A large amount of evidence have shown that circumcision is only required infrequently[13]. Clinical data suggests that most cases of phimosis can be treated with CC[14]. There have been multiple methods for treatment of phimosis, such as sleeve circumcision, dorsal slit (DS), Shang Ring circumcision (SRC) and a disposable circumcision suture device (DCSD). One of the most common surgeries is the conventional circumcision (CC) which has been recommended by World Health Organization (WHO) in 2008[15].
In this study, we showed that application of BCDT is an effective, safe and conservative treatment for children with various types of phimosis. It is noteworthy that the frequency of application depends on the type of preputial retractability. The more severe phimosis is, the higher fequency the course of BCDT is needed.
Typically, the prepuce begins to develop in the 3rd month of intrauterine life and is completed by 4-4.5 months[3]. At this stage, the inner surface of the prepuce and glans is covered with a stratified squamous epithelium and are fused. Later in gestation, the prepuce is detached from the glans under the influence of androgens and/or growth factors, which is a poorly understood biological process[16] that may continue to complete even up to the age of seventeen[3]. It is important to keep in mind that, this developmental procedure can be referred for consideration of possible phimosis, at any age of a child.
It is essential to recognize the physiological features of this condition. Physiological phimosis (tightness of prepuce), preputial adhesion, and smegma are common in children. Because the foreskin is too long, part of the foreskin mouth is small, the foreskin cannot be turned up, and it is difficult to discharge the exfoliated epithelium. When the foreskin cannot be reset after it turns up, incarcerated phimosis can be caused, and in severe cases, necrosis of the penis head can occur. There are potential benefits and complications of circumcision that should be thoroughly appreciated by physicians. Medical indications for circumcision include penile malignancy, traumatic foreskin injury, recurrent attacks of severe balanoposthitis, and recurrent febrile UTIs (Urinary Tract Infections) with abnormal urinary tract. Very few international societies support routine circumcision despite the potential medical benefits incurred.
Recently nonsurgical treatment of phimosis has been reported as a safe alternative.
During recent years, the role of BCDT in conservative treatment of phimosis has raised the interest of many investigators. In this study, successful treatment of phimosis with BCDT may obviate the surgical necessity for circumcision in many children.
The clinical treatment of the phimosis with BCDT is well accepted by the parents, since it is a simple procedure, and it presents low costs and risks, no side effects and a good compliance to the treatment when the children’s guardians are well informed.
Circumcision is a minor operative procedure with a low incidence of complications. However, hospital care, general anesthesia and postoperative care are required. Heinius et al reported that 34% of children had problems postoperatively and 11% required prolonged hospitalization[17]. Some studies claim that circumcision can produce a more hygienic penis as well as reduce the risk of penile and cervical cancer[18], genital herpes[19] and urinary tract infection. However, circumcision also can cause hemorrhage (1–7% of cases)[20, 21], meatitis and meatal ulceration (8–31%)[22], meatal stenosis (11%)[23], removal of an inadequate amount of skin leading to secondary phimosis, removal of excessive skin[24] and infection (4–6%), such as Fournier's syndrome[25] and septicemia[26].
In both groups of children of our study, the operative time in the BCDT group was shorter than that in the CC group. The median operation time in the BCDT group was 6.7 ± 1.3 mins in our study. The median operation time in the CC group was 8.9 ± 5.8mins, which is similar to 7.6 ± 4.5mins as reported by Lv, et al[27]. There were significant differences in the VAS scores of pain at two hours after surgery, or complications between the BCDT and CC groups. The most serious postoperative pain occurred in the CC group. The children in the BCDT group were more satisfied with the cosmetic aspects of the wounds than the children in the CC group.
In BCDT group, 5% lidocaine cream was applied to the surface of the penis prior to the operation, it is simple and convenient, but the traditional dorsal penile nerve block was applied to the children in CC group.
There are no scar and no time required for wound healing in the BCDT group. The randomized control trails of several African centers indicated that the median time to complete wound healing is 43 days in CC group[12, 28].
There was no significant difference in the incidence of incarceration between the children of the two groups.
During the BCDT procedure, the foreskin is separated between the inner and glans by balloon catheter. Therefore, no hematomas or exudations occurred in the BCDT group. However, hematoma or exudation occurred in the majority of the CC group.
In this study, five children in CC group exhibited partial wound dehiscence, which were discontinuously reinforced with absorbable sutures, and all the children recovered well after the operations. An analysis of the reason for wound dehiscence revealed that hematomas resulted in infection and inflammation, and then partial wound dehiscence. Among the children in BCDT groups, no wound infections had occurred.
One limitation of this study is that, this is an non-randomized control design(Take into account the wishes of the guardian), which could influence data collection and the reporting of clinical features. A study of larger and independent cohorts may validate these findings. The other main limitation of our study is that the follow-up was relatively short. We aim to establish long-term follow ups as our future study.