epidemiologicalUTI risk in the first year of life is 3-4% overall, with uncircumcised boys having 1/100 risk vs circumcised boys 1/1000 risk↗
▶Ep 2 · 3:20
epidemiologicalCircumcision provides decreased risk for HIV, syphilis, gonococcus, HPV, and HSV-2, but not for chlamydia↗
▶Ep 2 · 3:40
epidemiologicalKenya trial of ~3000 men showed 53% protection against HIV in circumcised cohort, trial stopped early due to significance↗
▶Ep 2 · 4:05
epidemiologicalUganda trial of ~5000 males showed 50% of circumcised men became infected vs control group, also stopped early↗
▶Ep 2 · 4:25
guidelineAAP policy states data are not sufficient to recommend routine neonatal circumcision, parents should receive accurate unbiased information↗
▶Ep 2 · 6:50
opinionOffice circumcision cutoff: 3 months of age or less than 13 pounds (personal practice guideline, no data support)↗
▶Ep 2 · 7:00
quoteif you're going to restrain the child any way either use a papoose board or anything else that when they get a little bigger it's going to be a little harder to do that↗
▶Ep 2 · 7:49
clinicalLiterature suggests exposing younger children to elective cases like circumcision under general anesthesia is not recommended from anesthetic safety standpoint↗
▶Ep 2 · 8:10
quoteI personally feel that if you don't do them that there's really no reason to not refer that child to somebody who does do them↗
▶Ep 2 · 8:51
clinicalBest analgesia method for circumcision is dorsal penile nerve block combined with ring block using 0.25% bupivacaine without epinephrine↗
▶Ep 2 · 9:50
opinionPlastibel device subjectively has more postoperative complications than Gomco or Mogan clamps↗
▶Ep 2 · 11:05
quotethe only time I've ever seen a major injury from a circumcision like Glands amputation has been when the Mogan clamp has been used↗
▶Ep 2 · 11:05
clinicalMajor injuries (glans amputation) from circumcision have been seen only with Mogan clamp use (2-3 cases observed)↗
▶Ep 2 · 11:28
clinicalDorsal penile nerves run at 2 o'clock and 11 o'clock positions, block placed below pubic symphysis at ~1.5cm depth using 1cc/kg of 0.25% bupivacaine↗
▶Ep 2 · 12:43
clinicalMogan clamp glans amputation occurs when glans is pulled through the slit along with foreskin, especially with smaller glans↗
▶Ep 2 · 14:13
clinicalGomco bell sizes are 1.1, 1.3, 1.45, and 1.6 cm; 75% of time a 1.3 bell is used↗
▶Ep 2 · 14:40
clinicalMismatched Gomco bell and base can cause bell to pull up, exposing glans and causing injury during cutting↗
▶Ep 2 · 15:10
clinicalMust take down preputial adhesions completely to see ridge under corona all around, or will leave asymmetric skin↗
▶Ep 2 · 17:00
quoteyou really want to force the skin off the bell rather than pull the bell off the skin↗
▶Ep 2 · 17:16
clinicalGomco bell should be left on for at least 5 minutes for older kids (near 3 months/13 lbs), 1-2 minutes for newborns↗
▶Ep 2 · 20:32
clinicalVaseline dissolves Dermabond, so parents must be instructed not to use Vaseline on Dermabond-dressed circumcisions↗
▶Ep 2 · 21:20
clinicalFor bleeding control, have 6-0 chromic or fast-absorbing plain suture and 1:1000 diluted epinephrine available in circumcision tray↗
▶Ep 2 · 22:04
opinionFast-absorbing plain gut (6-0 or 5-0) leaves nicer cosmetic appearance than Vicryl for circumcision closure↗
▶Ep 2 · 25:20
clinicalPhysiologic adhesions (distinct line visible) do not need treatment and will lyse on their own as baby grows↗
▶Ep 2 · 26:00
clinicalLysing physiologic adhesions in office can turn a non-problem into a problem by creating raw surface and true bridges↗
▶Ep 2 · 26:50
quoteyou can turn a problem that's not a problem into a problem↗
