Journal of Pediatric Surgery (2011) 46, 1469–1472
www.elsevier.com/locate/jpedsurg
Correspondence
Penile necrosis after circumcision owing to inappropriate
postoperative treatment
To the Editor:
Male circumcision is one of the most common surgical
procedures because of therapeutic or nontherapeutic reasons.
Although some complications of circumcision have been
previously reported [1], the most serious complication of
circumcision, penile necrosis, is rarely reported. Herein, we
report 6 cases of penile necrosis in older children owing to
inappropriate postoperative treatment.
Six male patients with a mean age of 16 years (range, 8∼24
years) underwent traditional circumcision in private hospitals.
To prevent bleeding, the penile wounds were tightly dressed
in 1 patient (8-years old) for 3 days resulting in necrosis of
the distal glans (Fig. 1A). For promoting wound healing,
5 patients (12∼24 years) received microwave thermotherapy
immediately after operation resulting in complete necrosis of
the distal penile (Fig. 1B). After removing the gauze, the distal
balanus and corpus penis presented as black and dry or gray
and erosive without any sense or blood supply. These patients
were subsequently referred to our hospital with penile necrosis
accompanied by infection. Partial penectomy was performed
to prevent the spread of infection. None of them received
plastic surgery because phalloplasty is still difficult, costly,
and rarely accessible in most areas of China.
At present, strategies for circumcision include traditional
excision, laser excision, and foreskin loop ligature using the
plastibell. The reported incidence of foreskin bleeding,
Fig. 1 A, An 8-year-old boy with distal glans necrosis covered by scab. B, The necrotic penis of a 20-year-old patient presented black.
0022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
severe foreskin edema, and short foreskin after circumcision
is about 0.64%, 0.82%, and 0.62%, respectively [2].
However, in some developing countries, the disordered
medical market, untrained medical personnel, and unfamil-
iarity with surgical procedures and postoperative care
increase the incidence of complications of circumcision.
The incidence of foreskin edema, infection, bleeding, and
wound dehiscence after circumcision was 35.71%, 12.11%,
12.42%, and 1.55%, respectively, in some small or private
hospitals in China [3]. However, more serious complications
after circumcision including penile necrosis have not been
reported. In our report, an important cause of penile necrosis
was tight dressing left in place for a long time after
circumcision. Although a tight dressing can avoid postoper-
ative bleeding, it may also compress the blood vessels and
completely occlude the blood supply to the penis, finally
resulting in avascular necrosis. Another important cause of
penile necrosis in our report was the misuse of microwave
thermotherapy. Transurethral microwave thermotherapy has
been used in the treatment of lower urinary tract symptoms
caused by benign prostatic hyperplasia [4]. However, in some
developing countries, incredible microwave thermotherapy is
performed widely after circumcision, although there have
been no recommended guidelines. The uninformed personnel
may assume that microwave thermotherapy can promote
wound healing through its noncontact heating. Nevertheless,
as noted in the cases we described, inappropriate use of
microwave thermotherapy after circumcision may worsen
wound healing or even result in avascular penile necrosis.
1470
Thus, inappropriate use of microwave thermotherapy should
not be used in children after circumcision. Once the penile
necrosis is confirmed, immediate surgical resection is needed
to prevent the spread of infection from the necrotic tissues.
Heng Zhang
En-qing Xiong
Urology Institute of PLA, Southwest Cancer Center
Southwest Hospital, Third Military Medical University
Chongqing 40038, China
Li-Mei Liu
Department of Pathology, Southwest Hospital
Third Military Medical University
Chongqing 40038, China
Shu-Xian Yan
Zhan-Song Zhou
Gen-Sheng Lu*
Urology Institute of PLA, Southwest Cancer Center
Southwest Hospital, Third Military Medical University
Chongqing 40038, China
*E-mail address: montest44@hotmail.com
doi:10.1016/j.jpedsurg.2011.03.006
References
[1] Ceylan K, Burhan K, Yilmaz Y, et al. Severe complications of
circumcision: an analysis of 48 cases. J Pediatr Urol 2007;3:32-5.
