Scrotal injuries during neonatal circumcision

Comparison of NeoAlis™ disposable circumcision device and sleeve technique in circumcision: Results from a referral health-care center in Turkey

BACKGROUND

Circumcision has been one of the most commonly performed surgical procedures worldwide since ancient times. Given the popularity of this procedure, the aim of this study was to evaluate the effectiveness, reliability, and results of circumcision performed using the NeoAlis™ clamp and compare them with those obtained using the sleeve technique.

STUDY DESIGN

The results of 2259 patients circumcised using the two techniques were evaluated retrospectively. The patients who were circumcised using the plastic NeoAlis™ device were classified as group 1 and those circumcised using the sleeve technique were designated as group 2. The groups were compared in terms of operation time, results, cost, complications, and cosmetic satisfaction scores.

RESULTS

A total of 1947 patients who met the inclusion criteria were included in the study. Group 1 consisted of 1454 patients, while group 2 comprised 493 patients. The total rate of complications, excluding bleeding in the form of oozing that stopped spontaneously, was 9.5% (n = 185). In group 1, the operation time was shorter, tolerability of local anesthesia was higher, satisfaction questionnaire scores were higher, cost was lower, and rates of early adhesion and meatal stenosis were lower. All of these parameters were significantly different from those in group 2. Notably, secondary phimosis was significantly higher in group 1. Although the bleeding that stopped with follow-up was significantly higher in group 2, there was no significant difference between the groups in terms of bleeding that required surgical intervention.

DISCUSSION

Our study, which reports the results of circumcisions performed using the NeoAlis clamp, has the largest sample size in the literature. Moreover, this is the only study in the literature wherein the results of sleeve circumcision, which is a time-tested surgical procedure, and the results of NeoAlis clamp circumcision, which we applied to a large number of patients, were compared with each other and with the literature. The retrospective design that focused on relatively short-term (one month) results is the major limitation of this study.

CONCLUSION

Mass circumcision performed with a plastic clamp technique is safe, timesaving, easily teachable, and cosmetically advantageous.

Systematic review of complications arising from male circumcision

Background

Neonatal male circumcision is the most common procedure performed on paediatric patients (Simpson et al., 2014) and one of the most common surgical procedures in the world (American Academy of Pediatrics, 2012).

Methods

A search was conducted for articles about complications arising from male circumcision surgeries by entering the term ‘male circumcision’ into PubMed on June 16, 2020. Six thousand six hundred forty‐one articles published from 1945 to 2020 were found. Seventy‐eight articles were ultimately selected for the systematic review.

Results

The 78 articles selected from the literature search were entered into one of three tables. The first table includes 15 articles pertaining to chart reviews and cohort studies and report complication rates. The second table reports specific complications from 51 case reports and case series, and the third table is a summary from 12 articles regarding physician questionnaires and society recommendations. Additionally, the 78 articles were used to compile a list of 47 specific complications arising from male circumcision surgeries.

Conclusions

Complications from neonatal male circumcisions are common and healthcare providers need to be better informed of the potential complications of the surgery so that they can more effectively counsel their patients about potential risks, likelihood of complications and what can be done to prevent them. While experienced providers who practice in sterile settings have better outcomes with fewer complications, encouraging parents to take into account who is performing their son's circumcision, what was their training, how clean is their practice and how much experience they have and reminding them they have the option to decline the procedure entirely allow the parents to get a more complete picture and play an essential role in the decision‐making process.

Glans injury during ritual circumcision

BACKGROUND

Circumcision is one of the most performed surgical procedure in the world, often performed for nontherapeutic reasons. Depending on cultural and social backgrounds, the procedure may be performed by various sources; from trained health care practitioners to laypeople, giving rise to different frequencies and types of complications. Glans injury during ritual circumcision is a rare yet serious complication due to its associated morbidity and long-term consequences.

OBJECTIVE

In this study we describe the experience of two medical centers with the management and follow up of glans injury after ritual circumcision.

METHODS

We have retrospectively reviewed the medical files of all pediatric patients who presented to the ER with glans injury, following ritual circumcision, over a 17-year period from two medical centers.

RESULTS

A total of 8 patients were identified, who underwent ritual circumcision between 7 and 9 days of age. On presentation, 1 infant had complete glans amputation, the others presented with partial amputation of the glans. 6 of the 8 patients had a simultaneous urethral injury. All patients underwent surgical correction for their injury; Patients with isolated glans injury, underwent primary glans anastomosis. Of the 6 cases with simultaneous urethral injury: 3 underwent end-to-end urethral anastomosis following anastomosis of the amputated glans, one patient with complete glans amputation underwent a similar procedure, with initial end-to-end urethral anastomosis followed by glans anastomosis to the corpora cavernosa and 2 were managed by urethrostomy together with anastomosis of the amputated glans tissue to the remaining glans. Both patients with urethral injury, in whom end to end urethral anastomosis has not been performed, were found to have hypospadias on follow up. The rest had good functional and cosmetic results.

DISCUSSION

There is no single method for managing glans injury following circumcision. Some authors describe healing by secondary intention with delayed formal repair, while others advocate for primary anastomosis of the amputated glans, together with distal urethra-urethrostomy, in cases with simultaneous urethral injury. In this study, both patients without urethral anastomosis, developed secondary hypospadias due to meatal regression and required additional surgery, while the others showed good results. The limitations of our study are its retrospective nature and the small number of cases, preventing us to come to a definitive conclusion regarding the best way to treat such a rare injury.

CONCLUSION

Prompt surgical correction by glanular replantation with urethro-urethrostomy, in case of concomitant urethral injury, give good cosmetic and functional results.