▶Ep 2 · 27:12
clinicalSkin bridges (no distinct line, two holes on each side) need treatment as they will not lyse and can tether penis with growth↗
▶Ep 2 · 27:50
clinicalMost skin bridges can be treated in office with EMLA cream 30-40 minutes, hemostat clamp, and fine scissor division↗
▶Ep 2 · 29:40
clinicalRedundant foreskin appearance often due to fat pad; if penis looks circumcised when fat pad pushed down, no intervention needed↗
▶Ep 2 · 30:20
quoteI personally in my career have never seen an adolescent come in complaining of too much foreskin↗
▶Ep 2 · 30:20
opinionHave never seen an adolescent complain of too much foreskin; suspect most cases resolve with puberty and penile growth↗
▶Ep 2 · 30:50
clinicalPerform 1-2 redo circumcisions per year in high-volume practice, suggesting most resolve spontaneously↗
▶Ep 2 · 31:59
clinicalMeatal stenosis is exclusively seen in circumcised boys, caused by meatal rubbing against diaper/underwear creating inflammatory web at 6 o'clock↗
▶Ep 2 · 32:40
clinicalMeatal stenosis requires intervention only when symptomatic: urine shoots straight up toward ceiling, child must sit to void↗
▶Ep 2 · 33:10
quoteI've never seen an adolescent with meatal stenosis↗
▶Ep 2 · 33:10
opinionHave never seen an adolescent with meatal stenosis; many subjectively narrow meatuses become normal with growth↗
▶Ep 2 · 33:40
clinicalMeatotomy can be done in office with EMLA cream, straight hemostat crush of 6 o'clock web, and fine scissor incision without sutures↗
▶Ep 2 · 34:20
clinicalNo data shows sutures at 3 and 6 o'clock reduce meatotomy recurrence rate compared to no sutures↗
▶Ep 2 · 36:23
clinicalMicropenis clinical definition: stretched penile length >2.5 standard deviations below normal mean for age↗
▶Ep 2 · 36:36
quotedon't be a hero with these things, you know, one of the highest areas of litigation are circumcisions that are done and then there's a problem afterwards↗
▶Ep 2 · 36:50
clinicalMean stretched penile length for 6-12 month old is about 4 cm (reference: Bin Abbas 1999)↗
▶Ep 2 · 37:30
clinicalBuried penis looks like a short squat pyramid, not a structure coming out of the body↗
▶Ep 2 · 37:40
quoteif it doesn't look quite right or quite like what you're used to just refer him to a pediatric neurologist, save yourself the hassle. It's just, it's not worth it↗
▶Ep 2 · 37:50
clinicalCongenital megaprepuce occurs mostly in Hispanic patients and should not be circumcised due to risk of complete shaft skin loss↗
▶Ep 2 · 38:50
clinicalPhysiologic phimosis (soft, supple skin, no symptoms) does not require treatment regardless of age↗
▶Ep 2 · 39:10
quoteeven though the AAP has published guidelines as to when the foreskin should retract based on age, I don't really go on those↗
▶Ep 2 · 40:00
clinicalBetamethasone 0.1% TID for 2-3 months results in >50% of children with phimosis having retractile foreskins↗
▶Ep 2 · 40:20
quoteI honestly think that that dose is too low and that time period is too low to actually see an effect↗
▶Ep 2 · 40:30
opinionLower betamethasone doses (0.05% BID for few weeks) are too low in dose and duration to see effect↗
▶Ep 2 · 41:30
clinicalSecondary phimosis (hard stenotic ring after circumcision) responds to betamethasone 0.1% TID for 2-3 months in >50% of cases↗
▶Ep 2 · 42:10
clinicalBalanitis xerotica obliterans (BXO) presents with paper-white, scaly, hard skin at prepuce tip and will not respond to steroids↗
clinicalBXO can spread onto glans and into urethra causing significant urethral strictures; requires circumcision↗
▶Ep 2 · 43:00
clinicalParaphimosis occurs when retracted foreskin is not brought back over glans, can become medical emergency with vascular compromise↗
