Surgical treatment of postcircumcision trapped penis

Background/purpose Trapped penis refers to a phallus that has become entrapped by a dense cicatricial scar usually following circumcision. It is associated with cosmetic, psychosocial, voiding, and hygienic complications and concerns. Prompt treatment is usually required to alleviate concerns and prevent complications. The treatment is essentially surgical. This prospective study was carried out to report the surgical management of cases of trapped penis, the necessary steps/procedures needed, and the outcome of surgical repair, and parent satisfaction.Patients and methods Patients with postcircumcision trapped penis indicated for surgical treatment were evaluated and managed. Evaluation included the age of patients, duration from circumcision, presenting complaints, predisposing conditions, surgical techniques, skin adequacy, and complications. The techniques used included scar excision, degloving, dermopexy, corporopexy, and skin coverage. Skin coverage was achieved by simple closure, split thickness skin graft (STSG), or scrotal flaps. One or more of the above-mentioned techniques were used depending on the individual characteristics of every case. The cases were evaluated for early complications, parent/patient satisfaction (evaluated subjectively), and recurrence.Results A total of 21 children were surgically managed during a 5-year period. The mean age at the time of correction was 28 months (range: 3–133 months). The most common presenting complaints were anxiety and hidden penis. The mean time between circumcision and presentation was 13.9 months (range: 1–117 months). The techniques used for repair included simple scar excision and skin closure in 17 patients, scrotal flap in one patient, and STSG in three patients. Dermopexy was added in seven patients, and corporopexy was added in four patients. Of the patients, six had buried penis, and one patient had megameatus intact prepuce. Parent/patient satisfaction was excellent to good in 95% of patients.Conclusion Postcircumcision trapped penis should be treated promptly to alleviate complications and anxiety, and improve body image. The treatment is mainly surgical; conservative treatment can be tried in early and mild cases. Circumcision in the buried penis converts a minor procedure to a complicated one. Skin coverage after the release of the trapped penis is a challenge and multiple plans should be available. STSG is a good option for penile coverage. Associated conditions and predisposing factors can be addressed in the same operation. The knowledge and practice of circumcision need to be improved

Megameatus intact prepuce variety of hypospadias: tips for repair using the modified glanular approximation procedure

Background/purpose Megameatus and intact prepuce (MIP) is an unusual, anterior hypospadias variant. Cosmetic remodeling is usually carried out to avoid disturbing the child’s psychological state. Several approaches are used for MIP repair. The purpose of this study was to present a single institution’s experience with the modified glanular approximation procedure (GAP) in the treatment of the MIP variant of hypospadias and the tips needed to obtain the best outcome.Patients and methods Seventeen patients with MIP were repaired between May 2004 and May 2009 by the modified GAP technique. The technique was used to achieve a conical glans with a vertical slit, tip-cited meatus, and a straight urine stream. Patient/parent satisfaction was assessed by a subjective score that ranged between 0 and 3 and complications were reported.Results All patients were repaired using the modified GAP technique. The age of the patients ranged from 6 months to 28 years. Four patients were circumcised with a history of intact prepuce. An intermediate layer was added in seven patients. Excision of a part of the redundant urethral plate was carried out in six cases. Disruption of the repair occurred in one patient as a result of wound infection. Excellent cosmetic results were achieved in 14 patients (10 with a subjective score of 3 and four with a subjective score of 2). Two patients expressed an acceptable score of 1 and one patient was dissatisfied with a subjective score of 0.Conclusion Good cosmetic results, such as achievement of a straight urine stream and patient satisfaction, can be achieved using the modified GAP procedure. The steps should be tailored to individual cases.Keywords: hypospadias, megameatus, modified glanular approximation procedur

