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- PATIENTS AND METHODS
The incidence of phimosis ranges from 8% in boys aged 6–7 years to 1% in adolescents aged 16–18 years . According to European Association of Urology Guidelines , the diagnosis of phimosis is justified in boys after completing the second year of life, if the prepuce is not or only partly retractable, or shows a constrictive ring, and thus a disproportion between the width of the foreskin and the diameter of the glans penis must be assumed. Problems with the foreskin should be resolved before school age. Earlier intervention may be necessary in cases of recurrent balanoposthitis and/or ballooning during micturition, or as a prophylactic procedure in children with congenital malformations, e.g. hydronephrosis, VUR or PUV.
Circumcision as a therapy for phimosis is indicated in children with balanitis xerotica obliterans or preputial scars after recurrent infection or attempted retraction . For traditional and religious reasons circumcision is one of the oldest surgical procedures. Male newborn circumcision is widespread in the USA and Canada, for prophylactic reasons.
As removing the foreskin is controversial and generates an emotional debate, numerous alternative surgical techniques have been developed for phimosis. Single dorsal incision , ventral slits , Y-V-plasties , Z-plasties and Foederl-plasty  are methods for preputial relief. In 1936 Welsh first described a triple incision preputioplasty, Wåhlin  improved it by setting the sutures obliquely, and Pascotto and Giancotti  reported comparable good results with a slightly modified technique.
The aim of the present study was to evaluate the functional and cosmetic results, and the patient’s/parent's acceptance, of triple incision plasty for phimosis in boys.
PATIENTS AND METHODS
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- PATIENTS AND METHODS
Between 1996 and 2001, 197 boys underwent triple incision plasty (mean age 5.8 years, range 0.25–18); the indications for surgery were recurrent balanoposthitis in 59 (30%), voiding problems in 30 (15%) and asymptomatic but stenotic phimosis in boys aged > 3 years in 108 (55%) .
All triple incisions were carried out under general anaesthesia, in 158 boys (80%) by oral intubation and in 39 (20%) by mask inhalation. The mean (range) operative duration was 18 (11–30) min; the children stayed in hospital for 1 day.
The surgical technique basically followed that described and outlined by Wåhlin . The prepuce is gently retracted until the stenotic ring is exposed (Fig. 1). Adhesions between the inner preputial layer and the glans are severed. If the frenulum is short a frenulotomy is performed. Three longitudinal full-thickness skin incisions are made across the stenotic ring down to the inner preputial layer, equally distributed over the dorsal, left and right circumference of the penile shaft. The prepuce must be fully mobile behind the glans, and back and forth. Further adhesions in the area of the coronal sulcus are separated and the glans is cleaned.
Keeping the foreskin retracted the rhomboid defects are closed with interrupted polyglactin 5/0 sutures, the first of which is set obliquely in the middle of each incision, creating oblique suture lines parallel to each other (Fig. 2). Thus, a slight rotation and shortening of the prepuce will be achieved which is equally distributed around the whole circumference of the penis, and avoids the so-called ‘dog ears’ foreskin deformity [8,10]. Also, three parallel displaced suture lines are more likely to prevent re-stenosis than an almost continuous ‘ring’ of transverse scars.
Figure 2. After triple incision, obliquely set interrupted sutures produce obliquely positioned parallel suture lines.
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Finally, a bacitracin/neomycin ointment is applied and the prepuce pulled forward; no dressing is necessary. Parents and children are instructed to move the foreskin back and forth twice a day for 14 days, starting 2 days after surgery.
The results were evaluated in two ways, using a questionnaire sent to all patients/parents and by inviting the children for an examination in the outpatient clinic of the urological department. The questionnaire elicited the reasons for deciding to have a preputioplasty rather than circumcision, the feared disadvantages after circumcision, the parent’s/children's satisfaction with functional and cosmetic results, and whether they would recommend triple incision plasty to other parents. During the clinical follow-up examination, the functional and cosmetic results were evaluated by a urologist. The mean (range) follow-up was 8 (3–19) months.
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The early complications after surgery comprised two children each with bleeding and infection; there was no urinary retention or severe oedema, and none of the children required analgesics. There was no meatal stenosis as a late complication during the follow-up.
The questionnaire was returned by 128 parents (65%); triple incision plasty as a preputial-sparing technique was recommended by urologists in 92 of 128 children (72%), by paediatricians in 23 (18%), by GPs in one (0.8%) and by other parents in 12 (9%). Seventy-two parents/children (56%) opted for foreskin preservation independently, after preoperative counselling by the operating urologist, and 56 parents (44%) after recommendation by another physician or other parents. The possible disadvantages after radical circumcision were cited by 91 parents (71%); the feared disadvantages after circumcision were a different appearance of the penis, cosmetically unsatisfactory result, later sexual problems and cultural reasons (Table 1).
