- •Preface
- •Acknowledgments
- •Contents
- •1.1 Introduction
- •1.2 Normal Embryology
- •1.3 Abnormalities of the Kidney
- •1.3.1 Renal Agenesis
- •1.3.2 Renal Hypoplasia
- •1.3.3 Supernumerary Kidneys
- •1.3.5 Polycystic Kidney Disease
- •1.3.6 Simple (Solitary) Renal Cyst
- •1.3.7 Renal Fusion and Renal Ectopia
- •1.3.8 Horseshoe Kidney
- •1.3.9 Crossed Fused Renal Ectopia
- •1.4 Abnormalities of the Ureter
- •1.5 Abnormalities of the Bladder
- •1.6 Abnormalities of the Penis and Urethra in Males
- •1.7 Abnormalities of Female External Genitalia
- •Further Reading
- •2.1 Introduction
- •2.2 Pathophysiology
- •2.3 Etiology of Hydronephrosis
- •2.5 Clinical Features
- •2.6 Investigations and Diagnosis
- •2.7 Treatment
- •2.8 Antenatal Hydronephrosis
- •Further Reading
- •3.1 Introduction
- •3.2 Embryology
- •3.3 Pathophysiology
- •3.4 Etiology of PUJ Obstruction
- •3.5 Clinical Features
- •3.6 Diagnosis and Investigations
- •3.7 Management of Newborns with PUJ Obstruction
- •3.8 Treatment
- •3.9 Post-operative Complications and Follow-Up
- •Further Reading
- •4: Renal Tumors in Children
- •4.1 Introduction
- •4.2 Wilms’ Tumor
- •4.2.1 Introduction
- •4.2.2 Etiology
- •4.2.3 Histopathology
- •4.2.4 Nephroblastomatosis
- •4.2.5 Clinical Features
- •4.2.6 Risk Factors for Wilms’ Tumor
- •4.2.7 Staging of Wilms Tumor
- •4.2.8 Investigations
- •4.2.9 Prognosis and Complications of Wilms Tumor
- •4.2.10 Surgical Considerations
- •4.2.11 Surgical Complications
- •4.2.12 Prognosis and Outcome
- •4.2.13 Extrarenal Wilms’ Tumors
- •4.3 Mesoblastic Nephroma
- •4.3.1 Introduction
- •4.3.3 Epidemiology
- •4.3.5 Clinical Features
- •4.3.6 Investigations
- •4.3.7 Treatment and Prognosis
- •4.4 Clear Cell Sarcoma of the Kidney (CCSK)
- •4.4.1 Introduction
- •4.4.2 Pathophysiology
- •4.4.3 Clinical Features
- •4.4.4 Investigations
- •4.4.5 Histopathology
- •4.4.6 Treatment
- •4.4.7 Prognosis
- •4.5 Malignant Rhabdoid Tumor of the Kidney
- •4.5.1 Introduction
- •4.5.2 Etiology and Pathophysiology
- •4.5.3 Histologic Findings
- •4.5.4 Clinical Features
- •4.5.5 Investigations and Diagnosis
- •4.5.6 Treatment and Outcome
- •4.5.7 Mortality/Morbidity
- •4.6 Renal Cell Carcinoma in Children
- •4.6.1 Introduction
- •4.6.2 Histopathology
- •4.6.4 Staging
- •4.6.5 Clinical Features
- •4.6.6 Investigations
- •4.6.7 Management
- •4.6.8 Prognosis
- •4.7 Angiomyolipoma of the Kidney
- •4.7.1 Introduction
- •4.7.2 Histopathology
- •4.7.4 Clinical Features
- •4.7.5 Investigations
- •4.7.6 Treatment and Prognosis
- •4.8 Renal Lymphoma
- •4.8.1 Introduction
- •4.8.2 Etiology and Pathogenesis
- •4.8.3 Diagnosis
- •4.8.4 Clinical Features
- •4.8.5 Treatment and Prognosis
- •4.9 Ossifying Renal Tumor of Infancy
- •4.10 Metanephric Adenoma
- •4.10.1 Introduction
- •4.10.2 Histopathology
- •4.10.3 Diagnosis
- •4.10.4 Clinical Features
- •4.10.5 Treatment
- •4.11 Multilocular Cystic Renal Tumor
- •Further Reading
- •Wilms’ Tumor
- •Mesoblastic Nephroma
- •Renal Cell Carcinoma in Children
- •Angiomyolipoma of the Kidney
- •Renal Lymphoma
- •Ossifying Renal Tumor of Infancy
- •Metanephric Adenoma
- •Multilocular Cystic Renal Tumor
- •5.1 Introduction
- •5.2 Embryology
- •5.4 Histologic Findings
- •5.7 Associated Anomalies
- •5.8 Clinical Features
