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Circumcision

Circumcision. Definition: Phimosis : stenosis of the preputal ring with an inability to retract the foreskin. Paraphimosis : retention of the retracted foreskin in a position proximal to the coronal sulcus. Balanitis : inflammation of the foreskin. Posthitis : inflammation of the glans.

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Circumcision

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  1. Circumcision • Definition: • Phimosis: stenosis of the preputal ring with an inability to retract the foreskin. • Paraphimosis: retention of the retracted foreskin in a position proximal to the coronal sulcus. • Balanitis: inflammation of the foreskin. • Posthitis: inflammation of the glans. • Meatitis: inflammation of the urethral meatus.

  2. Retractability of the foreskin • Birth 5% • 6months 15% • 1year 50%, • 3years 90%.

  3. Potential benefits of circumcision • Protection against penile cancer. • Protection againsturinary tract infection. • Protection against sexually transmitted • diseases. • Protection against carcinoma of the cervix.

  4. Indications • Medical • Pathological Phimosis • White, scarred prepuce (BXO - absolute) • May cause ballooning, bleeding, dysuria or retention • Alternatives are preputioplasty / steroid cream • Recurrent Balanitis • Exclude diabetes • Urinary Tract Infection Prophylaxis • Protects against UTI in infants with VUR, PUJ, posterior valves and hydronephrosis 1 • In VUR: 63% v 19% of circumcised boys suffered UTIs Religious 1 Herden CDA. J Urol 1999

  5. Contraindications to circumcision • Hypospadias. • Other associated genital anomalies. • Unstable or sick infant. • Family history of bleeding tendency.

  6. Contraindications • Premature Infants • Congenital Penile Abnormalities • Hypospadias, episapdias, chordee, penile webbing or concealed penis • Blood Dyscrasias

  7. Complications of circumcision. • Serious: life threatening: infection and bleeding. Not life threatening: fistula amputation. • Not serious: Inadequate skin removal (incomplete circumcision). Excessive skin removal. Inclusion cyst. Skin bridges etc.

  8. Complications • Chordee • Secondary to circumcision is related to excess skin removal • Urethrocutaneous Fistula • Urethral injury during excision of prepuce • Necrosis • May occur secondary to surgery or infection • Only use bipolar electrocautery sparingly and never with a ‘clamp’ device • Amputation of Glans • May occur using a ‘clamp’ device

  9. Death Bleeding (2-5%) Suture sinus tracts Infection (2%) Phimosis and concealed penis Adhesions Meatal stenosis Chordee Urethrocutaneous fistula Necrosis Amputation Hypospadias Meatitis Complications

  10. Surgical technique • Principles: freeing the foreskin, identifying the meatus, retracting the foreskin, identifying the coronal sulcus. • Anesthesia: Local, General, None. • Instruments: Gomco clamp, Plasty bell, etc.

  11. The ideal circumcision • Neonatal age. • Local anesthesia. • Selective delay for those who need so. • Instruction to parents about risks.infection, bleeding. • Follow up.

  12. HYPOSPADIAS • Hypo- below, Spadon- orifice • Urethral meatus opens on ventral side of the penis, proximal to the tip of glans penis • Incidence ……..1/125 to 1/250

  13. Hypospadias • Definition: Is a congenital defect of the penis resulting in incomplete development of the urethra, corpora cavernosa, and prepuce. • Clinically results in deflection of the urinary stream and abnormal appearance of the penis. • Severe hypospadias is associated with chordee which may result in infertility secondary to difficulty in insemination. • Cosmetic and functional defect.

  14. Subcoronal hypospadias

  15. Types of hypospadias

  16. EMBRYOLOGY • Cloacal membrane, genital tubercle, labioscrotal swellings • Androgen stimulation…phallus elongation • 3 phases of urethral formation • Posterior urethra formation • Anterior urethra formation • Glandular segment formation • Prepuce formation

  17. PARTS OF HYPOSPADIAS • Meatus … usually non-stenotic • Stenosis more common in distal hypospadias • Megalomeatus intact prepuce

  18. SKIN….. • Ventral defect & dorsal hood • Urethral delta • Hood of monk….Cobra eyes • Defects of spongiosum • Defects of cavernosa • Defective urethral plate

  19. CURVATURE • Skin attachments • Bucks defect • Urethral plate • Cavernosa defects • Problems of unhealthy urethra

  20. CLASSIFICATION (LOCATION) • DISTAL • Glandular, Coronal, Distal penile • MIDPENILE • Midshaft • PROXIMAL • Proximal penile, Penoscrotal, Scrotal, Perineal

  21. Classification • Anterior 50%, the meatus is on the glans, coronal or subcoronal position. • Middle 30%, the meatus is on the shaft of the penis. • Posterior 20%, the meatus is between the perenium and the penoscrotal junction.

  22. Associated anomalies • Undescended testis 10-30% depending on the severity of the hypospadias. • Inguinal hernia 10%. • Utricle, remnant of the Mullairian duct system. • Urinary tract anomalies are infrequent in isolated hypospadias. • Hypospadias alone or when associated with hernia do not require further investigations. • Severe hypospadias, specially when associated with undescended testis should be investigated for possible intersex with karyotyping and endocrine workup.

  23. ASSOSIATION WITH OTHER DEFECTS • Renal agenesis, dysplasia, reflux • Prostatic utricle • Hernia : 9% • Cryptorchidism : 9% • Father : 9% • Siblings : 14%

  24. Treatment • Surgery is best performed 6-18 months of age. • Single stage versus multistage repair. • Outpatient versus inpatient. • Goal of repair: normal urethra, normal glans. • Final goal: straight shaft, normal skin normal appearing meatus, normal skin coverage, and normal penoscrotal position. • Correction of functional and cosmetic defect is the goal of hypospadias surgery.

  25. Operations • Utilization of local tissue, skin, tabularization, flaps, grafts, urethral advancement. • Utilization ofadjacent tissue, skin, prepuce, penile skin scrotal skin in the form of flaps or grafts. • Utilization of remote tissue, skin mucosa, buccal, bladder. • Staged repair. • Operations for chordee correction.

  26. Results & complications • Success rate • 70-100% depends on • The severity of the hypospadias • The surgical technique • The surgeon.

  27. HYPOSPADIAS & INTERSEX • ? Form of androgen insufficiency • Mixed gonadal dysgenesis • Androgen insensitivity • Testosterone synthesis defects • 5 alpha reductase defects

  28. COMPLICATIONS • BLEEDING & HEMATOMA • MEATAL STENOSIS • URETHROCUTANEOUS INFECTION • URETHRAL DIVERTICULA • RECURRENT CURVATURE / STRICTURE • BREAK DOWN

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