Retrograde Progression of Inner Preputial Skin to Overcome Skin Shortage in Cases of Congenital Buried Penis.

Aim:The aim is to evaluate the outcome of right subumbilical transverse incision approach for the management of complicated appendicitis in paediatric age group.Materials and Methods:This is a retrospective multi-institutional study which was conducted in the Department of Paediatric Surgery, I Q City Medical College and Hospital, Durgapur, West Bengal, India and the Department of Paediatric Surgery, Rajiv Gandhi Super Speciality Hospital/Raichur Institute of Medical Sciences, Raichur, Karnataka, India. In this study, a review of 77 paediatric patients operated for complicated appendicitis using a right subumbilical transverse incision approach was done for a period of 3 years (from December 2017 to December 2020). All patients had proven complicated appendicular pathology like appendicular perforation, appendicular abscess or complicated appendicular lumps on ultrasonography or computed tomography scan, which mandated exploration.Results:There was no mortality. Average operative time was 1 h 48 min (ranging from 58 min to 3 h 12 min). Average length of hospital stay was 9 days (ranging from 5 days to 13 days). There was no incidence of fecal fistula. Seventeen (22%) patients developed superficial surgical site infection which subsided with regular dressings. There was no incidence of wound dehiscence or burst abdomen. Five (6.5%) patients required the incision to be extended beyond the midline to the left side to deal with the pathology and to access the entire peritoneal cavity. Nine (11.6%) patients required loop ileostomies, which was fashioned on the lateral aspect of the transverse incision. Only one patient had a doubtful caecal injury which was repaired and loop ileostomy was done. Six patients (7.7%) had adhesive intestinal obstruction postoperatively, of which three required re-exploration. There was no incidence of incisional hernia or any stoma-related complications.Conclusion:Complicated appendicitis is a condition which lacks standardisation of approach for management, and is inherently associated with complications. However, with a more logical incision and intra-operative approach we can keep the complications to minimum and improve outcomes to great extent in those patients requiring surgical intervention. We have been using the subumbilical transverse incision in all sizes of patients ranging from small children to adolescents with excellent results, and we believe that the same approach can be applied even in adult patients in similar clinical scenarios.