▶Ep 2 · 43:40
clinicalParaphimosis treatment: pain control (EMLA or penile block), D50-soaked bandage wrap to reduce swelling, manual reduction↗
▶Ep 2 · 44:20
clinicalManual paraphimosis reduction: thumbs on glans, fingers on shaft skin, pinch shaft skin and push glans back into foreskin↗
▶Ep 2 · 44:50
clinicalManual reduction works 9 out of 10 times with good pain control and D50 swelling reduction; have never needed dorsal slit↗
▶Ep 2 · 45:00
quoteI personally have never had to do a dorsal slit for a paraphymosis↗
▶Ep 2 · 45:26
clinicalMain cause of penile trauma is zipper injuries; treatment is cutting zipper bridge with bolt cutter rather than manipulating zipper↗
▶Ep 2 · 46:10
clinicalSecond most common penile trauma is toilet seat crush injuries; conservative management if child voids without gross hematuria↗
▶Ep 2 · 46:50
clinicalGross hematuria after penile trauma requires urologist involvement for potential urethral injury evaluation↗
▶Ep 2 · 47:50
clinicalBuck's fascia violation in penile trauma requires OR repair to prevent long-term scarring and potency issues↗
▶Ep 2 · 48:20
clinicalGross blood at meatus or gross hematuria after trauma requires full urinary tract evaluation and retrograde urethrogram before catheterization↗
▶Ep 2 · 48:30
quoteplease do not instrument that child because if there is a urethral injury, you can create a much bigger problem↗
▶Ep 2 · 49:40
epidemiologicalHypospadias incidence is about 1 in 150 live births↗
▶Ep 2 · 49:55
epidemiologicalHypospadias etiology is multifactorial; higher incidence in children conceived via in vitro fertilization↗
▶Ep 2 · 51:40
quotewe don't utilize the foreskin to do a reconstruction for mild hypospadius almost ever, if ever↗
▶Ep 2 · 51:40
clinicalForeskin is not used for distal hypospadias reconstruction; can complete circumcision if found during procedure↗
▶Ep 2 · 52:20
clinicalUndescended gonad with hypospadias requires full DSD workup; bilateral non-palpable gonads suggests congenital adrenal hyperplasia↗
clinicalPenile torsion repair not needed unless close to 90 degrees; foreskin not used in repair↗
▶Ep 2 · 1:00:50
clinicalPenoscrotal webbing is obvious, not subtle; some surgeons use foreskin flaps for repair↗
▶Ep 2 · 1:01:50
epidemiologicalLabial adhesions incidence is about 2% in first two years of life, not seen in newborns (maternal estrogen protective)↗
▶Ep 2 · 1:02:25
clinicalLabial adhesions require treatment only if symptomatic: post-void dribbling, skin breakdown, or recurrent UTIs↗
▶Ep 2 · 1:03:00
opinionBetamethasone ointment works well for labial adhesions; preferred over estrogen cream to avoid pubic hair development in toddlers↗
▶Ep 2 · 1:03:40
clinicalHave performed formal lysis of labial adhesions in OR only once in career; most respond to topical treatment↗
▶Ep 2 · 1:05:00
clinicalImperforate hymen treatment is incision to open the hymen and drain retained vaginal secretions↗
▶Ep 2 · 1:06:10
clinicalProlapsed urethrocele is smooth, mucosa-covered, protrudes from urethra distinct from vagina, associated with prenatal hydronephrosis↗
▶Ep 2 · 1:06:50
clinicalParaurethral and perivaginal cysts (Gartner's duct, Skene's gland) present at birth, spontaneously regress with maternal estrogen loss↗
▶Ep 2 · 1:08:00
clinicalVaginal rhabdomyosarcoma appears as 'bunch of grapes' mass, not a single bulge↗
Urology Part I
▶Ep 4 · 2:40
epidemiologicalUTI risk in the first year of life is 3-4% overall, with uncircumcised boys having 1/100 risk versus circumcised boys 1/1000 risk↗
▶Ep 4 · 3:16
clinicalCircumcision decreases risk of HIV, syphilis, gonococcus, HPV, and HSV-2, but does not change chlamydia risk↗