- •5.9 Investigations
- •5.10 Treatment
- •Further Reading
- •6: Congenital Ureteral Anomalies
- •6.1 Etiology
- •6.2 Clinical Features
- •6.3 Investigations and Diagnosis
- •6.4 Duplex (Duplicated) System
- •6.4.1 Introduction
- •6.4.3 Clinical Features
- •6.4.4 Investigations
- •6.4.5 Treatment and Prognosis
- •6.5 Ectopic Ureter
- •6.5.1 Introduction
- •6.5.3 Clinical Features
- •6.5.4 Diagnosis
- •6.5.5 Surgical Treatment
- •6.6 Ureterocele
- •6.6.1 Introduction
- •6.6.3 Clinical Features
- •6.6.4 Investigations and Diagnosis
- •6.6.5 Treatment
- •6.6.5.1 Surgical Interventions
- •6.8 Mega Ureter
- •Further Reading
- •7: Congenital Megaureter
- •7.1 Introduction
- •7.3 Etiology and Pathophysiology
- •7.4 Clinical Presentation
- •7.5 Investigations and Diagnosis
- •7.6 Treatment and Prognosis
- •7.7 Complications
- •Further Reading
- •8.1 Introduction
- •8.2 Pathophysiology
- •8.4 Etiology of VUR
- •8.5 Clinical Features
- •8.6 Investigations
- •8.7 Management
- •8.7.1 Medical Treatment of VUR
- •8.7.2 Antibiotics Used for Prophylaxis
- •8.7.3 Anticholinergics
- •8.7.4 Surveillance
- •8.8 Surgical Therapy of VUR
- •8.8.1 Indications for Surgical Interventions
- •8.8.2 Indications for Surgical Interventions Based on Age at Diagnosis and the Presence or Absence of Renal Lesions
- •8.8.3 Endoscopic Injection
- •8.8.4 Surgical Management
- •8.9 Mortality/Morbidity
- •Further Reading
- •9: Pediatric Urolithiasis
- •9.1 Introduction
- •9.2 Etiology
- •9.4 Clinical Features
- •9.5 Investigations
- •9.6 Complications of Urolithiasis
- •9.7 Management
- •Further Reading
- •10.1 Introduction
- •10.2 Embryology of Persistent Müllerian Duct Syndrome
- •10.3 Etiology and Inheritance of PMDS
- •10.5 Clinical Features
- •10.6 Treatment
- •10.7 Prognosis
- •Further Reading
- •11.1 Introduction
- •11.2 Physiology and Bladder Function
- •11.2.1 Micturition
- •11.3 Pathophysiological Changes of NBSD
- •11.4 Etiology and Clinical Features
- •11.5 Investigations and Diagnosis
- •11.7 Management
- •11.8 Clean Intermittent Catheterization
- •11.9 Anticholinergics
- •11.10 Botulinum Toxin Type A
- •11.11 Tricyclic Antidepressant Drugs
- •11.12 Surgical Management
- •Further Reading
- •12.1 Introduction
- •12.2 Etiology
- •12.3 Pathophysiology
- •12.4 Clinical Features
- •12.5 Investigations and Diagnosis
- •12.6 Management
- •Further Reading
- •13.1 Introduction
- •13.2 Embryology
- •13.3 Epispadias
- •13.3.1 Introduction
- •13.3.2 Etiology
- •13.3.4 Treatment
- •13.3.6 Female Epispadias
- •13.3.7 Surgical Repair of Female Epispadias
- •13.3.8 Prognosis
- •13.4 Bladder Exstrophy
- •13.4.1 Introduction
- •13.4.2 Associated Anomalies
- •13.4.3 Principles of Surgical Management of Bladder Exstrophy
- •13.4.4 Evaluation and Management
- •13.5 Cloacal Exstrophy
- •13.5.1 Introduction
- •13.5.2 Skeletal Changes in Cloacal Exstrophy
- •13.5.3 Etiology and Pathogenesis
- •13.5.4 Prenatal Diagnosis
- •13.5.5 Associated Anomalies
- •13.5.8 Surgical Reconstruction
- •13.5.9 Management of Urinary Incontinence
- •13.5.10 Prognosis
- •13.5.11 Complications
- •Further Reading
- •14.1 Introduction
- •14.2 Etiology
- •14.3 Clinical Features
- •14.4 Associated Anomalies
- •14.5 Diagnosis
- •14.6 Treatment and Prognosis
- •Further Reading