'Complications of circumcision should be few and rare' [ 1 ]; 'When the surgeon pays less than complete attention to the details of this common and straightforward procedure, misadventures are inevitable.' [ 2 ]. Male circumcision is a common procedure used for medical, prophylactic and ritual reasons by health professionals and surgical amateurs, thus creating a situation that is unique in urological surgery. The enormous variation in circumcision rates throughout the world (USA 70–80%; Great Britain 5–6%) causes significant differences in the medicolegal and economic implications of the procedure in different countries and/or cultural systems. Although circumcision is technically simple and has a low complication rate (with most of the untoward effects occurring during or shortly afterward), the operation must not be regarded as trivial. In 1980, Prucha wrote of the prepuce: 'The history of these few millimetres of skin is utterly epochal and fascinating.' That continues to be true. During the last three decades, few topics within urology have generated as much scientific and emotional controversy as the question of routine neonatal circumcision. This is reflected by the unusually high proportion of editorials and comments in the extensive literature (1889 hits in Medline with the keyword circumcision; 403 hits with the combined keywords circumcision and complication) and an overflowing correspondence section whenever this or similar issues are raised [3]. Clearly indicated in only six definite conditions (balanitis, posthitis, phimosis, paraphimosis, localized condyloma acuminata and localized carcinoma) circumcision is mostly performed for religious and prophylactic reasons. Once advocated as a simple and proper means of preventing genitourinary diseases and genital cancers, the justification for routine neonatal circumcision began to be questioned by a strong anti-circumcision movement in the late 1960s. Circumcision was discussed with regard to its associated risks and morbidity, producing psychological, sexual and medicolegal difficulties. Although the pros and cons continue to be assessed extensively (see [4]) the debate is unlikely to be resolved. This article focuses on those aspects of male circumcision that may be relevant in a medicolegal context. The objective of this review was to identify key publications that provide a firm scientific background for assessing medicolegal cases related to male circumcision. The specific issues addressed included definitive and poten-tial medical benefits, contraindications, complications (nature, severity, frequency) and preoperative counselling. As this particular procedure and its implications cannot be fully understood without the sociocultural context (most of the major complications occurred at the hands of lay persons during ritual circumcisions), the historical aspects are briefly outlined. The literature was searched using the National Library of Medicine Medline ( http://www.ncbi.nlm.nih/pubmed) and the search confined to papers in English and German. Only peer-reviewed data were considered. Abstracts were classified for their scientific value (review, original work, retrospective, prospective). The Medical Defence Union in the UK was consulted about the medicolegal issues that have been raised related to circumcision. The combination of the keywords 'circumcision' and 'complication' resulted in 403 references. Most of these articles had a specific emphasis (carcinogenesis, sexually transmitted diseases, female/ritual circumcision, anaesthesia, dermatological diseases, hypospadias) and were of limited significance for the present review. The keyword combination 'circumcision' and 'litigation' resulted in 62 references, most of which dealt with female circumcision (female genital mutilation). All relevant articles were retrieved. Circumcision, probably one of the oldest of all surgical procedures, almost certainly began as a religious ritual. The Egyptians depicted circumcision in bas-relief on the tombs of Ankh-Mahor. The first mummies examined were found to have been circumcised. For many the centuries Jewish communities have circumcised young boys; as described in the Bible in Genesis, ritual circumcision (bris milah) is performed when the boy is 8 days old. Religious circumcision is also practised by Muslims, black Africans, Australian aborigines and other ethnic groups in different parts in the world. Currently, about a sixth of the world's male population can be considered to be circumcised, mostly on religious grounds. In western societies, circumcision is mostly performed for medical reasons, the most common of which is phimosis. However, circumcision of newborn boys is a subject of great debate. From the early 1940s until the mid-1970s, circumcision of newborn boys was accepted in the USA as a simple procedure that promoted genital hygiene and prevented genital diseases (and genital cancers). In the late 1960s a strong anti-circumcision movement developed which focused the public's interest on the potential risks of circumcision and its consequences for these boys. Preston's article [5] serves as an impressive example of numerous pleas against routine neonatal circumcision. In 1975, the American Academy of Pediatrics (AAP) declared: 'There is no absolute indication for routine circumcision of the newborn.' This standpoint was supported by the American College of Obstetrics and Gynecologists. In 1983, the statement was reiterated. In the late 1980s the attitude towards circumcision changed. Evidence mounted for the medical benefits of this procedure, particularly in preventing UTI in infant boys, and sexually transmitted diseases (STDs) in adolescents and young men. Wallerstein's article [6] is a meticulous dissection of the conflicting evidence for the prophylactic benefits of circumcision. In view of this discussion, the AAP reviewed their policy and published an updated scholarly report on neonatal circumcision [7], covering penile hygiene, local infections, cancer of the penis, cervical carcinoma, UTI, STDs, pain and behavioural changes, surgical techniques and local anaesthesia. Only a brief paragraph is dedicated to complications. The authors concluded: 'Newborn circumcision has potential medical benefits and advantages as well as disadvantages and risks. When circumcision is being considered, the benefits and risks should be explained to the parents and informed consent obtained.' Schoen [8] undertook to define the status of circumcision in newborns at the beginning of the 1990 s, exclusively focusing on the prophylactic aspects of the procedure. His discussion is a thoughtful reflection on the changing attitudes towards the routine use of circumcision. He concluded that 'the benefits of routine circumcision of newborns as a preventive health measure far exceed the risks of the procedure, although some may question its cost effectiveness and priority in the delivery of health care'. The common medical indications for circumcision are usually seen in adults. Inflammation of the preputial skin (balanitis) or of the glans penis (posthitis) is often associated with diabetes. Obstinate and frequently recurring forms not responding to antimicrobial ointments usually require surgical intervention. Phimosis is stenosis of the preputial ring with resultant inability to retract a fully differentiated foreskin. The primary scarring of the distal margins of the foreskin often is a sequel of chronic balanitis. The circumferential fibrosis may make retraction of the foreskin impossible and occasionally create a pinpoint opening that, in the worst case, interferes with micturition. Urinary obstruction and UTI may be the consequence. Notably, only 4% of boys have a retractable foreskin at birth, increasing to 15% at 6 months and by 3 years the foreskin can be retracted in 80–90% of uncircumcised boys. Paraphimosis is retention of the preputial ring proximal to the coronal sulcus, creating a tension greater than the lymphatic pressure. This constellation may result in subsequent oedema of the prepuce distal to the ring and the glans. A potentially disturbed perfusion may lead to ischaemic pain, cyanosis and, if left untreated, skin loss and gangrene. Either manual reduction or dorsal incision of the oedematous preputial skin are adequate measures to relieve paraphimosis. Circumcision is advisable after the inflammatory process has resolved. When conservative therapy is futile or fails, circum-cision is the treatment of choice for a variety of dermatological conditions confined to the foreskin. The most common of these disease entities are condyloma acuminata or malignant basal or squamous cell carcinomas, with only low-stage tumours suitable for circumcision alone. Routine neonatal circumcision has been advocated as a means of preventing genitourinary diseases and genital cancers. Special attention to this issue is paid in the clearly structured review article by Niku et al.