Male Circumcision Complications - A Systematic Review, Meta-Analysis and Meta-Regression

Glans ischaemia after circumcision in adult males: A two-patient case series and a narrative review of the literature

INTRODUCTION

Glans necrosis after circumcision is an exceedingly rare complication among adult males, with only a handful of cases being reported in the literature.

MATERIALS AND METHODS

We present here two cases of glans ischaemia observations after circumcision in both a 19-year-old and a 26-year-old patient; both were managed with oral medications in the outpatient setting, with complete restitutio-ad-integrum. A narrative review of the literature was also performed to better describe the possible predisposing factors; the treatment/management options; and the typical outcomes among the adult males experiencing with this complication.

RESULTS

Penile dorsal anaesthetic blocks, monopolar cautery usage and compressive wound dressing are all reported to play a role as co-factors for glans ischaemia after circumcision, hence their adoption should be mindful. There is no consensus on the management of ischaemia of the glans after male circumcision.

CONCLUSIONS

The favourable outcomes being reported for most of the literature cases of glans ischaemia after circumcision among adults despite the adoption of diverse empirical therapeutic strategies suggest that the role of the proactive management may be questionable.

Comparing Penile Problems in Circumcised vs. Uncircumcised Boys: Insights From a Large Commercial Claims Database With a Focus on Provider Type Performing Circumcision

OBJECTIVES

To compare penile problems in circumcised relative to uncircumcised boys, and to determine which providers performing the circumcision have fewer post-circumcision problems.

METHODS

CPT codes in the 2011-2020 MarketScan database were used to identify boys who had a circumcision. Uncircumcised control subjects of the same age, state of residence, and insurance type were selected. The primary outcome was a penile problem, defined as penis-specific infection, inflammation, and urethral stricture/stenosis, among others. The secondary outcomes were procedure-related complications limited to 28 days after circumcision, and whether post-circumcision problems varied by the clinician performing the procedure. ICD-9/10 diagnostic codes were used to identify these problems.

RESULTS

We identified ∼850,000 cases and ∼850,000 matched controls. Overall, the rate of penile problems within the first five years of life was 1.7% in circumcised boys versus 0.5% in uncircumcised boys (p < 0.05). Multivariable regression models showed that the risk of penile problems was 2.9-fold higher among circumcised compared to uncircumcised males (95%CI [2.8-3], p < 0.001). Compared to males circumcised by pediatricians, those circumcised by surgeons had 2.1-fold higher penile problems in the year after circumcision (95% CI [2-2.3], p < 0.001). Procedure-related complications within 28 days of circumcision were infrequent (0.5%), with the most common being penile edema (0.2%).

CONCLUSIONS

Penile problems are very infrequent in boys in the first five years of life. However, when they occur, they are 3x more likely to occur in circumcised boys relative to uncircumcised boys. Penile problems are more likely to occur in boys circumcised by surgeons.

LEVELS OF EVIDENCE

Level II.

TYPE OF STUDY

Prognosis study.

Evaluating Safety of Ring Versus Clamp Devices in Neonatal Circumcision: A Meta-Analysis

BACKGROUND

While device-based circumcision is considered non-inferior to traditional dissection, there is no consensus on the efficacy and safety of ring devices in comparison with clamp devices. We aimed to compare the safety outcomes of ring-based versus clamp-based circumcision techniques in neonates.

METHODS

MEDLINE, EMBASE, Scopus, and CINAHL were searched following the Cochrane collaboration (PRISMA guidelines), without language restrictions, to identify relevant randomized controlled trials. Adverse events, bleeding events, infection events, and procedure time were extracted and analyzed from the selected studies.

RESULTS

From 1661 citations, seven trials were included, encompassing 3390 patients. These studies compared ring-based to clamp-based circumcision devices in neonates. No significant difference was found in overall adverse events between the two groups. However, ring devices showed significantly fewer bleeding events compared to clamp devices. Infection events and procedure time were similar for both groups.