- •15: Cloacal Anomalies
- •15.1 Introduction
- •15.2 Associated Anomalies
- •15.4 Clinical Features
- •15.5 Investigations
- •Further Reading
- •16: Urachal Remnants
- •16.1 Introduction
- •16.2 Embryology
- •16.4 Clinical Features
- •16.5 Tumors and Urachal Remnants
- •16.6 Management
- •Further Reading
- •17: Inguinal Hernias and Hydroceles
- •17.1 Introduction
- •17.2 Inguinal Hernia
- •17.2.1 Incidence
- •17.2.2 Etiology
- •17.2.3 Clinical Features
- •17.2.4 Variants of Hernia
- •17.2.6 Treatment
- •17.2.7 Complications of Inguinal Herniotomy
- •17.3 Hydrocele
- •17.3.1 Embryology
- •17.3.3 Treatment
- •Further Reading
- •18: Cloacal Exstrophy
- •18.1 Introduction
- •18.2 Etiology and Pathogenesis
- •18.3 Associated Anomalies
- •18.4 Clinical Features and Management
- •Further Reading
- •19: Posterior Urethral Valve
- •19.1 Introduction
- •19.2 Embryology
- •19.3 Pathophysiology
- •19.5 Clinical Features
- •19.6 Investigations and Diagnosis
- •19.7 Management
- •19.8 Medications Used in Patients with PUV
- •19.10 Long-Term Outcomes
- •19.10.3 Bladder Dysfunction
- •19.10.4 Renal Transplantation
- •19.10.5 Fertility
- •Further Reading
- •20.1 Introduction
- •20.2 Embryology
- •20.4 Clinical Features
- •20.5 Investigations
- •20.6 Treatment
- •20.7 The Müllerian Duct Cyst
- •Further Reading
- •21: Hypospadias
- •21.1 Introduction
- •21.2 Effects of Hypospadias
- •21.3 Embryology
- •21.4 Etiology of Hypospadias
- •21.5 Associated Anomalies
- •21.7 Clinical Features of Hypospadias
- •21.8 Treatment
- •21.9 Urinary Diversion
- •21.10 Postoperative Complications
- •Further Reading
- •22: Male Circumcision
- •22.1 Introduction
- •22.2 Anatomy and Pathophysiology
- •22.3 History of Circumcision
- •22.4 Pain Management
- •22.5 Indications for Circumcision
- •22.6 Contraindications to Circumcision
- •22.7 Surgical Procedure
- •22.8 Complications of Circumcision
- •Further Reading
- •23: Priapism in Children
- •23.1 Introduction
- •23.2 Pathophysiology
- •23.3 Etiology
- •23.5 Clinical Features
- •23.6 Investigations
- •23.7 Management
- •23.8 Prognosis
- •23.9 Priapism and Sickle Cell Disease
- •23.9.1 Introduction
- •23.9.2 Epidemiology
- •23.9.4 Pathophysiology
- •23.9.5 Clinical Features
- •23.9.6 Treatment
- •23.9.7 Prevention of Stuttering Priapism
- •23.9.8 Complications of Priapism and Prognosis
- •Further Reading
- •24.1 Introduction
- •24.2 Embryology and Normal Testicular Development and Descent
- •24.4 Causes of Undescended Testes and Risk Factors
- •24.5 Histopathology
- •24.7 Clinical Features and Diagnosis
- •24.8 Treatment
- •24.8.1 Success of Surgical Treatment
- •24.9 Complications of Orchidopexy
- •24.10 Infertility and Undescended Testes
- •24.11 Undescended Testes and the Risk of Cancer
- •Further Reading
- •25: Varicocele
- •25.1 Introduction
- •25.2 Etiology
- •25.3 Pathophysiology
- •25.4 Grading of Varicoceles
- •25.5 Clinical Features
- •25.6 Diagnosis
- •25.7 Treatment
- •25.8 Postoperative Complications
- •25.9 Prognosis
- •Further Reading
- •26.1 Introduction
- •26.2 Etiology and Risk Factors
- •26.3 Diagnosis
- •26.4 Intermittent Testicular Torsion
- •26.6 Effects of Testicular Torsion
- •26.7 Clinical Features
- •26.8 Treatment
- •26.9.1 Introduction
- •26.9.2 Etiology of Extravaginal Torsion