[9]. Circumcision of newborns facilitates genital hygiene throughout life under varying environmental conditions. It prevents preputial colonization with uropathic bacteria in infancy and childhood. Compared with circumcised children, uncircumcised boys have a 5–89-fold higher risk of acquiring UTI with the possibility of subsequent development of bacteraemia and meningitis [9]. Circumcision appears to have protective effects against certain STDs; uncircumcised men may be more susceptible to STDs that disrupt the epithelial surfaces, e.g. genital herpes, syphilis, condyloma acuminata, cancroid and even HIV [9]. One of the most striking arguments in support of circumcision is that in the newborn it almost completely eliminates the risks of developing cancer of the penis. It may also lessen the risks to female partners of circumcised men from having uterine cervical cancer. This effect appears to be a consequence of a lower incidence of infections with human papilloma virus and herpes simplex virus type 2, which are suspected to play a role as cofactors in the aetiology of genital cancers. The most recent analysis of the health benefits and risks of circumcision was published by Moses et al.[10], arriving at the balanced view that 'for individuals and their families to make an informed decision they should be provided with the best available evidence regarding the known benefits and risks of circumcision'. Contraindications to circumcision are congenital or acquired abnormalities that require the availability of preputial skin for surgical repair. Such abnormalities include hypospadias, epispadias, megalourethra, webbed penis and chordee. As the hypospadias complex is the most common of these conditions, it must always be excluded by careful inspection of the penis. The aim of circumcision is to excise enough shaft skin and inner preputial epithelium so that the glans is sufficiently uncovered to prevent or treat phimosis and render the development of paraphimosis impossible. Although there are many different techniques of circumcision they can be broadly classified into four types: dorsal slit, shield, clamp and excision. Although many of the methods are not used in urological practice the urologist will occasionally be faced with their complications. He must therefore be familiar with the different techniques, their specific advantages and pitfalls. To prevent complications with whatever technique is preferred, four principal factors should be strictly adhered to; attention to aseptic conditions, adequate but not excessive excision of outer and inner preputial layers, meticulous haemostasis and protection of the glans penis and the urethra. According to the literature, a realistic complication rate for circumcision appears to be 1.5–5%, although extremes of 0.06% and 55% have been reported. Complications can be regarded as immediate or delayed ( Table 1); at their most severe, some complications can cause loss of the entire penis. There are two excellent articles that extensively reviewed the complications. Williams and Kapila [11] provided the landmark paper on circumcision, and this should be mandatory reading for those involved in a medicolegal case. The review considers the whole spectrum of common and rare, trivial and exotic complications, and discusses the possible aetiological mechanisms in depth. After a brief history of circumcision they provide a comprehensive description of operative and non-operative complications. One section is dedicated to psychological and sexual complications, compensating for a major weakness in most of the other reviews. In their conclusion the authors hope that 'a greater awareness of the incidence and scope of associated complications will encourage a more carefully considered decision on whether or not to circumcise'. After outlining penile development and the natural history of the uncircumcised penis ('Forcible retraction is completely unnecessary because separation will occur physiologically without such manoeuvres') Kaplan's review [12] provides another detailed discussion of complications ('ranging from the insignificant to the tragic'). He concluded that virtually all of the complications are preventable with only a modicum of care. He noted that most complications occur at the hands of inexperienced operators who are neither urologists nor surgeons, and that it is left to the urologist to consult in the management of these complications. Wiswell and Geschke [13] compared the risks from circumcision during the first month of life with those for uncircumcised boys. The records of 136 086 boys born in US Army hospitals from 1980 to 1985 were reviewed for indexed complications related to circumcision status. For 100 157 circumcised boys, there were 193 complications (0.19%). These included 62 local infections, eight with bacteraemia, 83 with haemorrhage (31 requiring ligature and three requiring transfusion), 24 instances of surgical trauma (too much or too little skin removed in 15, injury to the urethra requiring plastic repair in one, circumcision in a child with hypospadias, wound dehiscence in seven) and 20 UTIs. In contrast, the complications in the 35 929 uncircumcised infants were all related to UTIs. Wiswell et al.[14] presented detailed data on 476 boys who were circumcised beyond the neonatal period. Complications occurred in eight patients (1.7%), and included excessive bleeding (three, one requiring transfusion), malignant hyperthermia (two, both survived), aspiration pneumonia, large haematoma development and postoperative fever. In a retrospective analysis Özdemir [15] compared the complications from circumcision caused during mass and single circumcisions performed by medically trained or untrained operators. Traditional (medically untrained) circumcisers were responsible for 85% of the complications and almost all the disastrous ones. The frequency of complications from mass circumcision was significantly higher than that from circumcisions performed singly in operating room conditions. Griffith et al.