Raisin Galiya, Kocherov Stanislav, Jaber Jawdat, Shenfeld Ofer, Hardak Benjamin, Chertin Boris
Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Jerusalem, Israel.
Department of Urology and Pediatric Urology, Shaare Zedek Medical Center, Jerusalem, Israel.
J Pediatr Urol. 2020 Aug;16(4):471.e1-471.e5. doi: 10.1016/j.jpurol.2020.06.014. Epub 2020 Jun 19.
Circumcision is one of the most performed surgical procedure in the world, often performed for nontherapeutic reasons. Depending on cultural and social backgrounds, the procedure may be performed by various sources; from trained health care practitioners to laypeople, giving rise to different frequencies and types of complications. Glans injury during ritual circumcision is a rare yet serious complication due to its associated morbidity and long-term consequences.
In this study we describe the experience of two medical centers with the management and follow up of glans injury after ritual circumcision.
We have retrospectively reviewed the medical files of all pediatric patients who presented to the ER with glans injury, following ritual circumcision, over a 17-year period from two medical centers.
A total of 8 patients were identified, who underwent ritual circumcision between 7 and 9 days of age. On presentation, 1 infant had complete glans amputation, the others presented with partial amputation of the glans. 6 of the 8 patients had a simultaneous urethral injury. All patients underwent surgical correction for their injury; Patients with isolated glans injury, underwent primary glans anastomosis. Of the 6 cases with simultaneous urethral injury: 3 underwent end-to-end urethral anastomosis following anastomosis of the amputated glans, one patient with complete glans amputation underwent a similar procedure, with initial end-to-end urethral anastomosis followed by glans anastomosis to the corpora cavernosa and 2 were managed by urethrostomy together with anastomosis of the amputated glans tissue to the remaining glans. Both patients with urethral injury, in whom end to end urethral anastomosis has not been performed, were found to have hypospadias on follow up. The rest had good functional and cosmetic results.
There is no single method for managing glans injury following circumcision. Some authors describe healing by secondary intention with delayed formal repair, while others advocate for primary anastomosis of the amputated glans, together with distal urethra-urethrostomy, in cases with simultaneous urethral injury. In this study, both patients without urethral anastomosis, developed secondary hypospadias due to meatal regression and required additional surgery, while the others showed good results. The limitations of our study are its retrospective nature and the small number of cases, preventing us to come to a definitive conclusion regarding the best way to treat such a rare injury.
Prompt surgical correction by glanular replantation with urethro-urethrostomy, in case of concomitant urethral injury, give good cosmetic and functional results.
包皮环切术是世界上实施最为广泛的外科手术之一，常常因非治疗性原因进行。根据文化和社会背景的不同，该手术可能由不同人员实施；从训练有素的医疗从业者到外行人，这导致了不同的并发症发生率和类型。仪式性包皮环切术中的龟头损伤是一种罕见但严重的并发症，因其相关的发病率和长期后果。
在本研究中，我们描述了两个医疗中心对仪式性包皮环切术后龟头损伤进行管理和随访的经验。
我们回顾性分析了两个医疗中心在17年期间所有因仪式性包皮环切术后龟头损伤而到急诊室就诊的儿科患者的病历。
共确定了8例患者，他们在7至9日龄时接受了仪式性包皮环切术。就诊时，1例婴儿龟头完全离断，其他患者表现为龟头部分离断。8例患者中有6例同时伴有尿道损伤。所有患者均接受了损伤的手术矫正；单纯龟头损伤的患者接受了一期龟头吻合术。在6例同时伴有尿道损伤的病例中：3例在离断龟头吻合术后接受了端端尿道吻合术，1例龟头完全离断的患者接受了类似的手术，先进行端端尿道吻合术，然后将龟头与海绵体吻合，另外2例通过尿道造口术并将离断的龟头组织与剩余龟头吻合进行处理。2例未进行端端尿道吻合术的尿道损伤患者在随访中被发现患有尿道下裂。其余患者功能和外观恢复良好。
包皮环切术后龟头损伤的处理方法尚无统一标准。一些作者描述通过二期愈合延迟进行正式修复，而另一些人则主张在同时伴有尿道损伤的情况下，对离断的龟头进行一期吻合，并进行远端尿道 - 尿道造口术。在本研究中，2例未进行尿道吻合术的患者因尿道口退缩出现了继发性尿道下裂，需要额外手术，而其他患者效果良好。我们研究的局限性在于其回顾性性质和病例数量较少，这使我们无法就治疗这种罕见损伤的最佳方法得出明确结论。
在伴有尿道损伤的情况下，通过龟头再植联合尿道 - 尿道造口术进行及时的手术矫正，可取得良好的外观和功能效果。