- •26.9.3 Clinical Features
- •26.9.4 Treatment
- •26.10 Torsion of the Testicular or Epididymal Appendage
- •26.10.1 Introduction
- •26.10.2 Embryology
- •26.10.3 Clinical Features
- •26.10.4 Investigations and Treatment
- •Further Reading
- •27: Testicular Tumors in Children
- •27.1 Introduction
- •27.4 Etiology of Testicular Tumors
- •27.5 Clinical Features
- •27.6 Staging
- •27.6.1 Regional Lymph Node Staging
- •27.7 Investigations
- •27.8 Treatment
- •27.9 Yolk Sac Tumor
- •27.10 Teratoma
- •27.11 Mixed Germ Cell Tumor
- •27.12 Stromal Tumors
- •27.13 Simple Testicular Cyst
- •27.14 Epidermoid Cysts
- •27.15 Testicular Microlithiasis (TM)
- •27.16 Gonadoblastoma
- •27.17 Cystic Dysplasia of the Testes
- •27.18 Leukemia and Lymphoma
- •27.19 Paratesticular Rhabdomyosarcoma
- •27.20 Prognosis and Outcome
- •Further Reading
- •28: Splenogonadal Fusion
- •28.1 Introduction
- •28.2 Etiology
- •28.4 Associated Anomalies
- •28.5 Clinical Features
- •28.6 Investigations
- •28.7 Treatment
- •Further Reading
- •29: Acute Scrotum
- •29.1 Introduction
- •29.2 Torsion of Testes
- •29.2.1 Introduction
- •29.2.3 Etiology
- •29.2.4 Clinical Features
- •29.2.5 Effects of Torsion of Testes
- •29.2.6 Investigations
- •29.2.7 Treatment
- •29.3 Torsion of the Testicular or Epididymal Appendage
- •29.3.1 Introduction
- •29.3.2 Embryology
- •29.3.3 Clinical Features
- •29.3.4 Investigations and Treatment
- •29.4.1 Introduction
- •29.4.2 Etiology
- •29.4.3 Clinical Features
- •29.4.4 Investigations and Treatment
- •29.5 Idiopathic Scrotal Edema
- •29.6 Testicular Trauma
- •29.7 Other Causes of Acute Scrotum
- •29.8 Splenogonadal Fusion
- •Further Reading
- •30.1 Introduction
- •30.2 Imperforate Hymen
- •30.3 Vaginal Atresia
- •30.5 Associated Anomalies
- •30.6 Embryology
- •30.7 Clinical Features
- •30.8 Investigations
- •30.9 Management
- •Further Reading
- •31: Disorders of Sexual Development
- •31.1 Introduction
- •31.2 Embryology
- •31.3 Sexual and Gonadal Differentiation
- •31.5 Evaluation of a Newborn with DSD
- •31.6 Diagnosis and Investigations
- •31.7 Management of Patients with DSD
- •31.8 Surgical Corrections of DSD
- •31.9 Congenital Adrenal Hyperplasia (CAH)
- •31.10 Androgen Insensitivity Syndrome (Testicular Feminization Syndrome)
- •31.13 Gonadal Dysgenesis
- •31.15 Ovotestis Disorders of Sexual Development
- •31.16 Other Rare Disorders of Sexual Development
- •Further Reading
- •Index
486 |
22 Male Circumcision |
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can be performed after preparation and treatment. The parents should be fully informed of the increased risks of complications.
•Circumcision is contraindicated in premature infants and those who are not clinically stable and in good health.
•A family history of hemophilia calls for a coagulation profile prior to circumcision.
22.7Surgical Procedure
•Open surgical circumcision (Figs. 22.4 and 22.5):
–This is usually performed under general anesthesia
–Open surgical circumcision is performed for adults, older children or for those with associated anomalies of the penis such as webbed penis, chordee and deviation of the penis.
–The amount of foreskin to be removed is determined and excised
–The edges of the skin are sutured with absorbable sutures.
