucosal collar or lateral shaft skin. These flaps retained a vascular pedicle and were mobilized to provide ventral and dorsal coverage.

RESULTS

Twenty-three boys underwent penile concealment repair requiring associated skin flap coverage. Mean dorsal/ventral measurements (cm) were 3.03/1.46 prior to correction and improved to 5.00/4.81. This yielded a mean dorsal/ ventral ratio of 2.07 pre-op and improved to 1.04 with reconstruction. Mean dorsal length improved 165% and mean ventral length improved 329%. All patients healed without complications and none required revision.

CONCLUSIONS

Newborn circumcision when performed aggressively can result in penile skin loss contributing to penile concealment. We describe a method to achieve improved penile symmetry, length and cosmesis.


16:23 - 16:26
S17-4 (PP)

[CANCELLED] BETTER COSMETIC OUTCOMES WITH COMPATIBLE FUNCTIONAL IMPROVEMENTS: A NOVEL METHOD OF NON-FIXATION PENOPLASTY FOR PEDIATRIC CONCEALED PENIS

Young Dong YU and Young Kwon HONG
Bundang CHA Hospital, Urology, Seongnam-Si, REPUBLIC OF KOREA

PURPOSE

To compare our non-fixation technique penoplasty with fixation suture method to repair concealed penis (CP) in terms of cosmetic and functional outcomes.

MATERIAL AND METHODS

From 2012 to 2017, 52 pediatric CP patients were treated with penoplasty, 28 of whom with four-stich fixation method (F group) and 24 with non-fixation method (NF group). The surgical techniques consisted of complete degloving of the phallus with vertical and circumferential incisions, and complete division of fibrotic bands of the dartos. Yet, fixation sutures between the dermis of penile skin and Buck’s fascia were not applied in the NF group. After suturing of penile skin, gentle traction of phallus was performed with the aid of compressive dressing, which was changed and maintained for a week or more after surgery. The operation time, adverse events, improvements of penile length and satisfaction were evaluated for both groups.

RESULTS

Fixation
(n=28)

Non-fixation
(n=24)

p-Value

Age, years (mean±SD)

5.9±7.2

6.1±5.3 

0.834

Operation time, minutes  (mean±SD)

65.3±11.8

57.5±7.5

<0.001

Follow-up, months (mean±SD)

18.6±5.8

18.3±6.1

0.203

Perioperative complications, n(%)

6/28 (21.4)

3//24 (12.5)

0.045

        Skin necrosis

0 (0.0)

0 (0.0)

        Postoperative bleeding

5 (17.8)

2 (8.3)

        Skin infection

3 (10.7)

1 (4.2)

        Dimpling or grooving

5 (17.8)

1 (4.2)

Penile length, cm (mean±SD)

 

 

0.601

Preoperative

2.10±0.65

2.24±0.70

 

        Postoperative

5.14±0.73

5.18±0.62

 

        Improved length

3.03±0.68

2.95±0.69

 

Recurrence, n(%)

2 (7.1)

2 (8.3)

0.103

Satisfaction

19 (67.9)

22 (91.7)

0.002

Satisfaction scale: 1-3, unsatisfied / 4-6, satisfied

The F group showed significantly better outcomes than the NF group regarding perioperative complications, operation time, and higher subjective satisfaction rate. 

CONCLUSIONS

Our novel method of non-fixation penoplasty was functionally compatible with fixation method and it showed better outcomes regarding satisfaction and perioperative complications.


16:26 - 16:29
S17-5 (PP)

CHILDREN CIRCUMCISION OVER 5 YEARS OF AGE UNDER LOCAL ANAESTHESIA IN A DEDICATED COMMUNITY CLINIC.

Abdul Rauf KHAN, Mohammed AMIN, Darrel GREGORY and Murtaza KHANBHAI
Thornhill Circumcision Clinic, GP Surgery, Luton, UNITED KINGDOM

BACKGROUND AND PURPOSE

Circumcision in older children is usually performed under general anaesthesia in a hospital. The acceptance of children’s circumcision under local anaesthesia in the community clinic remains debatable. We report outcomes of circumcision aged 5 to 16 years from a dedicated community clinic.

MATERIAL AND METHODS

The outcome of circumcisions was prospectively studied over a two year period (May 2016 to April 2018). Five children who deemed unsuitable for this clinic, were excluded. Informed consent was obtained from the parents and Gillick competent children. Paracetamol and ibuprofen were recommended before and after the procedure. Parents were fully involved for the whole process. Topical anaesthesia cream is applied 60 minutes before the procedure. When required, premedication (Midazolam 0.5mg/kg, max 20mg) was given 20-30 minutes before the procedure.  Circumcision was performed under penile block (mixture of lignocaine and levobupivacaine) by trained doctors, in a community clinic using a disposable ring or stitches. Children play games or watch movies during the procedure. Codeine phosphate is given to children over 12 years of age postoperatively. Any postoperative complication was recorded.

