Plastibell Circumcision with a Frenulum-Sparing Technique

Plastibell circumcision with frenulum-sparing technique

Ismael Zamilpa MD and Madison Haraway

Introduction: The penile frenulum connects the prepuce to the glans on the underside of the penis. Although the frenulum plays a role in sexual arousal, it can cause painful erections when its length is too short. Conventional neonatal circumcision techniques involve removing the entire foreskin covering the glans, often with division of the frenulum (1). Recently, tissue-sparing approaches have become a matter of interest to reduce the risk of complications, such as bleeding, altered glans sensitivity, and meatal stenosis.

Methods: We describe a frenulum-sparing technique in combination with the Plastibell method. Lysis of preputial adhesions near the frenulum is performed carefully. Selection of an appropriately sized bell is paramount as oversize or undersize can cause bell migration and tissue necrosis (2). The bell should fit snugly over two-thirds of the glans of the penis and fall off spontaneously within 3-7 days.

Results: The patient is a 2-month-old male who presented to Arkansas Children’s Urology with phimosis, which is preputial tightness that prevents foreskin retraction over the glans. He was born at 37 weeks gestation and was not circumcised at birth due to concern for heart murmur. After obtaining cardiac clearance and parental consent, Plastibell circumcision was performed with good preservation of the frenulum, and the patient tolerated the procedure well.

Discussion/conclusions: There is current controversy over the ideal extent of preputial preservation during circumcision. Several publications have highlighted the frenulum’s function in penile erection, owing to its innervation by fine-touch sensory receptors, such as Meissner’s corpuscles (1).

By leaving the frenulum intact, we aim to reduce the risk of complications, particularly meatal stenosis, which is the narrowing of the urethra in circumcised children (3). These children commonly present with symptoms of high-velocity stream (usually upwards), dysuria, and urinary frequency after toilet training.

In conclusion, this tissue-sparing approach potentially reduces complications, improves cosmesis, and retains sensitivity.

References:

Shenoy SP, Marla PK, Sharma P, Bhat N, Rao, AR. Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique. Journal of clinical and diagnostic research. 2015; (9)12: PC01-3. doi:10.7860/JCDR/2015/14972.6860.

Nagdeve NG, Naik H, Bhingare PD,Morey SM. Parental evaluation of postoperative outcome of circumcision with Plastibell or conventional dissection by dorsal slit technique: A randomized controlled trial. Journal of Pediatric Urology. 2013; 9(5): 675-682. doi:10.1016/j.jpurol.2012.08.001.

Abid AF, Hussein NS. Meatal stenosis posttraditional neonatal circumcision-cross-sectional study. Urology annals. 2021; 13(1): 62-66. doi:10.4103/UA.UA_30_20.

Robotic-assisted pyeloplasty for ureteropelvic junction obstruction

Introduction

We present a case of ureteropelvic junction obstruction secondary to aberrant crossing gonadal vessels in a symptomatic 11-year-old female with horseshoe kidney, treated with a robotic-assisted pyeloplasty.

Diagnostic Evaluation

The patient presented with intermittent right-sided flank pain and vomiting. Renal ultrasound showed right-sided hydronephrosis and an abnormal-shaped kidney. MAG-3 renal scan demonstrated decreased function of the right kidney and no drainage. A MR Urogram showed a horseshoe type kidney with malrotation and an anterior dilated renal pelvis.

Surgical Technique

The patient underwent a robotic-assisted dismembered pyeloplasty. Intraoperatively, the right kidney was confirmed to be malrotated with a large, anteriorly directed renal pelvis. A packet of aberrant crossing gonadal vessels was identified and dissected from the right ureter and surrounding tissue. The ureter was sharply divided at the level of the ureteropelvic junction and transposed above the crossing vessels. A tension free mucosal to mucosal water-tight anastomosis was performed starting at the apex of the incision. A double-J stent was introduced into the ureter. The remainder of the anastomosis was completed with interrupted sutures. There were no intraoperative or postoperative complications.

Conclusions

Robotic-assisted dismembered pyeloplasty is a safe and effective method for UPJO correction in symptomatic patients with complex renal anatomy.

Sign Up for Newsletter

"*" indicates required fields