–The end result is a cosmetically acceptable penis.
•For infant circumcision, devices such as the Gomco clamp, Plastibel and Mogen clamp are commonly used.
•These follow the same basic procedure.
–First, the amount of foreskin to be removed is estimated. The practitioner
opens the foreskin via the preputial orifice to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin (preputial epithelium) from its attachment to the glans.
–The practitioner then places the circumcision device (this sometimes requires a dorsal slit).
–Finally, the foreskin is excised.
•The AAP Task Force on Circumcision recommends the use of environmental, nonpharmacological, and pharmacologic interventions to reduce pain and distress during neonatal circumcision. These interventions include:
–The use of a sucrose pacifier
–The use of paracetamol suppositories
–The use of EMLA cream (a mixture of prilocaine and lidocaine)
–The use of penile nerve blocks (e.g. 0.5 % lidocaine without epinephrine)
•A ring block that consists of the circumferential subcutaneous injection of local anesthesia
•A dorsal penile block
–Oral acetaminophen or paracetamol suppositories provides adequate pain control after neonatal circumcision.
–In patients who undergo formal surgical circumcisions in the operating room, caudal blocks and dorsal penile blocks decrease the amount of pain medication required after the procedure.
Figs. 22.4 and 22.5 Clinical photographs showing open surgical circumcision
22.7 Surgical Procedure |
487 |
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|
•The use of unipolar diathermy during circumcision should be avoided.
•Prior to circumcision, it is important to determine the presence of a normal glans and penis without any evidence of hypospadias, epispadias, chordee, or other anomalies.
•Most cases of hypospadias or epispadias are evident clinically and these should not be circumcised.
•The foreskin in these patients can be used during the repair of hypospadias or epispadias.
•Circumcision is part of the repair of these patients.
•Epispadias is characterized by a deficient foreskin and a dorsally placed urethral opening (Figs. 22.6 and 22.7).
•Hypospadias is characterized by a deficient foreskin ventrally while the dorsally the foreskin is well formed like a hood. The urethral opening is placed ventrally (Figs. 22.8 and 22.9).
•A point of caution is in patients with mega meatus variant of hypospadias. These patients have a normal well developed and complete foreskin.
•This variant is called, the mega meatus intact prepuce (MIP) variant.
•The urethral meatus in these patients is large (mega meatus) (Figs. 22.10 and 22.11).
•These patients have a well-developed foreskin and the diagnosis of mega meatus is only made at the time of circumcision.
Figs. 22.6 and 22.7 Clinical photographs showing epispadias. Note the dorsally located urethral opening
Figs. 22.8 and 22.9 Clinical photographs showing hypospadias. Note the deficient foreskin ventrally and the hood like foreskin dorsally. Note also the abnormally located urethral opening on the ventral aspect of the penis
488 |
22 Male Circumcision |
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Figs. 22.10 and 22.11 Clinical photographs showing an infant with a megameatus. Note the normal looking foreskin. Note also the abnormally large meatus
Figs. 22.12 and 22.13 Clinical photographs showing an infant with a foresking resembelling that of hypospadias but a normally located urethral meatus
•Once the diagnosis is confirmed, circumcision is abandoned and postponed to be done at the time of repair of Mega meatus.
•Rarely, a deficient prepuce ventrally but a normally situated meatus is seen (Figs. 22.12 and 22.13).
•The surgical procedure of male circumcision may involve one of various devices including:
–The Circumplast
–The Gomco clamp
–The Plastibell
–The Mogen clamp
–The Shang ring
–The bone cutter
•The bone cutter is rarely used nowadays (Fig. 22.14).
•Plastibel Circumcision (Figs. 22.15, 22.16, 22.17, 22.18, 22.19, 22.20, 22.21, 22.22, 22.23, 22.24, 22.25, 22.26, 22.27, and 22.28):
–First, the amount of foreskin to be removed is estimated.
–The preputial orifice is widened with an artery forceps and the foreskin is opened.
–This will reveal the glans underneath and ensure it is normal.
–The inner lining of the foreskin (preputial epithelium) is bluntly separated from its attachment to the glans.
22.7 Surgical Procedure |
489 |
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|
Fig. 22.14 A photograph showing a bone cutter that is used for circumcision
Fig. 22.15 A clinical photograph showing plastibel circumcision. The size of the plastibel is large for the size of the penis
–The area is cleaned and any smegma is removed.