[16] reported a prospective survey of the indications and morbidity of circumcision in 140 boys in a paediatric day-care unit. This article provides a realistic insight into routine practice. The authors concluded that 'childhood circumcision has an appreciable morbidity, and should not be recommended without a medical reason'. The specific medicolegal issues raised by the Medical Defense Union in the UK relating to circumcision are haemorrhage, meatal stenosis and amputation of the glans; these are addressed below. Bleeding is the most common complication associated with circumcision, being reported in 0.1–35% of cases. Most of these bleeding episodes are minor and respond to gentle pressure. Excessive bleeding may be caused by inadequate haemostasis, blood coagulopathy or the existence of anomalous blood vessels. Bleeding is rarely dramatic enough to require blood transfusion or substitution of clotting factors. In most instances, the application of pressure alone is sufficient to control local haemorrhage but other methods of haemostasis may be required. One of the most commonly used aids to obtain haemostasis is electrocautery. This normally safe and effective method has the potential for damage when used uncritically. The use of unipolar diathermy must be considered obsolete because of the danger of current-induced extended penile necrosis; bipolar diathermy is safer. When electrocautery is used in conjunction with the Gomco clamp, catastrophic and irreparable injuries leading to extended penile necrosis have occurred [17]. As an alternative to electrocautery, bleeding may be stopped by suture ligation. Most problems are caused by poorly placed sutures. Bleeding from unsecured or insufficiently ligated vessels within the loose areolar tissue can produce significant subcutaneous haematomas. To evacuate the haematoma and to identify and ligate the responsible vessel, several sutures must be removed. A small Penrose drain may be placed through the suture line and removed after a few days. One of the most common sites for persistent bleeding is at the frenulum. Sutures placed in the area of the frenulum to control bleeding may lead to strangulation and necrosis of parts of the underlying urethra. This can result in the development of a urinary fistula. To obtain haemostasis a sterile circumferential dressing may be applied with an antibiotic salve. To avoid the development of iatrogenic paraphimosis care must be taken not to apply the dressing too tightly. Urethral obstruction may lead to urinary retention predisposing to UTI. Rare instances of penile necrosis have resulted from tight dressings. Vasoconstrictive agents may be used to stop minor bleeding. The application of pharmacological agents has the potential for systemic side-effects. Tachycardia and heart failure are the most striking symptoms of systemic absorption of locally applied adrenaline solution. Meatitis or meatal ulcer is a frequent complication of circumcision with an incidence of 8–20%. The removal of the prepuce exposes the glans to ammoniacal substances present in urine-soaked nappies. This may lead to irritation and injury of the external urethral meatus. Subsequent scarring of the meatus may result in meatal stenosis predisposing to UTI. et assessed patients who to treat meatal stenosis 3 months to years after circumcision patients were and presented to the with symptoms caused by meatal In all patients the There were no within the period. It was concluded that meatal stenosis is an complication of circumcision in neonatal and infant boys using and that can be it is rare, glans amputation is the most In et and and the of the glans and distal penile shaft by lay operators during circumcision. that amputation injuries should be using the of in surgery. As the distal glans tissue is well a is The report by et serves as a example of the In a a tight applied to the circumcision area to urinary retention and The entire glans penis The authors concluded that those circumcision should be of the potential dressing and and for the parents to after circumcision, may prevent complications. is a complication after circumcision that may occur for several reasons, but mostly as a consequence of injury to the urethra. of parts of the urethral and resultant necrosis and may be by the use of a clamp, or by a poorly placed suture to obtain forms of occur as a result of or penile such as et reported the surgical repair of and urethral that had occurred to circumcision in a small In four patients the glans was and a skin In four patients the urethral was by an from the dorsal or penile In three patients with a urethra after glans amputation the urethra was into a The repair was in all is the most common complication of circumcision, occurring in to of in most cases it is usually and by local inflammatory Most infections are of little consequence and respond to local However, in some cases the circumcision serves as the of for and are mechanisms which may lead to and their low these complications must be considered because of their potential to cause significant morbidity and even excision of foreskin and surgical techniques are the reasons for an of the of penile skin can occur as a consequence of the use of electrocautery or surgical of too much skin can result from too much of the skin the glans during the procedure. The skin a for penile may result from the failure to all Most of these cases can usually be only in the worst penile require skin or treatment with skin A consequence of excision of preputial skin is the a normally developed penis that by the the of the penile shaft and the glans cannot be seen but careful that the penile shaft is and in than a It has been that although an of skin is not enough inner preputial epithelium is As a as and fibrosis the penile shaft is into the with the resultant preputial ring at the of the skin of the of this complication on skin excision and complete dissection of the inner preputial epithelium from the glans. The treatment of this is surgical penis is a in which the skin the urethral of the penis. Excessive removal of penile skin may have this Although the webbed penis is usually the is often This may be by the which the penis from the and the skin excision of foreskin may lead to an or even result in the of the Phimosis may as the process is combined with wound and of the distal foreskin. This may produce a ring which can cause urinary be circumcision rates because of inadequate skin excision at the procedure are result of circumcision is the of the glans penis and the penile These as consequence of preputial at the of circumcision. skin are and may lead to of the penis, with pain or penile In may be under these the skin can be by simple surgical As a if the skin are as the wound is may also be caused by of in the circumcision As these a to large or to the treatment is surgical excision. is a complication of circumcision when performed during an of of a of in the area of the frenulum may cause and A dorsal than circumcision at the of may prevent this In some cases the penis may from the treatment must be are usually circumcised under anaesthesia, but it is with no anaesthesia. There is no that newborns circumcision with no pain and To pain and a complete can be by the dorsal penile at the of the penis, and by circumferential of the and A or with no adrenaline is recommended because the may cause and significant penile This dorsal has also been to provide pain control for as as 6 after circumcision. the and about the psychological effects of circumcision in the young firm scientific data on this issue are authors that circumcision, performed the is by the child as an of and Circumcision is to have effects on the and particularly on article on the psychological consequences of circumcision was published when the of was more than it As this paper is in those using it should be of the and that few individuals were in the about the psychological of circumcision were on a of from different and from a cultural background that may not be of other A more recent review on the medical benefits and risks of circumcision clearly that there is little evidence of effects on psychological and emotional As in all surgical procedures, the key to high with the of circumcision is realistic and comprehensive preoperative provided by the consent must be by if available on a the surgical technique and all potential complications of the The of circumcision must be on a of the for circumcision in the case, the surgical its potential and can be if there is a et that the policy of with a comprehensive of of possible risks and had no effect on the decision to have their circumcised. the procedure is performed under local by the the risks of this must also be a child is to be circumcised, it is to obtain the procedure in a that is to The operative must include the indication for circumcision, a description of the procedure with particular to specific of a frenulum and complications. The should all taken by the surgeon to prevent complications meticulous The must be by the surgeon and in the records with the consent in the must be about the procedure after circumcision and to if there is a of Medical 2,

