Hyman H. Rabinovitch

MEDICAL MANAGEMENT OF PHIMOSIS IN CHILDREN: OUR EXPERIENCE WITH TOPICAL STEROIDS

PURPOSE Circumcision has traditionally been regarded as primary therapy for persistent phimosis in boys. Recently groups in Europe and Australia have advocated the use of topical steroids as conservative treatment in children. We report our experience with this approach. MATERIALS AND METHODS Between July 1997 and February 1998, 25 boys with a mean age of 8.3 years who presented to our clinic with phimosis were started on a topical steroid. After counseling the family regarding treatment options we prescribed a 1-month course of 0.05% betamethasone cream applied twice daily. RESULTS Of the 25 patients 24 completed the treatment and were evaluated. A total of 16 boys (67%) had a normal appearing foreskin that was easily retracted, while in the remaining 8 the outcome was unsuccessful and circumcision was scheduled. CONCLUSIONS Our study demonstrates that the application of topical steroids is a viable alternative for treating phimosis in children. Appropriate candidates for this therapy include boys older than 3 years who have persistent phimosis and no evidence of infection.

Repeat torsion of “fixed” testis

Four cases of torsion of the spermatic cord are reported following previous fixation for the same condition. In all cases the initial fixation was by absorbable chronic catgut suture, and at the subsequent operation for repeat torsion the testes were found to be freely mobile. The use of nonabsorbable suture material (2-0 silk) is recommended for testis fixation in cases of torsion.

Experience with a modification of the Cloutier technique for hypospadias repair.

A modification of the Cloutier technique of hypospadias repair is described. The technique is applicable to all but the most minor degree of the anomaly. When free of complications the final result approximates a cosmetically and functionally normal penis. Since June 1985, 35 children have undergone both stages of the repair. The only complication encountered was fistula formation in 5, for a complication rate of 14.3 per cent.

Renal Operation in Children Via a Posterior Approach

Since July 1979, 10 children have undergone various renal operations via a posterior approach. The operative and postoperative courses have been uneventful. Advantages over the flank and anterior transperitoneal approaches are discussed.

Delayed spontaneous resolution of high grade vesicoureteral reflux after reimplantation.

Significant (grade III/V or greater, International Reflux Study) postoperative vesicoureteral reflux was noted in 4 children who underwent technically satisfactory ureteral reimplantation. All patients had moderate to severe preoperative ureteral dilatation necessitating ureteral tapering in 3 of the 8 ureters reimplanted. Reoperation was considered in all 4 children but a conservative approach was used, with subsequent spontaneous resolution of the reflux 19 to 55 months after reimplantation. We conclude that even high grade reflux after satisfactory reimplantation can resolve spontaneously.

Hydronephrosis secondary to colonic intussusception

We report on a two-month-old infant with bowel obstruction found to be secondary to a colonic intussusception (proved and reduced by barium enema). The finding of renal insufficiency prompted ultrasonographic renal evaluation uncovering a unilateral hydronephrosis. After resolution of the intussusception and hydration, the infants renal functions normalized. Follow-up ultrasound study and renal scan showed resolution of the hydronephrosis. We conclude that colonic intussusception can cause renal obstruction.

Bilateral ureteral meatal obstruction after ureteroneocystostomy

Anuria due to complete obstruction at the level of the ureteral meatus was encountered after bilateral ureteral reimplantation. The cause was thought to be due, at least in part, to excessive length of distal ureter drawn into the submucosal tunnel. At reoperation, both ureteral meatus were found to be stenotic and to project intravesically. Bilateral ureteral meatotomy was performed and proved to be curative.