RESULTS

The children mean age was 10±0.2 years (median 9.9). Of 194 circumcisions (with disposable ring n= 9 and stitches n=185), 190 had non-medical indications and 4(2%) had balanitis xerotica obliterans. Overall early minor complication rate was 6.7% [n=13/194, bleeding n=5(2.6%), infection n=4(2%), ring removal n=2(1%), buried penis n=1 (0.5%), adhesion n=1 (0.5%)]. There is significant difference in complications rate in ring (n=4/9) versus stitches (n=8/185) (p<0.5).  We preferred circumcision with stiches in this age group. Bleeding is most common complication in circumcision with stitches (5/185). One child with bleeding was admitted to hospital for treatment and bleeding stopped spontaneously in 4 children. Mean follow-up for 41 children (21%) were 15±6 days (median 4).

CONCLUSIONS

Circumcision performed in older children remains a safe surgical option under local anaesthesia in dedicated clinics.


16:29 - 16:32
S17-6 (PP)

SHEAR WAVE ELASTOGRAPHY EVALUATION OF TESTIS WITH PRADER-WILLI SYNDROME

Satoko MATSUYAMA, Futoshi MATSUI, Koji YAZAWA and Fumi MATSUMOTO
Osaka Women's and Children's Hospital, Urology, Osaka, JAPAN

PURPOSE

Hypogonadism in adult males with Prader-Willi syndrome (PWS) arises due to primary testicular dysfunction. However, few studies have evaluated the testicular histology of PWS, because repeat testicular biopsy is invasive. Shear wave elastography (SWE) is a new, non-invasive ultrasound technology to measure tissue rigidity and elasticity. SWE is increasingly being used to assess liver fibrosis. Intertubular fibrosis of the testis increases SWE values. We used SWE to evaluate the testis of patients with PWS.

MATERIAL AND METHODS

We prospectively enrolled 48 PWS males (mean age, 11.0 years (1.1-35.7)) at our hospital between May 2017 and September 2018. SWE was performed by a pediatric radiologist. SWE values were assessed based on normal values described in previous studies (<5 years: 3.9 kPa (2.3-6.2), >9 years: 2.4 kPa (2.0-2.9)).

RESULTS

Eight testes were extra-canalicular, 87 were scrotal, and one patient had previously undergone gonadectomy. Eighty-three testis (86.5%) underwent orchiopexy at 18.8 months (9-76) of age, of which 63 were extra-canalicular, 11 were intra-abdominal, and nine were intra-canalicular testes. Mean SWE values in children <9 years was 6.6 kPa (2.6-10.9). Among patients >9 years, mean SWE value was 4.9 kPa (2.7-12.5) and 37 testes (86.0%) had elevated values. Even testes without cryptorchidism had elevated SWE levels (3.4 kPa (2.8-4.4)). Younger age correlated with favorable testicular elasticity (<18 months: 3.9 kPa, >18 months: 6.1 kPa, P <0.05). Lower testicular position and underlying genetic defects were not associated with favorable testicular elasticity.

CONCLUSIONS

SWE values for testis of those with PWS during childhood can vary between normal and high. However, most testis showed elevated SWE values after puberty, suggesting that testicular dysfunction might become markedly noticeable after puberty.


16:32 - 16:37
S17-7 (VP)

A SIMPLE WAY TO TREAT PENILE CONCEALING DUE TO MEGAPREPUCE AND WEBBED PENIS.

Antonio MACEDO JR 1, Thaís TINTI 2, Tiago DEVITTE 2, Riberto LIGUORI 2, Ricardo MATTOS 2, Sérgio OTTONI 2, Gilmar GARRONE 2 and Marcela LEAL DA CRUZ 2
1) 1. Federal University of São Paulo (UNIFESP) 2. Center for Supporting Children with Urological Anomalies (CACAU), 1. Pediatrics 2. Urology, São Paulo, BRAZIL - 2) Center for Supporting Children with Urological Anomalies - CACAU, Urology, São Paulo, BRAZIL

PURPOSE

Megaprepuce and webbed penis represent a common genital abnormality consisting of penoscrotal transposition, ventral attachments of penile shaft from midshaft to proximal area and a stenotic ring of distal prepuce (phimosis or paraphimosis). Some authors propose an D/V penile length index by measuring the dorsal and ventral length of the penis.

MATERIAL AND METHODS

We want in this video to illustrate the steps of this common procedure associated with an excellent cosmetic result and improvement of self-esteem. Surgery consists of treating penoscrotal transposition when present by two inverted scrotal V-shaped skin flaps to be brought down to its natural position. The ventral penile shaft is detached from the scrotum, excising or dividing the fibrotic and fatty tissue. We dissect the skin and the deglove the penis proximally almost reaching the pelvic floor, producing a release of the penile shaft and increase in size. After that, we suture the ventral penile skin at the lowest level of dissection by two 3.0 vycril sutures anchoring it the Buck's fascia one at each side of the urethra. Subsequently the circumcision is performed and the scrotum reconstructed with removal of redundant skin when necessary.

RESULTS

The surgery produces a nice cosmetic appearance and can be performed as outpatient. Postoperative D/V penile length index can confirm the result of surgery.

CONCLUSIONS

Megaprepuce and webbed penis is a frequently under-recognized abnormality  by pediatricians, but a major cause of anxiety for parents. This technique can be regarded as an option to these patients.


16:37 - 16:58
Discussion