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I.8.5 Circumcision 203 I.8.5 Circumcision 203 volume disease (prophylactic lymphadenectomy) has a I.8.4.6 survival benefit compared to the delayed treatment of Results of Treatment clinically involved nodes. The improved survival for It is usually possible to provide good local control for some patients must be balanced with considerable penile cancer by all approaches for early disease (Ta– morbidity of lymphadenectomy. Tumour grade does T2), but for more advanced disease surgery is usually have some prognostic significance. This probably re- the preferred option. flects the propensity of poorly differentiated tumours The survival figures of penile cancer are summa- to metastasize, but it should not be forgotten that well- rized in Table I.8.10. differentiated tumours also metastasize. Table I.8.10. Survival figures for penile cancer. Percentages are I.8.4.8 mean 5-year survivals from various reported studies Prevention Treatment Survival (%) at tumour stage As has been described previously, early circumcision I II III IV can prevent the development of penile cancer, but re- Surgery6542270 cent epidemiological studies from Scandinavia have Radiotherapy 68 51 21 5 suggested that good hygiene associated with improved Adapted from Gillenwater J, Howards S, Grayhack J, Mitchell socioeconomic status can lead to a decreased incidence ME (2001) Adult and Pediatric Urology, 4th edn. Lippincott, of this disease. Wilkins & Williams, Philadelphia, p. 1990 I.8.4.9 I.8.4.7 Other Prognosis An increased incidence of cervical and vulval cancer As can be seen in the preceding section, patients with has been demonstrated in partners of patients with pe- localized disease have a good prognosis; however, nile cancer. This observation certainly appears to con- when there is evidence of spread (except in cases with firm that there is likely to be a common transmissible minimal inguinal node involvement) the results of factor in the development of these diseases. Recently treatment are rather disappointing. Several retrospec- there has been hope expressed that vaccination against tivestudieshaveshownthepresenceoflymphnodal HPV will prevent cervical cancer and one would hope involvement has a marked impact on survival. Others that a similar approach might bear fruit in preventing I.8 have additionally demonstrated that removal of low- the development penile cancer in some patients. I.8.5 Circumcision C.F. Heyns, J.N. Krieger Key Messages ■ Circumcision is the most ancient surgical ficiencyvirus(HIV),maybetwotoeighttimes procedure known, and has generated more higher in uncircumcised men, but there is not controversy than any other operation. yet any evidence that circumcision is a cost- ■ Medical indications for circumcision include effective strategy to reduce the infection rate. pathological (cicatrizing) phimosis, recurrent ■ Neonatal circumcision confers a threefold paraphimosis, recurrent balanitis, condylo- reduced risk of penile cancer, but almost two mata acuminata involving the foreskin and complications of circumcision can be expected glans, recurrent coital injury of the prepuce, for every case of penile cancer prevented. and placement of a penile prosthesis. ■ Although scientific evidence demonstrates ■ Neonatal circumcision may confer a three- to some medical benefits of circumcision, these sevenfoldreducedriskofurinarytractinfec- data are not yet sufficient to recommend tion (UTI), but the risk of UTI in an uncircum- routine neonatal circumcision. cised male infant is only about 1%. ■ The risk for acquiring sexually transmitted infections (STI), including human immunode- 204 I.8 Benign Lesions and Malignant Tumours of the Male Genital Tract I.8.5.1 I.8.5.2 Introduction Epidemiology of Circumcision Circumcision is the oldest surgical procedure in the There are substantial differences in circumcision rates world, and remains one of the most controversial sub- in different parts of the world, but approximately 80% jects in medicine. It has been practised for thousands of of the world’s males are uncircumcised. The prevalence years among certain peoples on all the inhabited conti- of neonatal circumcision is influenced by religious af- nents,andinEgypttheprocedurecanbedatedbackto filiation, country of origin, ethnicity, residential area, at least 6,000 years ago (Fig. I.8.16). The Jewish practice maternal education, socioeconomic status, type of of circumcision precedes its documentation in the To- health insurance and the attitudes of parents and physi- rah by over 1,000 years, and it is not a prerequisite for cians (Kaplan 1983; Laumann et al. 1997; Lerman and being Jewish. Circumcision was a common practice in Liao 2001). pre-Islamic Arabia and is considered an external sym- In the United States, the rate of neonatal