CONCLUSIONS

Both ring and clamp devices have similar safety profiles, with ring devices potentially offering a reduced risk of bleeding. A comprehensive understanding of ring-specific complications and cosmetic outcomes is necessary for a more complete evaluation of these circumcision techniques. Our analysis is limited from a lack of detailed examination of ring-specific complications and their impact on cosmetic results. The included studies varied in quality, and some exhibited a risk of bias.

LEVEL OF EVIDENCE

Level IV Treatment Study.

Efficacy and safety of two disposable circumcision suture devices for circumcision in adults: a prospective comparative multicenter study

The objective of this study was to evaluate and compare efficacy and safety of two different Disposable circumcision suture devices (DCSDs). A prospective comparative non-randomized multicenter study was performed between November 2019 and February 2023. Patients underwent circumcision using a DCSD (CircCurerTM or the ZSR® device) according to the surgeon preference and device availability. A total of 378 patients were circumcised; 184 using CircCurerTM and 194 patients using ZSR®. No differences in baseline characteristics were observed. CircCurer and ZSR Groups showed similar rates of operative time (7.7 ±2.1 vs 7.3 ±2.0 min), surgical site infection (1.1% Vs 1.5%), edema (13% Vs 8.2%), hematomas (2.7% Vs 1.1%), and postoperative pain (2.5 Vs 2.0 points). ZSR Group had a significantly higher rate of clip fallout (62.9% Vs 38%, p < 0.001). At 2 months, patients of both groups reported a median satisfaction of 9 (8-9) points. Main limitation consist in non-randomized study. DCSDs seem to be effective and safe, with short operative times, uncommon and mild complications, and high patient satisfaction. ZSR® device has a higher rate of spontaneous staple dropout.

Phimosis in Adults: Narrative Review of the New Available Devices and the Standard Treatments

BACKGROUND

Phimosis is the inability to completely retract the foreskin and expose the glans. The treatment of phimosis varies depending on the age of the patient and the severity of the disease; a great number of conservative or surgical treatments are currently available.

AIM

To provide the first review summarizing the available options for the treatment of adult phimosis.

METHODS

A PubMed, Cochrane and Embase search for peer-reviewed studies, published between January 2001 and December 2022 was performed using the search terms "phimosis AND treatment".

RESULTS

A total of 288 publications were initially identified through database searching. Thirty manuscripts were ultimately eligible for inclusion in this review. Conservative treatment is an option. and it includes topical steroid application and the new medical silicon tubes (Phimostop™) application for gentle prepuce dilation. Concerning the surgical approach, the gold-standard treatment is represented by circumcision in which tissue synthesis after prepuce removal can be also obtained with barbed sutures, fibrin glues or staples. Laser circumcision seems to be providing superior outcomes in terms of operative time and postoperative complication rate when compared to the traditional one. Several techniques of preputioplasty and use of in situ devices (which crush the foreskin and simultaneously create haemostasis) have been also described. These in situ devices seem feasible, safe and effective in treating phimosis while they also reduce the operative time when compared to traditional circumcision. Patient satisfaction rates, complications and impact on sexual function of the main surgical treatments are presented.

CONCLUSION

Many conservative and surgical treatments are available for the treatment of adult phimosis. The choice of the right treatment depends on the grade of phimosis, results, complications, and cost-effectiveness.

A prospective randomized controlled trial measuring satisfaction and parents stress after Gomco and Plastibell infant circumcision

PURPOSE

To compare the physician and parental satisfactions between the two types of circumcision maneuvers used in our units, Gomco and Plastibell circumcision.

METHODOLOGY

This study was performed from 2019 to 2021. A total of 190 children were circumcised either by Gomco or Plastibell procedure. Each child was evaluated during the procedure, immediately after the operation, and 1, 2, and 3 weeks after the procedure. Data were collected, statistically analyzed using SPSS version 25.

RESULTS

A total of 190 children underwent circumcision from 2019 to 2021. Of the total 190, 98 children (51.6%) underwent circumcision by Gomco, while 92 (48.4%) underwent circumcision by Plastibell. Bleeding was significantly higher in Plastibell method, while excess skin was significantly higher in Gomco method (p value 0.048). Physician evaluation results show no significant difference between both methods in late physician evaluation. 23/92 (28%) of parents were not satisfied after Plastibell circumcision, compared to 8/98 (8.2%) of parents who were not satisfied with the results of Gomco circumcision (p value 0.002).