Sacrococcygeal teratoma: management and outcomes

Background/aim Sacrococcygeal teratomas are the most common tumor during the neonatal period. They are either benign (mature) or malignant (immature, composed of embryonic elements). This retrospective study aims at reviewing our experience in management and outcome of this pathology during the period from January 2008 to November 2013.Patients and methods Charts were designed to collect the following data: the age at presentation, sex, clinical presentation, associated anomalies, Altman’s classification, investigations, management modality, tumor histology with respect to type and resection margins, outcome of treatment, and bowel or urinary complications.Results A total of 20 patients were included in this study. There were six male patients and 14 female patients. Ten patients were Altman type I, seven were type II, one was type III, and two were type IV. Surgical intervention was carried out using a posterior sacral approach in 17 patients (all type I and II patients) or combined abdominal and posterior sacral approaches in the remaining three patients (types III and IV). Recurrence occurred in two patients; these were types III and IV. We had one mortality. Two patients reported involuntary bowel movements, two reported frequent soiling, and five reported constipation.Conclusion Awareness about this pathology among practitioners is essential and would have avoided complications in this series. Early diagnosis and complete excision with removal of the coccyx is associated with good prognosis. Recurrence is related to tumor spillage during excision. Long-term lower gastrointestinal problems (constipation, fecal soiling) correlate with Altman’s classification of the tumor.Keywords: Altman’s classification, sacrococcygeal teratoma, Teratoma

Variables determining the success of ultrasound-guided hydrostatic reduction of intussusception in infants: a tertiary center experience

Background: Intussusception represents one of the most common urgent surgical admissions during early infancy and childhood period. It’s a form of intestinal obstruction which is manifested by colicky abdominal pain, red current jelly stool and abdominal mass. Abdominal Ultrasound is the method of choice for diagnosis. Treatment of intussusception ranged from simple non operative reduction either by pneumatic or hydrostatic enema to surgical exploration. There multiple variables that may affect the result of of non operative management.Aim: We tried to study them to know whom patient would pass without surgery.Patients and methods: Two hundred patients diagnosed with intussusceptions included in this study. All of them received ultra sound guided hydrostatic reduction using warm saline. The maximum number of attempts of reduction was three times. We used intrvenous sedation in irritable infants.Results: 2 hundred cases with intussusception were treated in this study. One hundred forty were reduced (group A) and 60 cases (group B) required surgical exploration. The mean body weight in group A was 7.3 Kg while in group B 9.3Kg. seventy five cases from both groups were operated.Conclusion: Several factors affect the result of hydrostatic reduction as total leukocytic count, CRP and duration of symptoms. In addition the size of the mass and the presence or absence of free peritoneal fluid affects the non operative management.Keywords: hydrostatic, intussusception, ultrasoun

The use of objective assessments in the evaluation of technical skills in cardiothoracic surgery: A systematic review

OBJECTIVES: With reductions in training time and intraoperative exposure, there is a need for objective assessments to measure trainee progression. This systematic review focuses on the evaluation of trainee technical skill performance using objective assessments in cardiothoracic surgery and its incorporation into training curricula. METHODS: Databases (EBSCOHOST, Scopus and Web of Science) and reference lists of relevant articles for studies that incorporated objective assessment of technical skills of trainees/residents in cardiothoracic surgery were included. Data extraction included task performed; assessment setting and tool used; number/level of assessors; study outcome and whether the assessments were incorporated into training curricula. The methodological rigour of the studies was scored using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: Fifty-four studies were included for quantitative synthesis. Six were randomized-controlled trials. Cardiac surgery was the most common speciality utilizing objective assessment methods with coronary anastomosis the most frequently tested task. Likert-based assessment tools were most commonly used (61%). Eighty-five per cent of studies were simulation-based with the rest being intraoperative. Expert surgeons were primarily used for objective assessments (78%) with 46% using blinding. Thirty (56%) studies explored objective changes in technical performance with 97% demonstrating improvement. The other studies were primarily validating assessment tools. Thirty-nine per cent of studies had established these assessment tools into training curricula. The mean ± standard deviation MERSQI score for all studies was 13.6 ± 1.5 demonstrating high validity. CONCLUSIONS: Despite validated technical skill assessment tools being available and demonstrating trainee improvement, their regular adoption into training curricula is lacking. There is a need to incorporate these assessments to increase the efficiency and transparency of training programmes for cardiothoracic surgeons

Abnormal coagulation and enhanced fibrinolysis due to lysinuric protein intolerance associates with bleeds and renal impairment

