Cost-effective Treatment of Phimosis

Objective. To determine the most costeffective treatment for phimosis. Design. The costs of three treatment strategies for treating phimosis were evaluated using a decision-tree analysis. Three therapeutic approaches were considered: circumcision, preputial plasty (the use of plastic surgical techniques to enlarge the preputial opening without removing tissue), and topical therapy with steroids and nonsteroidal antiinflammatories. Published failure and complication rates were used to calculate the cost per case. Outcome Measures. Cost in dollars to treat each case of phimosis. Results. Topical steroid therapy was the most costeffective strategy, costing between $758 and $800 per case. Preputial plasty cost between $2515 and $2580 per case. Circumcision cost between $3009 and $3241 per case. Conclusions. The most cost-effective management for treating phimosis is to initiate topical therapy. Daily external application from the tip of the foreskin to the glandis corona with betamethasone 0.05% cream for 4 to 6 weeks has been demonstrated to be very effective, resulting in a 75% savings compared with circumcision. Surgical intervention should not be considered until topical therapy has been given an adequate trial. When contemplating surgery, the lower morbidity, lower costs, and tissue preservation of preputial plasty may make it preferable. Pediatrics 1998;102(4). URL: http://www. pediatrics.org/cgi/content/full/102/4/e43; phimosis, betamethasone, preputial plasty, circumcision. ABBREVIATION. BXO, balanitis xerotica obliterans. It has recently been demonstrated that patients with true phimosis can be treated successfully with topical creams in 65% to 95% of cases.1–10 Also, a number of prepuce-sparing surgical treatments (preputial plasty) for phimosis have been developed.11–18 Two studies have compared the results of preputial plasty with conventional circumcision,19–20 finding that the plastic procedure lowered morbidity and recovery time as well as the incidence of meatal stenosis after surgery. With the advent of these newer, less invasive, less morbid alternatives, it is important to document the most cost-effective manner of treating phimosis. METHODS A decision-tree analysis was performed for three initial treatment strategies: circumcision, preputial plasty, and topical steroids. The costs, complication rates, failure rates, and time missed from work (parental or personal) are listed in Table 1. The failure rate for topical therapy was calculated by combining the results of the 10 studies published to date (Table 2).1–10 Time lost from work was based on the mean time it took after surgery for underpants to be worn comfortably.19 Income was assumed to be $35 000 per annum. Although the British study by Cuckow et al19 documented a 20% overnight hospitalization rate after circumcision, the rate in the United States is unknown. Most of the overnight hospitalizations were secondary to anesthesia complications. Overnight hospitalization rates of 6% (the rate of reoperation for bleeding) and 20% were used for calculations. Hospitalization rates for preputial plasty were 40% of those for circumcision.19 The reported rates of meatal stenosis requiring meatotomy after circumcision range from 2.8%21 to 11.1%.22 Calculations were made using meatotomy rates of 2.8% and 8%.20 For the preputial plasty group, failures were treated with circumcision. For the topical therapy, failures were treated with circumcision under the assumption that those who failed topical therapy did not respond because the underlying pathology was balanitis xerotica obliterans (BXO) based on the determination that the failure rate of topical therapy was nearly the same as the incidence of BXO in circumcision specimens (Table 3).23–29