Megaprepuce: presentation of a modified surgical technique with excellent cosmetic and functional results

Congenital buried penis (CBP) is a rare condition characterized by penis with normal length obscured under penopubic and penoscrotal skin and subcutaneous tissue. Though rare, this condition causes great parental anxiety because of abnormal shape and appearance of penis, dribbling of urine and poor hygiene. Abnormal distal attachment of fundiform ligament on penile shaft, large, redundant preputial sac, and severe paucity of nonpigmented penile skin are important anatomical factors responsible for CBP. We here describe a different approach for degloving of penis and achieving penile skin cover using skin and fascial sheath of preputial sac. This method is simple and easy to learn, teach and reproduce.

The aim of this study was to collect data of patients treated by elastic stable intramedullary nailing (ESIN), regarding epidemiology, indications, results, and complications. Altogether, 400 patients with fractures of the humerus, the lower arm, the femur and the lower leg, treated with ESIN, were evaluated. The participating hospitals, each collecting 100 patients, were the Department of Pediatric Surgery, Inselspital of the University of Bern, Switzerland, the Department of Pediatric Surgery, University of Graz, Austria, the Department of Pediatric Surgery, St. Hedwig’s Hospital Regensburg, Germany, and the Department of Pediatric Surgery, Dr. von Hauner’s Children’s Hospital of the University of Munich, Germany. This study concentrates on 123 patients (30.8%) with humeral fractures. Of these, 29 had sustained proximal humeral fractures, 14 shaft fractures, and 80 distal humeral fractures. In most cases good and excellent results with regard to functional and cosmetic outcome were observed. Rare, but typical problems and complications included implant dislocations, secondary axial deformations, and temporary nerve damages. ESIN of the humerus is now the standard operation to treat proximal and shaft fractures in childhood. ESIN of supracondylar fractures has advantages if performed by an expert, though the surgital technique is not simple.