▶Ep 4 · 4:16
clinicalCircumcision provides 53% protection against HIV transmission in randomized trials from Kenya and Uganda, with both trials stopped early due to significant benefit↗
▶Ep 4 · 6:56
opinionOffice circumcision should be limited to infants 3 months or younger or weighing less than 13 pounds to minimize restraint difficulty and bleeding risk↗
▶Ep 4 · 7:53
clinicalExposing young children to elective general anesthesia such as for circumcision is not recommended from an anesthetic safety standpoint↗
▶Ep 4 · 8:05
quoteI personally feel that if you don't do them that there's really no reason to not refer that child to somebody who does do them↗
▶Ep 4 · 9:28
clinicalThe best analgesia for circumcision is a dorsal penile nerve block combined with a ring block using 0.25% bupivacaine without epinephrine↗
▶Ep 4 · 10:22
opinionThe Gomco clamp is preferred over Plastibell (subjectively more complications) and Mogen clamp (risk of glans amputation)↗
▶Ep 4 · 11:07
clinicalGlans amputation during circumcision has been seen 2-3 times with Mogen clamp when small glans is pulled through the slit↗
▶Ep 4 · 15:55
clinicalComplete preputial adhesion takedown is essential—you must see the ridge under the corona all the way around to avoid asymmetric skin removal↗
▶Ep 4 · 16:56
clinicalWhen using Gomco, leave the bell on for at least 5 minutes for older infants (closer to 3 months/13 pounds) and 1-2 minutes for newborns↗
▶Ep 4 · 17:01
clinicalWhen removing the Gomco bell, force the skin off the bell rather than pulling the bell off the skin to avoid separating crushed edges↗
▶Ep 4 · 17:51
clinicalA safety pin through both edges of the dorsal slit helps pull foreskin through the Gomco base hole more easily↗
▶Ep 4 · 19:35
clinicalBefore clamping, check underneath the bell to ensure shaft skin (not scrotal skin) is visible and the median raphe is centered to avoid twisting↗
▶Ep 4 · 20:47
clinicalVaseline dissolves Dermabond, so parents must be instructed not to apply Vaseline after Dermabond circumcision↗
▶Ep 4 · 21:27
clinicalOffice circumcision tray should include 6-0 chromic or fast-absorbing plain suture for bleeding and 1:1000 epinephrine for topical hemostasis↗
▶Ep 4 · 22:17
clinicalFor OR circumcision, 6-0 or 5-0 fast-absorbing plain gut (used by plastic surgeons on face) heals nicely; Vicryl causes pie-crusting unless subcuticular↗
▶Ep 4 · 25:38
clinicalPhysiologic post-circumcision adhesions (distinct line visible, common in chubby babies) do not need treatment and will lyse spontaneously as the child grows↗
▶Ep 4 · 26:21
clinicalLysing physiologic adhesions in the office can turn a non-problem into a problem by creating a raw surface that forms a true skin bridge↗
▶Ep 4 · 26:48
quoteyou can turn a problem that's not a problem into a problem↗
▶Ep 4 · 27:15
clinicalTrue skin bridges (no line, two holes on each side) require treatment because they tether the penis and do not resolve spontaneously↗
▶Ep 4 · 27:47
clinicalMost skin bridges can be lysed in office with EMLA cream for 30-40 minutes, hemostat placement, and fine scissor division↗
▶Ep 4 · 29:25
clinicalRedundant foreskin appearance after circumcision is usually due to suprapubic fat pad displacing skin distally; if penis looks circumcised when fat pad is pushed down, no revision is needed↗
▶Ep 4 · 29:57
clinicalDr. Gargollo has never seen an adolescent complain of too much foreskin after circumcision, suggesting most cases resolve with puberty↗
▶Ep 4 · 30:53
clinicalDr. Gargollo performs only 1-2 redo circumcisions per year despite high volume, indicating most redundant skin resolves spontaneously↗
▶Ep 4 · 32:11
