Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention-15 African Countries, 2015-2019.
Fistula
HIV
Intraoperative complications
Male circumcision
Journal
BMC urology
ISSN: 1471-2490
Titre abrégé: BMC Urol
Pays: England
ID NLM: 100968571
Informations de publication
Date de publication:
12 Feb 2021
12 Feb 2021
Historique:
received:
15
10
2020
accepted:
01
02
2021
entrez:
13
2
2021
pubmed:
14
2
2021
medline:
23
7
2021
Statut:
epublish
Résumé
Voluntary medical male circumcision (VMMC) is an HIV prevention strategy recommended to partially protect men from heterosexually acquired HIV. From 2015 to 2019, the President's Emergency Plan for AIDS Relief (PEPFAR) has supported approximately 14.9 million VMMCs in 15 African countries. Urethrocutaneous fistulas, abnormal openings between the urethra and penile skin through which urine can escape, are rare, severe adverse events (AEs) that can occur with VMMC. This analysis describes fistula cases, identifies possible risks and mechanisms of injury, and offers mitigation actions. Demographic and clinical program data were reviewed from all reported fistula cases during 2015 to 2019, descriptive analyses were performed, and an odds ratio was calculated by patient age group. In total, 41 fistula cases were reported. Median patient age for fistula cases was 11 years and 40/41 (98%) occurred in patients aged < 15 years. Fistulas were more often reported among patients < 15 compared to ≥ 15 years old (0.61 vs. 0.01 fistulas per 100,000 VMMCs, odds ratio 50.9 (95% confidence interval [CI] = 8.6-2060.0)). Median time from VMMC surgery to appearance of fistula was 20 days (interquartile range (IQR) 14-27). Urethral fistulas were significantly more common in patients under age 15 years. Thinner tissue overlying the urethra in immature genitalia may predispose boys to injury. The delay between procedure and symptom onset of 2-3 weeks indicates partial thickness injury or suture violation of the urethral wall as more likely mechanisms of injury than intra-operative urethral transection. This analysis helped to inform PEPFAR's recent decision to change VMMC eligibility policy in 2020, raising the minimum age to 15 years.
Sections du résumé
BACKGROUND
BACKGROUND
Voluntary medical male circumcision (VMMC) is an HIV prevention strategy recommended to partially protect men from heterosexually acquired HIV. From 2015 to 2019, the President's Emergency Plan for AIDS Relief (PEPFAR) has supported approximately 14.9 million VMMCs in 15 African countries. Urethrocutaneous fistulas, abnormal openings between the urethra and penile skin through which urine can escape, are rare, severe adverse events (AEs) that can occur with VMMC. This analysis describes fistula cases, identifies possible risks and mechanisms of injury, and offers mitigation actions.
METHODS
METHODS
Demographic and clinical program data were reviewed from all reported fistula cases during 2015 to 2019, descriptive analyses were performed, and an odds ratio was calculated by patient age group.
RESULTS
RESULTS
In total, 41 fistula cases were reported. Median patient age for fistula cases was 11 years and 40/41 (98%) occurred in patients aged < 15 years. Fistulas were more often reported among patients < 15 compared to ≥ 15 years old (0.61 vs. 0.01 fistulas per 100,000 VMMCs, odds ratio 50.9 (95% confidence interval [CI] = 8.6-2060.0)). Median time from VMMC surgery to appearance of fistula was 20 days (interquartile range (IQR) 14-27).
CONCLUSIONS
CONCLUSIONS
Urethral fistulas were significantly more common in patients under age 15 years. Thinner tissue overlying the urethra in immature genitalia may predispose boys to injury. The delay between procedure and symptom onset of 2-3 weeks indicates partial thickness injury or suture violation of the urethral wall as more likely mechanisms of injury than intra-operative urethral transection. This analysis helped to inform PEPFAR's recent decision to change VMMC eligibility policy in 2020, raising the minimum age to 15 years.
Identifiants
pubmed: 33579261
doi: 10.1186/s12894-021-00790-y
pii: 10.1186/s12894-021-00790-y
pmc: PMC7881669
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
23Subventions
Organisme : World Health Organization
ID : 001
Pays : International
Références
J Pediatr. 1968 Jan;72(1):105-6
pubmed: 5634930
Niger J Clin Pract. 2014 Mar-Apr;17(2):145-8
pubmed: 24553021
Urology. 2011 Mar;77(3):728-9
pubmed: 20800885
Lancet. 2007 Feb 24;369(9562):657-66
pubmed: 17321311
Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003362
pubmed: 19370585
J Pediatr Urol. 2013 Apr;9(2):206-11
pubmed: 22391111
U S Nav Med Bull. 1949 Jan-Feb;49(1):120-2
pubmed: 18123683
JAMA. 1968 Dec 2;206(10):2318
pubmed: 5696092
BMC Health Serv Res. 2019 Nov 21;19(1):855
pubmed: 31752838
Lancet. 2007 Feb 24;369(9562):643-56
pubmed: 17321310
J Pak Med Assoc. 2018 Jun;68(6):955-958
pubmed: 30323369
J Int AIDS Soc. 2019 Jul;22(7):e25369
pubmed: 31368235
BMC Urol. 2020 Apr 25;20(1):45
pubmed: 32334596
J Int AIDS Soc. 2017 Feb 20;19(1):21394
pubmed: 28362066
Ann Afr Med. 2009 Oct-Dec;8(4):266-70
pubmed: 20139551
PLoS One. 2019 Jun 10;14(6):e0218137
pubmed: 31181096
PLoS Med. 2005 Nov;2(11):e298
pubmed: 16231970
Br J Surg. 1993 Oct;80(10):1231-6
pubmed: 8242285