Introduction: Undescended testis is a relatively common congenital anomaly in male children with a prevalence of 1%-2% in live births. Upon discovering an empty scrotum, it is important to determine whether the testis is palpable, ectopic, retractile, or nonpalpable. A canalicular or "emergent" testis is a peeping one that freely slides to and fro between the abdominal cavity and inguinal canal. It may be impalpable initially, but at a time, it emerges from the internal ring to be palpable when it is "milked" down (where it was concealed from detection). It is reported that 15%-40% of cryptorchidism are viable peeping/canalicular testis. The laparoscopic approach for treating intracanalicular undescended testes offers many advantages over open inguinal orchiopexy. It maintains the integrity of the inguinal canal and eliminates the need to divide the epigastric vessels during dissection. The ability to dissect the testicular vessels at a higher level would increase the vessel length available to bring the testis down to the scrotum without strain. The aim of this study is to present our experience and evaluate laparoscopic approach for management of intracanalicular testes regarding operative safety, efficacy, and postoperative outcomes. Patients and Methods: This is a prospective study conducted at Department of Pediatric Surgery, MCH Hospital, Bisha, Saudi Arabia and Pediatric Surgery Department, Al-Azhar University Hospitals, Cairo, Egypt, in the period from October 2018 to August 2020 to evaluate the safety and efficacy of laparoscopic orchiopexy for intracanalicular testis. Patients with retractile testes, ectopic testes, testes located distal to the external inguinal ring, and nonpalpable testes were excluded from the study. Results: The study was conducted on 62 male children with 70 intracanalicular (peeping) testes, with age range from 8 months to 48 months (mean age: 24 months). Among them, 26 cases (∼42%) were left-sided, 28 (∼45%) were right-sided, and 8 (∼13%) cases were affected bilaterally. Postoperatively, all testes maintained good size without postoperative hydrocele or inguinal hernia. One case (1.4%) required open redo-orchiopexy because of testicular re-ascent to the level of scrotal neck. Moreover, there was no evidence of testicular atrophy confirmed by postoperative ultrasonography. All patients had good satisfied cosmetic results obtained by parent's questionnaire at postoperative follow-up visits. Conclusion: Laparoscopic orchiopexy for management of (intracanalicular) undescended testes is safe, effective, less invasive, without disturbance of inguinal canal anatomy, and with better cosmetic results.

Introduction: Several surgical procedures are used for the correction of distal hypospadias. Institutional protocols vary regarding the ideal procedure. The goal of modern hypospadias surgery is to achieve a functionally and cosmetically normal penis. Mathieu described a technique that utilises the perimeatal skin proximally to create a flap for the repair of distal hypospadias. It is a time-tested method with minimal complications. Aim: To highlight the incidence of complications and the surgical outcomes of distal hypospadias using Mathieu’s meatal-based flip flap technique. Materials and Methods: A retrospective cohort study was conducted in the Department of Paediatric Surgery at a tertiary care hospital at the Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India on 55 children aged 2-16 years from January 2021 to August 2024. The study population included children with distal penile hypospadias with or without mild skin-level chordee. Patients underwent surgery using the Mathieu meatal-based flip flap technique. The length of the skin flap was determined by the distance from the meatus to the glans tip, after which a ventral meatal-based skin flap was incised. The maximum flap length used was 2 cm. The proximal flap was dissected from the underlying urethra, flipped distally, and anastomosed to the distal urethral plate with running subcuticular sutures of 6-0 Polydiaxanone. The urethra was stented using an infant feeding tube for eight days, and the dressing with the catheter was removed on postoperative day 9. Postoperative complications were analysed using descriptive statistics of frequency and percentage. Results: The mean age at the time of urethroplasty was 6.6±3.2 years. Out of 55 patients, 1 (1.8%) developed meatal stenosis, 1 (1.88%) developed a urethrocutaneous fistula, 2 (3.6%) experienced meatal regression, and 3 (5.4%) had glans dehiscence. All patients (and their caregivers) were satisfied with the cosmetic and functional outcomes postoperatively during follow-up. Conclusion: In present study, Mathieu’s meatal-based flip flap urethroplasty resulted in successful outcomes with low complications. Thus, Mathieu’s meatal-based flip flap urethroplasty remains a time-tested and effective method for select cases of distal hypospadias.

The aim of a circumcision is to remove sufficient foreskin from the penile shaft and preputial epithelium to uncover the glans. Removal of too much preputial skin may lead to an unsatisfactory cosmetic and functional result. Patients with a congenital anomaly known as 'buried penis' are particularly susceptible to this. In this condition, abnormal dartos fascial bands or muscle fibres tether the penile shaft and as a result conceal its true length. A 5-year-old boy underwent circumcision but his 'buried penis' was not recognised by the surgeon pre-operatively. Unfortunately, his penile shaft was left almost entirely denuded of skin as a result. The wound required a full thickness graft. Follow-up at 1 year has so far been satisfactory. This case highlights the importance of early recognition of a buried penis when considering circumcision. It demonstrates the abnormal anatomy of a buried penis and its management. It also provides a potential reconstructive option in cases of excess skin removal.