[2] Hirji H, Charlton R, Sarmah S. Male circumcision: a review of the
evidence. JMHG 2005;2:21-30.
[3] Li HN, Xu J, Qu LM. Shang Ring circumcision versus conventional
surgical procedures: comparison of clinical effectiveness. Nat J Androl
2010;16:325-7.
[4] Walmsley K, Kaplan SA. Transurethral microwave thermotherapy for
benign prostate hyperplasia: separating truth from marketing hype.
J Urol 2004;172:1249-55.
Re: Laparoscopic repair of diaphragmatic Morgagni hernia
in children: review of 3 cases
To the Editor,
We note that Van De Winkel et al [1] confirm the efficacy
of our technique in repairing anterior diaphragmatic hernia,
as reported previously in this journal [2]. However, it is
surprising to find the authors describe each of the three
hernias to be left-sided when their figure clearly shows a
central defect in the anterior diaphragm. The authors contend
that anterior diaphragmatic hernia is the result of imperfect
fusion of the septum transversum and the costal arches, but if
this were true the defect would be parasternal, through the
foramen first described by Morgagni [3] and now honored
with his eponym. This perpetuates a common misunder-
standing about the differences between anterior diaphrag-
matic hernias in children and adults.
Correspondence
Evidence suggests that these hernias in children are true
midline defects and are congenital rather than acquired [4]. In
adults, the hernia is acquired and paramedian, through a
relatively poorly muscled space between the pars sternalis
and the pars costalis of the diaphragm. The etiology of
anterior diaphragmatic hernia therefore differs in adults and
children, evidenced by the bimodal distribution of the
disease (childhood and after the fifth decade) and by the
differing sex ratios in these distributions (male predominance
in children, female in adults). Morgagni [3] himself confused
the 2 pathologies, describing his eponymous hernia as
paramedian but congenital. This is excusable, as he did not
ever claim to have seen a hernia himself and certainly did not
have the advantages of the fine views of the defect provided
by laparoscopy. Morgagni's [3] conclusions were based on
dissections in people without hernias and after a report from
a colleague.
It is time to dispense with left and right in describing
Morgagni hernias in children and to accept the evidence
before our eyes that these are midline defects.
Craig A. McBride
Royal Children's Hospital
Herston, Australia
E-mail address: craig_mcbride@health.qld.gov.au
Spencer Beasley
Christchurch Hospital
Christchurch, New Zealand
doi:10.1016/j.jpedsurg.2011.03.073
References
[1] Van De Winkel N, De Vogelaere K, De Backer A, et al. Laparoscopic
repair of diaphragmatic Morgagni hernia in children: review of 3 cases.
J Pediatr Surg. 46:e23-6.
[2] Azzie G, Maoate K, Beasley S, et al. A simple technique of laparoscopic
full-thickness anterior abdominal wall repair of retrosternal (Morgagni)
hernias. J Pediatr Surg 2003;38:768-70.
[3] Morgagni GB. Letter the fifty-fourth. Treats of wounds and blows of the
belly, loins, and arms. De Sedibus et Causis Morborum per Anatomen
Indagatis (On the Seats and Causes of Disease Investigated by
Anatomy). London: Millar and Cadell; 1769. p. 205-6.
[4] McBride CA, Beasley SW. Morgagni's hernia: believing is seeing.
ANZ J Surg 2008;78:739-44.
Reply to “Robot-assisted resection of choledochal cysts
and hepaticojejunostomy in children less than 10 kg.”
Dawranta MJ, Najmaldin AS, Alizai NK. Journal of
Pediatric Surgery (2010);45:2364-2368
To the Editor,
The authors are to be congratulated on the results of
this complex robotic surgery in babies weighing less than
10 kg.