Routine histopathological examination of the foreskin after circumcision for clinically suspected lichen sclerosus in children: Is it a waste of resources?

INTRODUCTION: Circumcision is one of the most widely performed procedures in the world. One of the indications for circumcision is lichen sclerosis (LS). The natural history of LS in children is not as well-documented as in adult patients. Surgeons use the appearance of the foreskin or meatus to predict the diagnosis of LS. Indeed, if the diagnosis of LS is made in childhood, does it change management in the long-term? Pathological analysis of the excised foreskin is routinely done if there is suspicion of LS. Our aim is to assess the concordance between the clinical and pathological diagnosis of suspected LS and to assess the need for sending the foreskin for pathological examination. METHODS: We conducted a retrospective chart review of 64 of 420 boys who underwent circumcision in a tertiary children's hospital from June 2005 to June 2014, and who had their foreskin sent for pathology due to the clinical suspicion of LS. Demographics, presenting symptoms, presumed clinical diagnosis, pathological findings, and followup data were collected and analyzed. RESULTS: Over the review period, 64 patients underwent circumcision for presumed LS. The mean age of the children was 9.7 years (range 3-16.5). All the children who had circumcision for presumed LS diagnosis were symptomatic. LS was confirmed in 47 of 64 foreskins (73.5%). Balanitis xerotica obliterans (BXO) was clinically suspected in 40 (85%) of the 47 patients. The mean followup was 10 months (range 1-15), with seven recurrences (15%) during that period. The recurrences required revision surgery in two patients and five were managed with steroids only. CONCLUSIONS: In our series, the clinical diagnosis correlated with the pathological diagnosis in most cases. A clinical suspicion of LS without routine foreskin pathological assessment will reduces the overall cost to the healthcare system. Appropriate counselling of the patient/parents and their primary caregiver is imperative, as recurrence is common.

Environmental, parental and gestational factors that influence the occurrence of hypospadias in male patients.

OBJECTIVE: Hypospadias is a congenital defect, which affects normal development of the male urogenital external tract. In this malformation, the urethral orifice of the penis is positioned ventrally, thus interfering with normal urination and creating, in some adults, problems during sexual intercourse. Heritability of hypospadias has been shown in some reports, and the abnormality has been associated with the presence of mutations in one of the genes involved in urogenital development. However, even for patients who were born in families with a higher incidence rate of this defect, no evident genetic alteration could be identified in known genes, indicating that the list of loci involved is still incomplete. To further complicate matters, recent reports also underline that epigenetic changes, without any identifiable gene sequence mutation, may be involved in gene function impairment. Therefore, the inheritance of most hypospadias cases is not evident, suggesting that the genetic background is not the only cause of this malformation; indeed, the majority of hypospadias cases are classified as sporadic and idiopathic. MATERIALS AND METHODS: Evidence has accumulated highlighting the role of the environment and of its relationships with the genome in the etiology of this abnormality. In particular, the interaction between some chemicals, which are able to mimic endogenous molecules such as sexual hormones--for this reason called endocrine disrupting compounds (EDC)--and specific receptors has been extensively investigated during the pregnancy. Additionally, several articles have shown that parental and gestational factors play a significant role too. Indeed, physiological alterations, such as body weight of the mother and/or of the newborn, mother's diabetes, impaired father fertility, and exposure of one parent to job-related pollutants, show in many cases a direct correlation with hypospadias incidence. The overall prevalence of this condition has been studied in many countries, suggesting that at least in some periods and/or in specific populations there are detectable fluctuations, probably mirroring the different natural environments. However, many articles present data that do not agree with these findings and, consequently, most causes of hypospadias are still highly debated. RESULTS: In this review, we summarize the developmental steps involved in urogenital tract formation, with a particular emphasis on the genes that most frequently are associated with this condition, or that are subject to environmental stress, or that may be the targets of hormone-like, exogenous molecules. Then, we make an overview of the identified factors able to impair the function of important genes, even in the absence of their mutations, including those for which contradictory reports have been published. Finally, we propose an explanation of sporadic cases of hypospadias that reconciles these contradictions and suggest some steps for moving forward in the research focused on this condition. CONCLUSION: We hypothesize that most patients develop hypospadias because of gene-environment interactions acting on polymorphic genes that, in the absence of environmental stimuli, would otherwise cause no developmental anomaly during urogenital development.

Is there a role for tamsulosin after shock wave lithotripsy in the treatment of renal and ureteral calculi?

INTRODUCTION: Our study aimed at defining the role of tamsulosin as adjunctive therapy after extracorporeal shock wave lithotripsy (ESWL) in patients with stones in the kidney and ureter. MATERIALS AND METHODS: A placebo-controlled, randomized, double-blind clinical trial prospectively performed between February 2008 and September 2009 on 150 patients with 4-20 mm in diameter renal and ureteral stones referred to our ESWL center. After ESWL, all patients randomly assigned to two groups (placebo and tamsulosin). The drugs administration was started immediately after ESWL and was continued for a maximum of 30 days. RESULTS: From 150 patients, 71 in control group and 70 in case group completed the study. Of 71 patients (60.56%) in control group, 43 patients became stone free; and other patients (39.44%) did not succeed in stone expulsion during 12 weeks after ESWL. In case group of 70 patients (71.4%), 50 patients became stone free. Time of stone passage in most of the patients happened between 20th and 30th day in control group (32.6%) and between 10th and 20th day (50%) in case group after ESWL. There is no statistically significant difference between stone passage in two groups (p = 0.116) and location of stone (p = 0.114), but there is statistically significant difference in time of stone passage from onset of treatment in case and control groups (p = 0.002). CONCLUSION: At last, this study suggested that tamsulosin facilitate earlier clearance of fragments after ESWL.