Meningomyelocele is a defect of the spinal cord, vertebrae, and the overlying skin and is the most common form of open spinal dysraphism. Rapid closure of the back defect in the early postnatal period is mandatory to reduce the frequency of infection-related complications of the central nervous system. Majority of the cases present with small defects, which can be closed primarily, with or without subcutaneous dissection. However, direct closure is not possible in 25% of the cases. Different types of local flaps (skin or muscle flaps) are widely used for covering the skin defects; and with varying results. A prospective nonrandomized study was conducted in the department of pediatric surgery at a tertiary hospital, from September 2007 to October 2011. Overall 35 patients with large meningomyelocele defects that could not be closed primarily were included in the study. All patients were treated using subcutaneous tissue based pedicle flap with bilateral V-Y advancement. There were 27 neonates, 7 infants, and 1 child, with a male:female ratio of 1.19:1. There were 3 thoracolumbar, 14 lumbar, 14 lumbosacral, 3 sacral, and 1 multiple meningomyelocele defects with an average size of 8.5 cm (range 6.5-11 cm). Average intraoperative blood loss was 8 mL (range 6-10.5 mL). Average operative time which included flap reconstruction time, after closure of dura, was 38.6 min. Total seven patients had wound complications viz. fat necrosis (n = 2), flap necrosis (n = 2), hematoma (n = 1), cerebrospinal fluid leak followed by wound dehiscence (n = 1), wound infection which led to meningitis (n = 1). Average healing time for flap repair was 7.52 days. Overall 80% (n = 28) of the patients had good flap texture and contour with satisfactory cosmesis. Closure of large meningomyelocele wound defects with subcutaneous based pedicle flap with bilateral V-Y advancement is an effective technique. The main advantages of this technique are its simplicity, short operative time, good tolerance, early healing, and good cosmetic outcome with an excellent flap texture and contour match with minimal complications.

Purpose Color Doppler ultrasound has been used for the diagnosis of torsion of testes. The purpose of this study was to evaluate the sensitivity of this noninvasive tool in detecting impalpable testes. Patients and methods Twenty-five children with nonpalpable testes were treated at the Department of Pediatric Surgery, Institute of Medical Science, Banaras, between 2007 and 2009. Color Doppler ultrasound was used for detecting the position, size, and vascularity of nonpalpable testes. These patients were subsequently revaluated by laparoscopy. Results Out of 25 cases, 15 cases were unilateral and 10 cases were bilateral (a total of 35 nonpalpable testes). The color Doppler ultrasound study successfully localized 30 of the 35 nonpalpable testes, which were confirmed by subsequent laparoscopic examination. The sensitivity of color Doppler in locating testes was 85.71% (95% confidence interval = 0.64–0.97). Conclusion Color Doppler ultrasound is an effective noninvasive method for the initial diagnosis of impalpable testes and for planning its subsequent management. Keywords: color Doppler ultrasound, laparoscopy, nonpalpable testes

BackgroundAmongst the numerous causes of intestinal obstruction listed in the literature, sclerosing encapsulating peritonitis also called Abdominal Cocoon (AC) is one of the rarest entities. Its characteristic feature is a thick fibrotic membrane encasing varying lengths of the small and large gut in a cocoon. In India, there is an increasing incidence of tuberculosis, especially in the rural areas.Aims and objectivesThe aim of this study was to investigate the clinical presentation and evaluate the operative findings of tuberculous AC. We also evaluated the outcomes and response to anti tuberculous treatment (ATT) in all the patients diagnosed with this condition.Material and methodsThis study was carried out at M.M. Institute of Medical Sciences and Research, Mullana, Ambala, India between April 2013 – March 2016 in the Department of Pediatric Surgery. This is a prospective study. A total of 17 patients diagnosed with abdominal cocoon secondary to tuberculosis have been included in the study.ResultsA total of 17 patients presented to the emergency ward with features of acute intestinal obstruction. The average age was 15.3 years (range 9 years to 16 years). There were 14 females and 3 males. All patients presented with abdominal pain, bilious vomiting, constipation and abdominal distention. The patients were operated in our hospital and relieved of their obstruction. Based on their operative findings and after histopathological confirmation, patients were given ATT. In the follow-up, all patients did well, without recurrence of tuberculosis or intestinal obstruction.ConclusionTuberculosis as a cause of childhood AC is rather common in developing countries and is potentially a fatal condition. A strong clinical suspicion, sonographic and computed tomography scan findings help establish a pre-operative diagnosis. Tuberculous AC has a strong prevalence in females. Surgery is the mainstay of treatment followed by anti-tuberculous drugs.