Table 1. The ‘feared’ disadvantages after circumcision (multiple answers possible), the functional and cosmetic satisfaction of parents/children after triple incision (in 128 respondents) and of the urologist (for 91 patients)
|Penis looks different from other boys|| 59 (46)|
|Cosmetically unsatisfactory result|| 32 (25)|
|Later sexual problems with girls|| 32 (25)|
|Circumcision is not part of local/national culture|| 32 (25)|
|Retraction of prepuce behind the glans:|
|No problems||108 (84)|
|Problems|| 20 (17)|
|Very satisfied||102 (80)|
|Moderately satisfied|| 23 (18)|
|Not satisfied|| 3 (2)|
|Functional and cosmetic assessment by urologist|
|Very good functional and cosmetic result|| 71 (78)|
|Preputial adhesions|| 10 (11)|
|Insufficient retraction of the prepuce|| 5 (6)|
|Persistent/recurrent phimosis (failure)|| 5 (6)|
Triple incision would further be recommended by 119 parents (93%) to other patients. Table 1 also shows the functional and cosmetic satisfaction of parents/children after triple incision, respectively. Of 197 boys, 91 (46%) attended the follow-up examination; the results of the functional and cosmetic assessment are also shown in Table 1.
Preputial re-adhesions were severed after applying an anaesthetic ointment (lidocaine/prilocaine) during the outpatient visit. Three children (3%) with unsatisfactory results were circumcised and two are still awaiting a re-operation. In the two boys with a persistent stenotic ring or phimosis the case history showed that they had not moved the prepuce after surgery; the reasons were children not complying or insufficient instruction from the parents, respectively. Since then, we ensure that all parents receive written information about moving the prepuce before they leave the hospital with their sons.
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The origins of male circumcision are unclear, but it is thousands of years old, as Egyptian wall paintings and mummies attest. An estimated sixth of the world's men have been circumcised. Reasons for removing the prepuce were and remain cultural, religious and medical. Tribal cultures sacrificed the foreskin for a good harvest, and in the 19th century circumcision might have been a form of social control to show the power of the church . In Jewish belief circumcision is a covenant between God and Abraham, as written in the Bible (Genesis) and should be performed by a mohel when the boy is 8 days old . Muslim society considers it a tradition of the Prophet Mohammed (Sunnah) to introduce the boy into the religious Islamic community, although it is not mentioned in the Holy Koran [13,14]. Medical reasons, e.g. preventing infection and penile/cervical cancer, led to the widespread use of neonatal circumcision in north America, especially in the USA. Interestingly, South Korea (influenced by American culture during the 1950s) currently has an extraordinarily high rate of male circumcision .
In 1999, 65% of all male newborns in USA hospitals were circumcised ; this decrease from the previous 80–90% followed the circumcision policy statement by the American Academy of Paediatrics in 1989, which stated the potential medical benefits and advantages, and the disadvantages and risks, of circumcision . From recent publications there is no clear evidence that removing the prepuce decreases the incidence of UTI, sexually transmitted diseases, and penile or cervical cancer [18–20].
Circumcision, like any other surgical intervention, is not without risk. The complication rates from different surgical techniques are 1.5–5%, with haemorrhage, infection, meatitis and meatal stenosis more common than glans amputation, urethral injuries, skin bridges, inclusion cysts, chordee and re-phimosis [21,22].
The prepuce is an integral and normal part of the external genitalia; it has been present in primates for at least 65 million years. The unique innervation of the prepuce establishes its function as an erogenous tissue and it mechanically stimulates the underlying penile structures during sexual intercourse [23,24]. While Masters and Johnson  could show no difference in erogenous sensitivity between circumcised and uncircumcised men, recent studies confirm different sexual behaviour by men with and with no foreskin and their female partners .
Based on the controversial debates for and against circumcision during the last decades, the old methods of ‘un-circumcision’, i.e. restoring the prepuce, have gained new interest. Adults being circumcised may seek these cosmetic operations, which are not standard and require careful preoperative counselling [27,28].
When phimosis is diagnosed in boys aged ≥ 3 years many parents wish to preserve the natural appearance of their son's penis. They have to be counselled that according to Gairdner  and Øster , respectively, there is a reasonable chance of the spontaneous resolution of their son's preputial narrowness until puberty. Another conservative approach may be to apply topical steroids [30,31]; if this therapy fails, or parents want an immediate solution to the problem, we recommend triple incision plasty with full preservation of the prepuce. With thorough counselling before surgery and adequate instructions about managing the foreskin afterwards, both parents and child will be very satisfied, as the functional results of foreskin preservation are excellent with this technique.
We conclude that triple incision is a safe, quick and easy treatment for unscarred phimosis, which is supported by the high patient acceptance, and thus it represents a good alternative to circumcision. Every boy with phimosis should be given the opportunity to decide on the subsequent destiny of his prepuce.