Introduction: Lysinuric protein intolerance (LPI), a rare autosomal recessive transport disorder of cationic amino acids lysine, arginine and ornithine, affects intestines, lungs, liver and kidneys. LPI patients may display potentially life-threatening bleeding events, which are poorly understood. Aims: To characterize alterations in haemostatic and fibrinolytic variables associated with LPI. Methods: We enrolled 15 adult patients (8 female) and assessed the clinical ISTH/ SSC-BAT bleeding score (BS). A variety of metabolic and coagulation assays, including fibrin generation test derivatives, clotting time (CT) and clot lysis time (CLT), thromboelastometry (ROTEM), and PFA-100 and Calibrated Automated Thrombogram (CAT), were used. Results: All patients had mild-to-moderate renal insufficiency, and moderate bleeding tendency (BS 4) without spontaneous bleeds. Mild anaemia and thrombocytopenia occurred. Traditional clotting times were normal, but in contrast, CT in fibrin generation test, and especially ROTEM FIBTEM was abnormal. The patients showed impaired primary haemostasis in PFA, irrespective of normal von Willebrand factor activity, but together with lowered fibrinogen and FXIII. Thrombin generation (TG) was reduced in vitro, according to CAT-derived endogenous thrombin potential, but in vivo TG was enhanced in the form of circulating prothrombin fragment 1 and 2 values. Very high D-dimer and plasmin-alpha 2-antiplasmin (PAP) complex levels coincided with shortened CLT in vitro. Conclusions: Defective primary haemostasis, coagulopathy, fibrin abnormality (FIBTEM, CT and CLT), low TG in vitro and clearly augmented fibrinolysis (PAP and D-dimer) in vivo were all detected in LPI. Altered fibrin generation and hyperfibrinolysis were associated with the metabolic and renal defect, suggesting a pathogenetic link in LPI.Peer reviewe

Fundamentals for a Systematic Approach to Mild and Moderate Inherited Bleeding Disorders : An EHA Consensus Report

Healthy subjects frequently report minor bleedings that are frequently 'background noise' of normality rather than a true disorder. Nevertheless, unexpected or unusual bleeding may be alarming. Thus, the distinction between normal and pathologic bleeding is critical. Understanding the underlying pathologic mechanism in patients with an excessive bleeding is essential for their counseling and treatment. Most of these patients with significant bleeding will result affected by non-severe inherited bleeding disorders (BD), collectively denominated mild or moderate BD for their relatively benign course. Unfortunately, practical recommendations for the management of these disorders are still lacking due to the current state of fragmented knowledge of pathophysiology and lack of a systematic diagnostic approach. To address this gap, an International Working Group (IWG) was established by the European Hematology Association (EHA) to develop consensus-based guidelines on these disorders. The IWG agreed that grouping these disorders by their clinical phenotype under the single category of mild-to-moderate bleeding disorders (MBD) reflects current clinical practice and will facilitate a systematic diagnostic approach. Based on standardized and harmonized definitions a conceptual unified framework is proposed to distinguish normal subjects from affected patients. The IWG proposes a provisional comprehensive patient-centered initial diagnostic approach that will result in classification of MBD into distinct clinical-pathological entities under the overarching principle of clinical utility for the individual patient. While we will present here a general overview of the global management of patients with MBD, this conceptual framework will be adopted and validated in the evidence-based, disease-specific guidelines under development by the IWG.Peer reviewe

Vascular Endothelial Growth Factor Receptor-2 Couples Cyclo-Oxygenase-2 with Pro-Angiogenic Actions of Leptin on Human Endothelial Cells

The adipocyte-derived hormone leptin influences the behaviour of a wide range of cell types and is now recognised as a pro-angiogenic and pro-inflammatory factor. In the vasculature, these effects are mediated in part through its direct leptin receptor (ObRb)-driven actions on endothelial cells (ECs) but the mechanisms responsible for these activities have not been established. In this study we sought to more fully define the molecular links between inflammatory and angiogenic responses of leptin-stimulated human ECs../Akt/COX-2 signalling axis is required for leptin's pro-angiogenic actions and that this is regulated upstream by ObRb-dependent activation of VEGFR2. These studies identify a new function for VEGFR2 as a mediator of leptin-stimulated COX-2 expression and angiogenesis and have implications for understanding leptin's regulation of the vasculature in both non-obese and obese individuals