Oxidative damage induces alteration in the status of pro-inflammatory markers like IL-6 and TNF-α in meningocele. The study was performed with estimation of the levels of MDA (Malonyldialdehyde), SOD (Superoxide dismutase) taken as oxidative damage markers and IL-6 (interleukin 6) and TNF-α (Tumour necrosis factor alpha) taken as inflammatory markers, in the serum of meningocele patients and age, sex matched normal neonates. Correlation among the different serum levels of MDA, SOD, IL-6 and TNF-α was determined. It is a case-control study, comprising of 153 participants: 101 newborns with meningocele and 52 healthy newborns. The study was conducted in the Department of Biochemistry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, in collaboration with the Department of Paediatric Surgery and Department of Obstetrics and Gynecology, Sir Sunderlal Hospital, Banaras Hindu University, Varanasi. The study was conducted during the period of 2012 to 2014. Serum was extracted from blood collected from both groups i.e. meningocele patient group and healthy neonatal control group. The levels of MDA and SOD were determined by spectrophotometric method. IL-6 was determined by the Human IL-6 High Sensitivity ELISA Kit and TNF-α was determined by the Human TNF-α ELISA KIT. The levels of MDA, TNF-α and IL-6 were found to be much higher and level of SOD was found lower in the patients with meningocele as compared to the normal healthy neonates. Increased MDA (oxidative damage product), IL-6, and TNF-α (inflammatory marker) and low level of SOD shows an increased inflammatory response in Meningocele. Our study shows Negative Correlation between MDA and SOD in case & control groups, while a Positive Correlation between TNF alpha and IL-6 in control & case groups.

Preputial skin has similar color, texture, and composition to the skin of the penile shaft. The inner preputial skin may be transferred as a flap based upon Dartos fascia to resurface full-thickness burns of the penile shaft, providing a gliding and stretchable surface cover unique to the penis. The advantages of using the inner prepuce skin to resurface full-thickness burns of the penile shaft will be elucidated and the technique will be described. A retrospective chart review was performed of three patients whose penile shaft was resurfaced with inner prepuce flaps after tangential excision of their full-thickness scald burns. Patient 1 was a 9-year-old boy who sustained an 8% TBSA scald burn resulting in a full-thickness burn to the dorsum of his penis. Patient 2 was a 3-year-old boy who sustained a 60% TBSA immersion scald burn as a victim of child abuse, resulting in a circumferential penile burn. Patient 3 was an 8- year-old boy who sustained a 3% TBSA grease burn to the dorsum of his penis. The inner surface of the prepuce of the patients was intact. They were treated with an inner preputial flap. Full-thickness scald burns to the penis are unusual and challenging for the patient, family, and burn surgeon. It is advantageous that inner preputial skin is commonly spared. This specialized thin skin is ideal for resurfacing the penile shaft and should be used when available.

BJU InternationalVolume 92, Issue s3 p. e33-e33 Spermatic cord lymphangioma in a 7-year-old child masquerading as a hydrocele S.K. RATAN, S.K. RATAN Departments of Paediatric Surgery and Search for more papers by this authorK.N. RATTAN, K.N. RATTAN Departments of Paediatric Surgery and Search for more papers by this authorT. SEHGAL, T. SEHGAL Departments of Paediatric Surgery and Search for more papers by this authorS. MAGGU, S. MAGGU Radiology, Pt BD Sharma Post Graduate Institute of Medical Sciences, Rohtak, IndiaSearch for more papers by this author S.K. RATAN, S.K. RATAN Departments of Paediatric Surgery and Search for more papers by this authorK.N. RATTAN, K.N. RATTAN Departments of Paediatric Surgery and Search for more papers by this authorT. SEHGAL, T. SEHGAL Departments of Paediatric Surgery and Search for more papers by this authorS. MAGGU, S. MAGGU Radiology, Pt BD Sharma Post Graduate Institute of Medical Sciences, Rohtak, IndiaSearch for more papers by this author First published: 07 December 2007 https://doi.org/10.1111/j.1464-410X.2003.04046.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume92, Issues3December 2003Pages e33-e33 RelatedInformation

INTRODUCTION Buried or concealed penis is an uncommon condition in which the penile shaft is partially or completely obscured by preputial skin. In the majority of cases, it is congenital. Many patients are ill-advisedly referred for circumcision, a procedure which can compromise future repair and cosmetic outcome. We report on the management and outcome of two boys with