circumci- bolofbeingaMuslim,butnotaconditionforbecoming sion declined from about 90% in the 1950s to around one. 60–70% in the 1980s, while recent studies have re- The real motives for circumcision in ancient cul- ported rates varying from 65% to 82%. Circumcision is tures are open to speculation, but theories suggest that veryuncommoninEuropeancountries,Centraland it originated as a: South America and Asia. In the UK, circumcision rates fell from about 30% in 1940 to 6% by 1975. South Korea 1. Rite of passage or initiation ceremony is the only Asian country where circumcision has been 2. Mark of defilement imposed on slaves or prisoners widely performed since the Korean war in the 1950s, of war with a circumcision rate for high school boys above 3. Form of social control in patriarchal societies 90% (Gairdner 1949; Frisch et al. 1995; Niku et al. 1995; 4. Method of “pain imprinting” to enhance the child’s Dunsmuir and Gordon 1999; Goldman 1999; Ham- ability for survival later in life mond 1999; Rickwood 1999; Quayle et al. 2003; Alanis 5. Mark of cultural identity and Lucidi 2004). 6. Fertility rite 7. Hygienic or preventive health intervention 8. Measure to control male sexuality I.8.5.3 9. Rite of male bonding Embryology and Function of the Foreskin (Gairdner 1949; Kaplan 1983; Dunsmuir and Gor- Development of the prepuce begins at 8–12 weeks I.8 don 1999; Elchalal et al. 1999; Glass 1999; Goldman of intrauterine life and is usually complete by 16– 1999; Goodman 1999; Hammond 1999; Rizvi et al. 20 weeks. The epithelium of the inner prepuce and 1999; Lerman and Liao 2001; Alanis and Lucidi glansisstratifiedsquamousintype,withbothlayers 2004). Fig. I.8.16. Modern replica on papyrus of a decoration from the tomb of Ankh- Mahor at Saqqara (2400 BCE), depicting circumcision in ancient Egypt I.8.5 Circumcision 205 initially fused to each other. Separation of the prepuce duringthe1styearoflife.Afterabout5yearsofage,pe- from the glans begins by 24 weeks of gestation, but is riurethral colonization by uropathogens is found only usually incomplete at birth. Thus, the normal neonatal in boys who get recurrent UTIs (Gairdner 1949; Øster prepuce is not retractable. During the first 3–4 years of 1968; American Academy of Pediatrics 1999; Cold and life, the prepuce and glans separate as a consequence of Taylor 1999). several processes, including growth of the penile body, The prepuce is often regarded as a redundant vesti- accumulation of epithelial debris (smegma) and inter- gial structure, but its functions may include: mittent penile erections. Ventral or dorsal preputial de- 1. Preventing meatal ulceration due to injury of the velopmentisusuallydeficientwithhypospadiasand glans by contact with sodden nappies epispadias, respectively (Kaplan 1983; Niku et al. 1995; 2. Enhancing the pleasure of sexual activity by means Cold and Taylor 1999; Lerman and Liao 2001). of its sensory innervation Gairdner (1949) found that the incidence of a nonre- 3. Providing lubrication for atraumatic vaginal inter- tractable prepuce progressively decreased from 96% in course newborns to 6% in boys aged 5–13 years. Similarly, 4. Forming part of the cutaneous mucosal immune Øster (1968) found that the foreskin was retractable in system, because it contains Langerhans cells almost all boys by 17 years of age (Fig. I.8.17). 5. Being a source of live human fibroblasts for cell- Kayaba et al. (1996) classified preputial status into culture research five types based on retractability and found that the in- 6. Providing tissue for genital tract reconstructive cidenceoftypeVprepuce(easyexposureofthewhole surgery glans) increased from 0 in boys younger than 1 year to (Gairdner 1949; Cold and Taylor 1999; Dunsmuir 63% in those 11–15 years old. A tight prepuce, defined and Gordon 1999; Hammond 1999). as a stenotic ring that prevented the prepuce from be- ing retracted, decreased from 84% at ages 0–6 months to 9% at 11 –15 years. I.8.5.4 Smegma is a white, creamy material consisting of desquamated epithelial cells which may collect under Indications for Circumcision theprepuce.Malesmegmacontainssteroids,sterols Indications for circumcision include: and fatty acids which may have a protective function. 1. Pathological phimosis In boys 5–13 years old, inspissated smegma may be- 2. Recurrent paraphimosis come malodorous, which does not occur in younger 3. Recurrent balanitis or balanoposthitis boys. The production of smegma increases in quantity 4. Lichen sclerosus of the penis (balanitis xerotica ob- I.8 at the age of 12 –13 years. literans) Uropathogenic bacteria adhere to and readily colo- 5. Condylomata acuminata (if extensive) and rare le- nize the mucosal (inner) surface of the foreskin. In sions such as lymphogenous cysts of the prepuce, newborn boys, the periurethral area is
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