clinicalMeatal stenosis is a condition exclusively seen in circumcised boys, caused by meatal inflammation from rubbing against diaper/underwear creating a 6 o'clock web↗
▶Ep 4 · 32:45
clinicalMeatal stenosis requires intervention only when urine stream deviates straight upward or child must sit to void, not for subjectively narrow meatus alone↗
▶Ep 4 · 33:29
clinicalDr. Gargollo has never seen an adolescent with meatal stenosis, suggesting many subjectively narrow meatuses normalize with growth↗
▶Ep 4 · 33:29
quoteI've never seen an adolescent with meatal stenosis↗
▶Ep 4 · 33:44
clinicalOffice meatotomy can be performed with EMLA cream, straight hemostat crush of 6 o'clock web, and fine scissors; sutures at 3 and 6 o'clock have no proven benefit for reducing recurrence↗
▶Ep 4 · 35:37
clinicalMicropenis is defined as stretched penile length greater than 2.5 standard deviations below the mean for age; mean is 4 cm at 6-12 months↗
▶Ep 4 · 36:47
quotedon't be a hero with these things, you know, one of the highest areas of litigation are circumcisions that are done and then there's a problem afterwards↗
▶Ep 4 · 36:58
clinicalHypospadias, buried penis, penile-scrotal webbing, penile torsion, and congenital megaprepuce are contraindications to routine circumcision and should be referred to pediatric urology↗
▶Ep 4 · 37:22
clinicalA buried penis appears as a short squat pyramid rather than a protruding structure; attempting circumcision can result in complete shaft skin loss requiring skin grafting↗
▶Ep 4 · 38:47
clinicalPhysiologic phimosis (soft, supple foreskin without symptoms) requires no treatment regardless of age, even in 5-8 year olds↗
▶Ep 4 · 40:15
clinicalFirst-line treatment for symptomatic phimosis is betamethasone 0.1% three times daily for 2-3 months, with >50% success rate↗
▶Ep 4 · 41:13
clinicalSecondary phimosis (post-circumcision cicatrix causing stenotic ring) responds to betamethasone 0.1% TID for 2-3 months in >50% of cases↗
▶Ep 4 · 42:20
clinicalBalanitis xerotica obliterans (BXO) presents with white paper-like, scaly, hard skin at prepuce tip and does not respond to steroids; requires circumcision to prevent urethral stricture↗
▶Ep 4 · 44:02
clinicalParaphimosis management includes pain control, D50-soaked bandage wrap to reduce edema, and manual reduction with thumbs on glans pushing back through foreskin↗
▶Ep 4 · 45:02
clinicalDr. Gargollo has never had to perform a dorsal slit for paraphimosis, as manual reduction with proper pain control and D50 wrap is successful↗
▶Ep 4 · 45:55
clinicalThe main cause of penile trauma is zipper injuries; treatment is cutting the zipper bridge with bolt cutters rather than manipulating the zipper↗
▶Ep 4 · 46:32
clinicalToilet seat crush injuries to penis can be managed conservatively if child is voiding without gross hematuria; glands hematoma may look necrotic but resolves↗
▶Ep 4 · 47:36
clinicalBuck's fascia violation in penile trauma requires OR repair to prevent long-term scarring and potency issues↗
▶Ep 4 · 48:11
clinicalGross blood at urethral meatus or gross hematuria after trauma mandates full urinary tract evaluation and retrograde urethrogram before catheterization↗
▶Ep 4 · 49:34
epidemiologicalHypospadias incidence is approximately 1 in 150 live births, likely multifactorial etiology including in vitro fertilization exposure↗
▶Ep 4 · 50:34
clinicalHypospadias assessment requires evaluation of meatus location and degree of ventral curvature (chordee); more proximal meatus and greater curvature indicate more complex repair↗
▶Ep 4 · 51:14
clinicalFor distal hypospadias discovered during circumcision, the circumcision can be completed because foreskin is not used in modern distal hypospadias repairs↗
