BRITISH JOURNAL OF UROLOGY, Volume 56; Pages 319-321, June 1984.Copyright © British Association of Urological Surgeons S. HOFFMAN, P. METZ and J. EBBEHØJ
Department of Plastic Surgery and Burns Unit,
Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
Summary - The operation for phimosis aims at achieving normal preputial retractability and the prepuce need not be removed. A method is described in which multiple Y-V-plasties relieve the phimosis without resecting any preputial tissue.
The indications for circumcision may be non-medical or medical. The former include ritual, religious and family traditional reasons and the latter include phimosis, recurrent post-coital ulceration of the prepuce, protection against penile carcinoma, and the occasional need to facilitate cystoscopy, urinary bladder catheterisation or sub-preputial hygiene.
The EbbehØj Procedure
A local anaesthetic (with noradrenaline) is injected subcutaneously around the penile root.
If the prepuce cannot be retracted (Fig. 1) four longitudinal incisions, are made in the outer layer as far as the distal rim of the preputial constriction. (Fig 1B). After cautiously incising the edge, the prepuce can be retracted. (Fig. 1C) The incisions are now continued in the inner layer, all four curving a little to the same side (Fig. 1D). From the middle of this curve incisions are made that reach the proximal end of the neighbouring curved incision. The ventral incision in the outer layer is done in the penile raphe, so that the ventral curved incision in the inner layer is clear of the frequently insufficiently anaesthetised and often bleeding area around the frenulum. The procedure is continued as described below (Fig. 2D.E).
If the prepuce can be retracted (Fig. 2), this is done and a saw-toothed incision is made along the circumference of the preputial stenosis, the angle between adjoining limbs being about 90 degrees and at equal distances from the stenosis (Fig. 2B). The Vs of the saw-toothed incision are now converted into Ys by longitudinal incisions in both directions (Fig. 2C,D). The incisions extend only through the skin and fibrosis of the stenosis, thereby avoiding the subcutaneous vessels. Due to the looseness of the tissue the flaps can now be advanced without undermining (Fig. 3), and the tips of the flaps are fastened with corner stitches in the bottoms of the stems of the Ys (Fig. 2E). Thus, each Y is transformed into a tall narrow V and the circumference is normalised at the site of the stenosis. Four Y-V plasties are usually sufficient. The wound is closed with a continuous 4/0 catgut suture. The prepuce is reset and retained in this position with two catgut stitches, this rendering dressing unnecessary and providing sufficient compression of the suture lines against the glans. The patient is advised to micturate in the sitting position until these stitches burst, normally within 3 to 5 days and to avoid sexual activity for 2 to 3 weeks.
[Seven schematic line drawings] Fig. 1 Schematic drawings of the use of multiple Y-V plasties in the repair of phimosis in case of non-retractable prepuce. Above: ventral view: below: seen from the tip. The vertically shaded area indicates the preputial stenosis.
[Five schematic line drawings] Fig. 2 Schematic drawings of the use of multiple Y-V plasties in the repair of phimosis in the case of retractable prepuce. Dorsal view.
[one photograph] Fig. 3 Per-operative photo demonstrating the easy adaptability of flaps.
[Two photographs] Fig. 4 Post operative result in a 24-year-old patient 6 months after multiple Y-V plasties for phimosis. (A) The prepuce covering the glans. (B) The prepuce fully retracted.
Unnecessary removal of human tissue should be avoided and the prepuce is no exception. In traumatic skin loss the prepuce may serve as a convenient and sufficient source of wound cover.
Circumcision apparently reduces the risk of penile carcinoma. However, this reduction is less marked if the operation is performed later than infancy (Boczko and Freed, 1979). The retained smegma is believed to be the carcinogenic agent, but inadequate penile hygiene is due to preputial non-retractability, not to the prescence of the prepuce. A number of prepuce-saving techniques for the repair of phimosis have been suggested. They include the dorsal slit (Diaz and Kantor, 1971), oblique dorsal incision (Schloffer, 1901), modified Z-plasties (Marschner, 1971); Kodega and Kus, 1973), Multiple Z-plasties (Parkash, 1972) and the four V-flap plasty (Emmett, 1975). Because of the good cosmetic result and the very low risk of haematoma formation, we prefer our procedure. It is easy to perform, takes less than 30 minutes, and the functional and cosmetic results are excellent (Fig 4A,B). During the last three years this method, with minor modifications has been used in our department on 44 patients (aged 10-73 years). Any one recurrence has been encountered and that was in a patient who had balanitis xerotica obliterans.
CIRP Note: When this paper was written in 1984, smegma was still suspected as a carcinogenic agent. Today we know that smegma is NOT carcinogenic. The major risk factors for penile cancer are the use of tobacco and infection with human papilloma virus (HPV).
S. Hoffman, MD. Houseman.
P. Metz, MD, Senior Registrar.
J. Ebbehøj, MD, Consultant.
Requests for reprints to J. Ebbehøj, Department of Plastic Surgery and Burns Unit, Afsnit 335,
Hvidore Hospital, University of Copenhagen,
Kettegaard Alle 30,
Accepted for publication 29 July 1983.
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