What is the procedure and management for dorsal slit circumcision in patients with phimosis?

Dorsal Slit Circumcision: Procedure and Management

When to Use Dorsal Slit Technique

The dorsal slit technique is especially useful in patients with phimosis where tissue visualization and access are limited, and should be extended to the level of the coronal sulcus for adequate visualization and complete tissue removal. 1, 2

• The dorsal slit is the preferred approach when the foreskin cannot be retracted, making the standard sleeve technique difficult or impossible 2
• This technique provides superior access in emergency situations like paraphimosis when manual reduction fails 3

Operative Technique

Anesthesia

• Perform a dorsal penile nerve block, with or without a circumferential penile block, which provides adequate anesthesia for the procedure 2

Surgical Steps

• Extend the dorsal slit incision to the level of the coronal sulcus to ensure adequate visualization and complete tissue removal 1
• Maintain surgical margins of 5-10 mm, which are considered safe and provide adequate tissue control 1
• Close skin edges with absorbable sutures using either interrupted or running technique 1
• Apply petroleum-based ointment and a light, non-constrictive dressing to prevent adhesion and promote healing 1

Important Surgical Considerations

• The sleeve technique may provide better control of bleeding in patients with large subcutaneous veins, though the dorsal slit remains preferable when phimosis limits access 2
• Surgical time is significantly shorter with dorsal slit compared to formal circumcision, though bleeding rates may be slightly higher with circumcision (1.7%) 4

Critical Pathology Requirement

All excised tissue must be sent for histopathological examination to confirm diagnosis and exclude penile intraepithelial neoplasia or squamous cell carcinoma. 1, 5

• A significant proportion of children with phimosis actually have undiagnosed lichen sclerosus, which has malignant potential and requires different long-term management 5
• One study found that 14-100% of pediatric phimosis cases had underlying lichen sclerosus on pathology, indicating this condition is severely underrecognized 5

Postoperative Management

Immediate Care

• Assess for bleeding, infection, wound healing, and urinary function in the early postoperative period 1
• If inflammatory changes or lichen sclerosus is present on pathology, apply topical steroids postoperatively to prevent Koebnerization and recurrence 1

Follow-Up Protocol

• Schedule follow-up at 3 months to evaluate for residual disease on the glans and coronal sulcus, particularly if lichen sclerosus is confirmed 1
• Review histopathology results to confirm diagnosis and guide long-term management 1

Long-Term Considerations

• Circumcision does not guarantee protection against further disease flares; 50% of men requiring circumcision for lichen sclerosus continue to have lesions 5
• Recurrence is common when residual moist skin folds are left or unavoidable, such as in obese patients 5, 6
• For confirmed lichen sclerosus limited to glans and foreskin, circumcision alone is successful in 96% of cases 5, 6

Common Pitfalls to Avoid

• Do not proceed without sending tissue for pathology - this is the only way to identify underlying lichen sclerosus and assess malignancy risk 5, 1
• Do not assume all phimosis is benign - lichen sclerosus may be present in up to 30% of adult phimosis cases and requires long-term surveillance 5
• Ensure complete excision to the coronal sulcus - inadequate tissue removal increases recurrence risk 1