▶Ep 4 · 51:20
quotefinish the circumcision, you know, don't leave the skin kind of hanging there, just get it done↗
▶Ep 4 · 52:46
clinicalNon-palpable gonad with hypospadias requires full disorder of sexual differentiation (DSD) workup; bilateral non-palpable gonads suggests congenital adrenal hyperplasia↗
opinionVery mild hypospadias variants (megameatus, distal) raise controversy about timing of repair given anesthesia exposure concerns in young children↗
▶Ep 4 · 56:12
clinicalHypospadias repair involves urethroplasty (tubularizing urethra with second-layer coverage) and phalloplasty (straightening chordee, often resolved by degloving alone)↗
▶Ep 4 · 57:22
clinicalEpispadias (dorsal urethral defect) is extremely rare (<1/50,000) and represents the bladder exstrophy-epispadias spectrum with associated incontinence, pubic diastasis, and vesicoureteral reflux↗
▶Ep 4 · 59:58
clinicalPenile torsion (twisted median raphe) requires surgical correction only if rotation is ≥90 degrees↗
▶Ep 4 · 1:01:48
epidemiologicalLabial adhesions occur in approximately 2% of girls in the first 2 years of life, not in newborns due to protective maternal estrogen↗
▶Ep 4 · 1:02:29
clinicalLabial adhesions require treatment only for symptoms: post-void dribbling, skin breakdown, or recurrent UTIs; asymptomatic adhesions should not be treated↗
▶Ep 4 · 1:02:53
clinicalFirst-line treatment for symptomatic labial adhesions is betamethasone ointment BID for 6 weeks, preferred over estrogen cream to avoid pubic hair development in prepubertal girls↗
▶Ep 4 · 1:03:31
clinicalSurgical lysis of labial adhesions is rarely needed; Dr. Gargollo has performed it only once in his career↗
▶Ep 4 · 1:04:52
clinicalDifferential diagnosis for midline genital bulge includes imperforate hymen, prolapsed urethrocele, paraurethral/perivaginal cysts, and vaginal rhabdomyosarcoma↗
▶Ep 4 · 1:06:30
clinicalProlapsed urethrocele is distinct from vagina on exam, associated with prenatal hydronephrosis, and requires renal bladder ultrasound and VCUG↗
▶Ep 4 · 1:07:34
clinicalParaurethral and perivaginal cysts (Gardner's duct, Skene's gland) present at birth, spontaneously regress with loss of maternal estrogen, and show patent urethra and vagina on exam↗
▶Ep 4 · 1:08:03
clinicalVaginal rhabdomyosarcoma appears as a 'bunch of grapes' mass rather than a single bulge and requires oncology involvement↗
Summaries Patricio gave as host
· 6 summaries
Recaps of other experts' statements, not Patricio's own clinical position.
Summaries Patricio gave as host · Urinary Tract Infection6 summaries
host summaryPatricio Gargollo summarizing a resource: these data are not sufficient to recommend routine neonatal circumcision↗
▶Ep 2 · 4:35
host summaryPatricio Gargollo summarizing a resource: parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision↗
Urology Part I
▶Ep 4 · 5:19
host summaryPatricio Gargollo summarizing a resource: The AAP states that data are not sufficient to recommend routine neonatal circumcision, and parents should be given accurate, unbiased information↗
▶Ep 4 · 5:19
host summaryPatricio Gargollo summarizing a resource: these data are not sufficient to recommend routine neonatal circumcision↗
▶Ep 4 · 5:30
host summaryPatricio Gargollo summarizing a resource: parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision↗
▶Ep 4 · 31:42
host summaryPatricio Gargollo summarizing a resource: I've never done a redo circumcision in an adolescent, probably because these children grow and their penises grow and the skin stretches, and we don't need to do anything↗
