quiz bilateral inguinal hernias & circumcision

[Ahmed Nabil]

A full term newborn boy is found to have bilateral inguinal hernias at birth. The genitalia and foreskin appear normal. Hernia repair and circumcision were planned before the baby’s discharge due to mild difficulty in reducing the hernias. The hernias were repaired uneventfully using an inguinal approach. During the circumcision, the foreskin was stretched and a dorsal slit was fashioned using a clamp and scissors to accommodate a bell device.

At this point, it was appreciated that distal (glandular) hypospadias may be present. The next best step in management is

A stop the circumcision, suture the edges of the skin flaps leaving them intact.

B reconstruct the foreskin.

C complete the circumcision.

D perform concurrent hypospadias repair.

E reconstruct the foreskin leaving a Foley catheter in place.

[Admin]

correct answer
C complete the circumcision.

Physical examination is important in these types of cases. In most instances, hypospadias is readily recognized. If so, no circumcision would be undertaken until definitive repair of the hypospadias. However, in cases of distal hypospadias, the penis may appear normal until the glans is well exposed. If circumcision has already been started and distal hypospadias is then discovered, it would be acceptable to finish the circumcision. Currently, distal hypospadias is typically repaired using the tubularized incised plate urethroplasty (TIP) technique that has essentially eliminated the need for skin flaps. Thus, if circumcision has already been performed in an infant with distal hypospadias, appropriate repair of hypospadias can still be accomplished.

The most likely scenario where an unexpected hypospadias may be encountered is during circumcision for an intact prepuce. In addition, in a normal penis, if the ventral prepuce attachment to the meatus is still intact and tethering, some practitioners performing the circumcision may believe they are encountering hypospadias thereby deciding to abort the procedure. Two recent large series by Snodgrass and Pieretti have shown that prior circumcision did not interfere with subsequent successful repair of hypospadias. Therefore, their recommendations are to complete the circumcision even if hypospadias is found or is suspected. They also support that practitioners should not be bound by legal concerns if circumcision is performed in the presence of previously unrecognized hypospadias. It should be recognized as well by practitioners that the circumcision did not result in the hypospadias found.

In this scenario, then, the appropriate course is to complete the circumcision. Hypospadias repair is not typically undertaken until three to six months, so there is no need for immediate hypospadias repair at circumcision in the clinical scenario in the question.

[Sharon]

c

[Tariq]

c

[Admin]

correct answer
C complete the circumcision.

Physical examination is important in these types of cases. In most instances, hypospadias is readily recognized. If so, no circumcision would be undertaken until definitive repair of the hypospadias. However, in cases of distal hypospadias, the penis may appear normal until the glans is well exposed. If circumcision has already been started and distal hypospadias is then discovered, it would be acceptable to finish the circumcision. Currently, distal hypospadias is typically repaired using the tubularized incised plate urethroplasty (TIP) technique that has essentially eliminated the need for skin flaps. Thus, if circumcision has already been performed in an infant with distal hypospadias, appropriate repair of hypospadias can still be accomplished.

The most likely scenario where an unexpected hypospadias may be encountered is during circumcision for an intact prepuce. In addition, in a normal penis, if the ventral prepuce attachment to the meatus is still intact and tethering, some practitioners performing the circumcision may believe they are encountering hypospadias thereby deciding to abort the procedure. Two recent large series by Snodgrass and Pieretti have shown that prior circumcision did not interfere with subsequent successful repair of hypospadias. Therefore, their recommendations are to complete the circumcision even if hypospadias is found or is suspected. They also support that practitioners should not be bound by legal concerns if circumcision is performed in the presence of previously unrecognized hypospadias. It should be recognized as well by practitioners that the circumcision did not result in the hypospadias found.

In this scenario, then, the appropriate course is to complete the circumcision. Hypospadias repair is not typically undertaken until three to six months, so there is no need for immediate hypospadias repair at circumcision in the clinical scenario in the question.