–The size of the plastibel to be used is estimated based on the size of the glans penis. Improper plastibel size will give unsatisfactory results (Fig. 22.15).
–Plastibel come in different sizes: 1.1, 1.2, 1.3, 1.4, 1.5 and 1.7.
–A dorsal slit is made in the prepuce. This will help and facilitate introducing the plastibel.
–To minimize bleeding from the dorsal slit edges, each edge is held with an artery forceps.
–The plastibel is placed over the glans and the edges of the dorsal slit are pulled by an assistant who also pushes the plastibel and keep it in place.
–A ligature is applied around the foreskin and firmly tied in an already made groove in the plastibel. The pushed plastibel protect the glans penis.
–Finally, the foreskin distal to the plastibel is amputated.
–The handle of the plastibel is snapped of the plastibel.
–Sometimes, the frenulum band may need to be broken or crushed and cut from the corona near the urethra to ensure that the glans can be freely and completely exposed. This may nictitates the use of diathermy to control bleeding. Only bipolar diathermy is used and monopolar diathermy should be avoid. There are small battery operated portable bipolar diathermy which can be used for this purpose (Figs. 22.29, 22.30, 22.31, and 22.32).
–The tied suture causes ischemic necrosis of the remaining foreskin which falls down together with the plastibel in 5–7 days (Figs. 22.33, 22.34, 22.35, and 22.36).
–A plastibel that does not fall after 7 days should be removed.
•There are also restrainers which can be used during plastibel circumcision to control the movement of the infant (Fig. 22.37).
•Circumplast circumcision (Fig. 22.38):
–The procedure is similar to the plastibel
–The glans is freed
–The Circumplast is placed over the glans, and the foreskin is placed over the Circumplast.
–A ligature is then tied firmly around the foreskin and tightened into a groove in the Circumplast to achieve hemostasis.
–The foreskin distal to the ligature is excised and the handle is snapped off the Circumplast device.
–The Circumplast falls from the penis after the wound has healed, typically in 4–6 days.
490 |
22 Male Circumcision |
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|
Fig. 22.16 A photograph showing the different sizes of plastibells
Figs. 22.17 and 22.18 Photographs showing the different shapes of plastibells
• Gomco clamp circumcision (Fig. 22.39): |
the foreskin may be cut away with a scalpel |
|
from above the base plate. |
||
– |
The foreskin is dorsally crushed with a |
|
|
hemostat and then slit with scissors from |
• Mogen clamp circumcision (Figs. 22.40, |
|
the tip to the coronal sulcus. |
22.41, 22.42, and 22.43): |
– The foreskin is drawn over the bell shaped |
– The foreskin is pulled dorsally with a |
|
|
portion of the clamp and inserted through a |
straight hemostat, and lifted. |
|
hole in the base of the clamp. |
– The Mogen clamp is then slid between the |
– The clamp is tightened, “crushing the |
glans and hemostat, following the angle of |
|
|
foreskin between the bell and the base |
the corona to “avoid removing excess skin |
|
plate.” |
ventrally and to obtain a superior cosmetic |
– |
The crushed blood vessels provide hemo- |
result” to Gomco or Plastibell circumcisions. |
|
stasis. The flared bottom of the bell fits |
– The clamp is locked, and a scalpel is used to cut |
|
tightly against the hole of the base plate, so |
the skin from the flat (upper) side of the clamp. |
22.7 Surgical Procedure |
491 |
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|
Figs. 22.19, 22.20, and 22.21 Clinical photographs showing an uncircumcised infant. The preputial opening is dilated and opened
Figs. 22.22 and 22.23 Clinical photographs showing the dorsal slit and the introduced plastibell. The suture for tining is already prepared
•The Shang ring circumcision (Figs. 22.44 and 22.45):
–The Shang Ring is a disposable MC device invented by Mr. Jianzhong Shang in China.
–It is commercially available in China in 32 sizes, ranging from 9 to 42 mm in diameter, for use with neonates to adults.
–The Shang Ring consists of two parts, an inner ring and an outer ring.
–The inner ring has a shallow groove on its outer surface that is lined by a silicone band which confers a non-bioreactive surface against which the outer ring sandwiches the foreskin.
–The outer ring consists of two halves that are hinged together at one end.
–The outer ring is closed securely via a ratchet style closure.
–Hemostasis provided by the locking rings minimizes bleeding and removes the need for sutures.