CONCLUSION

Gomco needs a longer operative time, and Plastibell circumcision is less preferable by parents. There is no significant difference in physician satisfaction between the two procedures, but parents are less satisfied with Plastibell circumcision.

Type 2 diabetes mellitus increases the risk of circumcision among men aged between 30 and 69 years using a nationwide population-based dataset in Taiwan: a five-year follow-up study

BACKGROUND

Diabetes is an important factor in the development of penile inflammation. We studied whether type 2 diabetes (DM), with/without hypertension and hyperlipidemia increased the risk of circumcision among men aged between 30 and 69 using a population-based dataset in Taiwan during a 5-year follow-up period.

METHODS

The research data in this study were obtained from Taiwan's National Health Insurance Research Database between 1997 and 2010. We identified 23,197 patients who had a new diagnosis of DM and randomly matched 115,985 subjects as controls. We observed whether circumcision was the treatment after a new DM diagnosis. The initial step involved analyzing the data using Poisson regression analysis. To address potential confounding factors, this study employed propensity score matching based on three variables. Additionally, a Cox regression with a Gamma frailty was utilized to compare outcomes between different groups.

RESULTS

Poisson regression analysis showed that DM (RR = 1.75, 95CI = 0.10 ~ 1.22), but not hypertension (RR = 1.14, 95CI=-0.44 ~ 0.70), hyperlipidemia (RR = 0.94, 95CI=-0.66 ~ 0.53), or age (RR = 0.83, 95CI=-0.43 ~ 0.62), had an impact on circumcision treatment. Cox regression with a frailty model found that DM was a risk factor associated with circumcision (HR = 2.31, 95% CI = 1.74 ~ 3.06, p-value < 0.01), whereas no significant difference was noted between circumcision and hypertension (HR = 1.10, 95% CI = 0.80 ~ 1.51), hyperlipidemia (HR = 1.05, 95% CI = 0.79 ~ 1.40), or age (HR = 1.00, 95% CI = 0.99 ~ 1.02).

CONCLUSIONS

Type 2 diabetes mellitus, but not hypertension, hyperlipidemia or age increases the risk of circumcision in men aged between 30 and 69 years.

Comments by opponents on the British Medical Association's guidance on non-therapeutic male circumcision of children seem one-sided and may undermine public health

The British Medical Association (BMA) guidance on non-therapeutic circumcision (NTMC) of male children is limited to ethical, legal and religious issues. Here we evaluate criticisms of the BMA's guidance by Lempert et al. While their arguments promoting autonomy and consent might be superficially appealing, their claim of high procedural risks and negligible benefits seem one-sided and contrast with high quality evidence of low risk and lifelong benefits. Extensive literature reviews by the American Academy of Pediatrics and the United States Centers for Disease Control and Prevention in developing evidence-based policies, as well as risk-benefit analyses, have found that the medical benefits of infant NTMC greatly exceed the risks, and there is no reduction in sexual function and pleasure. The BMA's failure to consider the medical benefits of early childhood NTMC may partly explain why this prophylactic intervention is discouraged in the United Kingdom. The consequence is higher prevalence of preventable infections, adverse medical conditions, suffering and net costs to the UK's National Health Service for treatment of these. Many of the issues and contradictions in the BMA guidance identified by Lempert et al stem from the BMA's guidance not being sufficiently evidence-based. Indeed, that document called for a review by others of the medical issues surrounding NTMC. While societal factors apply, ultimately, NTMC can only be justified rationally on scientific, evidence-based grounds. Parents are entitled to an accurate presentation of the medical evidence so that they can make an informed decision. Their decision either for or against NTMC should then be respected.

Primary syphilis, an extremely uncommon cause of acute-onset phimosis

We present a case of phimosis in the context of primary syphilis with a preputial chancre. An accurate diagnosis after an appropriate examination and patient history allowed conservative treatment with antibiotics and the avoidance of circumcision in this patient.

Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa

The study investigates the statistical relationship between male circumcision and HIV prevalence in Africa, in the context of the Voluntary Medical Male Circumcision (VMMC) campaigns in place since 2008. Data from the Population-based HIV Impact Assessment (PHIA) surveys conducted in African countries in 2017-2018 were utilized. Six countries with high HIV prevalence, low traditional circumcision and large VMMC programs were selected: Eswatini, Lesotho, Malawi, Namibia, Zambia, Zimbabwe. The statistical analysis investigated the relative risk (RR) of HIV prevalence by circumcision status (circumcised vs intact) among men age 20-59, and the age-incidence of HIV in the two groups among men age 20-49, defined as the linear-logistic slope of the relationship between prevalence and age. Results show that the standardized RR was not different from 1 at older ages (50-59): RR = 0.923, 95% CI = 0.769-1.108, P = 0.390. Furthermore, the age-incidence was at least as high or higher among the circumcised groups than among the intact groups. The standardized RR was lower than 1 at younger ages, and this could be explained by selection biases. HIV prevalence at age 40-59 (27.3%) was also the same in the four groups of circumcision status (intact, traditional, medical, unknown). Results matched earlier observations made in South Africa that circumcised and intact men had similar levels of HIV infection. The study questions the current strategy of large scale VMMC campaigns to control the HIV epidemic. These campaigns also raise a number of ethical issues.

[Development of circumcision rates in Germany since the approval of ritual circumcision : A population-based analysis from 2013 to 2018]

INTRODUCTION

The religious and cultural circumcision of male infants in Germany is controversially discussed. After the passing of the religious circumcision bill in 2012, an increase of infant circumcisions without medical indication was feared. The aim of this study was to analyze the development of the circumcision case numbers.

MATERIALS AND METHODS

We used the research database of the German Institute for Applied Health Research with a representative anonymous sample of 4.9 million insured persons to estimate the annual circumcision numbers in Germany from 2013-2018. We stratified the data according to age (< 18 vs. ≥ 18 years). The number of male adolescents in the study period was taken from the database of the German Federal Statistical Office.

RESULTS

In the study period, 673,819 circumcisions were performed. From 2014, there was a significant decrease in the number of cases across all age groups (p = 0.049). Thereby, circumcisions in minors significantly increased (p = 0.002) and procedures in adults significantly decreased (p = 0.01) during the entire study period. The number of male minors increased by 4% from 6,709,137 (2013) to 6,992,943 (2018). The corresponding population-based number increased from 7.5 circumcisions per 1000 minors in 2013 to 8 in 2018 (p = 0.037).

CONCLUSIONS

After the passage of the circumcision bill in 2012, there was a significant increase of circumcisions in the age group of < 18 years in Germany. A major limitation of our study is that presumably many ritual circumcisions might not be provided within the health care system.

Foreskin restorers: insights into motivations, successes, challenges, and experiences with medical and mental health professionals - An abridged summary of key findings

Demographically diverse surveys in the United States suggest that 5-10% of non-voluntarily circumcised American males wish that they had not been circumcised. Similar data are unavailable in other countries. An unknown proportion of circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth investigation into foreskin restorers' lived experiences. An online survey containing 49 qualitative and 10 demographic questions was developed to identify restorers' motivations, successes, challenges, and experiences with health professionals. Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust. Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by medical and mental health professionals.

Does using a laser improve outcomes of conventional circumcision in adult and children populations? Results from a systematic review and meta-analysis

BACKGROUND

Male circumcision is a well-known old surgery, and several recently developed techniques have been scaled up, including the introduction of laser technology, as alternative approaches to overcome morbidity of conventional surgery scalpel/suture method OBJECTIVES: We aimed to perform a systematic review and meta-analysis of studies comparing laser circumcision versus conventional circumcision technique in terms of perioperative outcomes and efficacy (complications, unacceptable appearance, reoperation rate) both in children and adults.

MATERIALS AND METHODS

This review was performed following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Continuous variables were analyzed using the inverse variance of the mean difference with a random effect, 95% confidence interval (CI), and p-value. The incidence of complications, unacceptable appearance, and reoperation rate were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and reported as odds ratio (OR), 95% CI, and p-value. Significance was set at p-value ≤0.05 and 95%CI.

RESULTS

Seven studies were included. In comparison to the conventional circumcision, laser circumcision shoved lower visual analogue score at 24-h, and 7 days after surgery, a lower rate of overall complication rate (OR 0.33, 95% CI 0.24-0.47, p < 0.001), scarring (OR 0.09, 95% CI 0.02, 0.41, p = 0.002), and unacceptable appearance (OR 0.09, 95% CI 0.05, 0.15, p < 0.001). We found no statistically significant difference in surgical time, and incidence of bleeding, infection, wound dehiscence, and reoperation rate.

DISCUSSION AND CONCLUSION

Our review infers that laser-assisted circumcision is certainly a safe and strong contender as the procedure of choice in both children and adult populations.

Circumferential full-thickness skin grafting: An excellent method for the treatment of short penile skin in adult men

Objective

Short penile skin due to excessive circumcision is a complex condition requiring surgical care. The study aims to investigate the effect of full-thickness skin grafting (FTSG) in treating short penile skin.

Methods

A retrospective analysis was performed on 24 patients with insufficient penile skin. The included patients underwent full-thickness skin grafting from the scrotum and the groin region in the Genital Plastic Surgery Center between February 2014 and September 2021. Morphology of the penis, length of the penis, complication, and donor area healing status was observed by the authors. Additionally, the International Index of Erectile Function Questionnaire (IIEF-5) and the patient's evaluation of penile appearance were investigated.

Results

An aesthetically pleasing appearance of the penis was obtained by FTSG in 24 patients. The length of penis was improved after surgery (5.70 cm ± 1.24 cm vs. 6.05 cm ± 1.33 cm, P value < 0.05). All patients had good healing of the penile area without serious complications. Only 2 cases showed minor partial necrosis and recovered soon after proper treatment. A high patient's evaluation of penile appearance was received (4.08 ± 0.71, mean ± SD) and the scores of IIEF-5 increased significantly after surgery (18.38 ± 2.24 vs. 21.08 ± 1.79, P-value < 0.05).

Conclusions

FTSG from the scrotum and inguinal skin provides good aesthetic and functional results for treating short penile skin. FTSG, particularly the scrotum-derived skin graft, offers a great supplement to penile skin. It could be suggested as a promising method of treating insufficient penile skin, which meets both functional and aesthetic needs.

A Retrospective Taiwanese-Population-Based Clinical Study on Determining the Efficacy and Safety of Disposable Circumcision Anastomat

Traditional approaches for male circumcision are tedious and could lead to complications such as peri-/postoperative pain, bleeding, and infection. Thus, for the first time, we investigated the surgical outcomes of recently the discovered Disposable Circumcision Anastomat Type A (Dongguan ZSR Biomedical Technology Company Ltd., China), a disposable circumcision suture device (DCSD), in terms of the operation time, surgical complexity, safety, satisfaction, and aesthetic outcomes and most importantly the prognostic factors for postoperative infection. A total of 394 individuals were circumcised, with a mean age, body mass index (BMI), stretched penile length (SPL), and penile circumference of 30.1 ± 7.05 years, 25.47 ± 4.73, 10.12 ± 1.61, and 7 ± 0.73 cm, respectively. Associated comorbidities included diabetes mellitus (6.09%), hypertension (2.03%), gout (1.02%), end-stage renal disease (ESRD, 0.25%), and HIV (0.25%). The mean operation time, average postoperative bleeding, and wound infection rate was 31.4 ± 9.96 min, 2.54%, and 9.39%, respectively. The mean VAS postoperative pain scores at D0 and D1 were 4.4 ± 2.4 and 1.9 ± 1.6, respectively. Moreover, 1.27% of subjects required reoperation, and a 2.03% rate of instrument malfunction was noted. The significant factors associated with the post-operative infection group were age (p = 0.0313), BW (p = 0.0081), BMI (p = 0.0026), penile circumference (p = 0.0343), and DM (p ≤ 0.001). Multivariate analyses revealed only DM as a statistically significant factor (p < 0.001). Our box−whisker plot revealed no significant difference between the HbA1c level of infection (Hb1Ac = 7.77 ± 1.39) and non-infection groups (Hb1Ac = 6.92 ± 1.84). However, a trend of higher glycemic index in the infection group was observed. Conclusively, DSCD could be an effective and safe alternative to performing circumcision. However, in the population with advanced aging, phimosis, elevated BMI, and DM (HbA1C > 9%), users should be highly cautious due to the increased risk of infection, dehiscence, and hematoma.

The efficacy of tissue glue in pediatric circumcision wound approximation: A meta-analysis of randomized controlled trial

INTRODUCTION

Tissue glue has been examined extensively for its effectiveness in pediatrics, and the findings are good. The purpose of this research was to examine the effectiveness of tissue glue compared to absorbable sutures for wound approximation in pediatric circumcision.

METHODS

A systematic review and meta-analysis on children who had circumcision using tissue glue and absorbable suture were done in line with the PRISMA criteria. RevMan 5.4 was used to perform the meta-analysis. The mean differences for continuous and dichotomous data are determined using inverse variance, and the odds ratio is calculated using the Mantel-Haenszel technique.

RESULTS

The inclusion criteria were met by six trials containing a total of 817 patients. According to the analysis, tissue glue significantly reduces the duration of the operation (MD - 7.98; 95% CI -12.35, -3.62; p = 0.0003), pain severity (SMD -0.57; 95%CI -0.80, -0.32; p < 0.00001) and the duration of pain (MD - 2.33; 95% CI -2.57, -2.08; p < 0.00001) compared to absorbable suture. However, we found that there was no significant difference in the incidence of postoperative bleeding, infection, dehiscence, or overall complication when comparing tissue glue to traditional suture.

CONCLUSION

Our systematic review and meta-analysis using the most recent data suggest that tissue glue usage might reduce the operation time, as well as the intensity and duration of postoperative pain.

Can circumcision be avoided in adult male with phimosis? Results of the PhimoStopTM prospective trial

Background

Circumcision as surgical treatment of adult phimosis is not devoid of complications. Efficacy of alternative non-surgical options is unclear. PhimoStop^TM is a therapeutic protocol which involves the use of appropriately shaped silicone tuboids of increasing size to obtain a non-forced dilation of the prepuce. The aim of the study was to evaluate the efficacy and durability of results of PhimoStop^TM device for the treatment of adult male phimosis.

Methods

A prospective trial was conducted between 2018 and 2020 on 85 consecutive adult male patients affected by phimosis and with an indication for circumcision. Patients were treated with PhimoStop^TM protocol and they were evaluated at baseline and after treatment through a subjective (patient self-reported information on various domains of his sexual function) and an objective assessment (evaluation of phimosis severity grade according to the Kikiros scale pre- and post-treatment, re-assessment of indication for circumcision post-treatment and validated questionnaires scores). Primary endpoint was to avoid the scheduled circumcision in 33% of the patients enrolled.

Results

Seventy-one patients (84%) completed the device usage phase as per study protocol. Median duration of tuboid application was 60 days. Thirty-seven patients (52.1%) had no indication for circumcision after treatment. Even considering patients lost to follow-up as failures, primary endpoint was reached in 43.5% of cases. There was a significant reduction of the grade of phimosis after treatment (P<0.001). Moreover IIEF-5 showed a statistically significant improvement after treatment (P<0.001). Thirty/37 patients who met the primary endpoint (81%) still have a successful resolution of their phimosis avoiding circumcision at a median follow-up of 24 months.

Conclusions

PhimoStop^TM device is effective for the treatment of adult male phimosis of Kikiros grade ≤2. The results seem to be durable in most patients at a median follow-up of 24 months. Randomized clinical trials are necessary in order to confirm our results and assess cost-efficacy.