Circumcision: postoperative complications that required reoperation

Surgical repair of extensive penile shaft skin injuries following neonatal circumcision

Circumcision is a common procedure performed since ancient times with an excellent safety profile and potential health benefits. In the United States, it is commonly performed in the neonatal period using devices such as the Gomco, Mogen, or Plastibell device. In the rare circumstance of a complication, it is often related to bleeding and usually managed conservatively. However, complications requiring surgical intervention can occur and remind practitioners of the importance of proper equipment and technique. Herein, we report a case in which extensive injuries to the penile skin after neonatal circumcision using a Gomco clamp required emergent intervention.

Plastic Clamp Versus Conventional Surgical Dissection Technique in Pediatric Circumcision: A Systematic Review and Meta-Analysis

PURPOSE

Phimosis is a common condition of the urinary system in children and often requires surgical treatment. However, the optimal method of circumcision for children has not been determined. We conducted a systematic review and meta-analysis to compare the safety and effectiveness of plastic clamp with conventional surgical circumcision in pediatric circumcision.

METHODS

A literature search was carried out to compare the plastic clamp and conventional dissection technique in the pediatric population. The following search terms were used: "circumcision", "plastic clamp", "conventional", "plastibell", "children" and etc. Meta-analysis was used to pool and evaluate variables such as operative time, blood loss, wound infection, bleeding, edema, and total postoperative complications.

RESULTS

The plastic clamp technique (PCT) was used in 10,412 of the 17,325 participants in the nine studies, while the conventional surgical dissection technique (CST) was used on 6913 patients. When compared to the CST approach, the PCT approach resulted in shorter operative times (mean difference (MD) -17.48, 95% CI -22 to -12.96; P < 0.001), less blood loss (MD -4.25, 95% CI -7.75 to -0.77; P = 0.02), and a higher incidence of postoperative edema (OR 2.33, 95% CI 1.34 to 4.08; P = 0.003). However, no significant difference was found in the incidence of postoperative complications, including wound infection and bleeding between PCT and CST.

CONCLUSIONS

PCT is a safe and time-saving option in the pediatric population. However, this method appeared to have a significant greater rate of postoperative edema.

Meatal stenosis following three types of circumcision with frenular artery preservation (FAP), the Plastibell device (PD), and frenular artery ligation (FAL): a long-term follow-up

BACKGROUND

Despite the simplicity of male circumcision, complications occur frequently. Post-circumcision meatal stenosis is a concerning complication that might require several interventions.

AIM

This study aims to evaluate the incidence of meatal stenosis in long-term follow-up, following three common circumcision methods: frenular artery preservation, frenular ligation, and the Plastibell device.

METHODS

This study is the continuation of the previous randomized clinical trial, the preliminary abstract of which has been accepted in the annual meeting of the American Urological Association in 2011. However, in this paper, we only included the patients with results of long-term follow-up. Patients were followed for a median of 11 years (range, 7-17). Follow-ups were recorded by evaluation of meatus and signs and symptoms of meatal stenosis.

RESULTS

Two hundred six boys (80 neonates and 126 non-neonates) at the time of procedure were included in this study. The circumcision was conducted on 23.3% (48/206) of boys with the Plastibell device (PD) and 39.3% (81/206) of cases with frenular artery preservation (FAP) and 37.4% (77/206) of cases with frenular artery ligation (FAL). Meatal stenosis presented in 13 children during follow-up. Considering the three methods of circumcision, a significant difference in the incidence of meatal stenosis among the types of circumcisions was observed (6.3% in PD and 1.2% in FAP, 11.7% in FAL, P = 0.026).

CONCLUSION

The present study revealed that the technique preserving the frenular artery is associated with a significantly lower incidence of meatal stenosis. Hence, the FAP is the recommended technique for circumcision as compared to two other methods.

Examining Clinical Practice Guidelines for Male Circumcision: A Systematic Review and Critical Appraisal Using AGREE II

OBJECTIVE

To identify and critically appraise available clinical practice guidelines (CPGs) targeting male circumcision using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument.

STUDY DESIGN

A literature search was conducted using electronic databases, CPG databases, and national/international societies providing recommendations to guide clinical decision making for male circumcision. We selected pediatric-focused CPGs related to male circumcision published between January 2010 and December 2020. Non-English CPGs and publications involving narrative reviews, primary research, training manuals, patient and allied health professional guidelines, and technical guides were excluded from our search. Complete CPG documents (including full-text articles, supplemental documents, and associated information) were reviewed. Quality appraisal of CPGs was conducted in accordance with the AGREE II manual.

RESULTS

A total of 163 CPGs were identified, of which 93 were screened and 13 were reviewed. All AGREE II domains demonstrated good to excellent interrater reliability, with intraclass correlation coefficients ranging from 0.82 (95% CI, 0.72-0.89) to 0.93 (95% CI, 0.90-0.95). Most CPGs performed satisfactorily in the clarity of presentation domain and performed poorly in the applicability and editorial independence domains. The top 3 CPGs identified were those of the American Academy of Pediatrics, Centers for Disease Control and Prevention, and Canadian Urological Association. Consistencies among the CPGs were demonstrated across most recommendations.

CONCLUSIONS

Current CPGs are of variable quality, and our findings should be taken into consideration by clinicians and health care professionals when selecting appropriate guidelines for male 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.

To wrap or not to wrap: A retrospective review of circumcision dressing and post-procedural bleeding

INTRODUCTION

Bleeding is an infrequent, but important, complication after circumcision. Our aim was to examine postoperative bleeding events after circumcision comparing patients managed with a circumferential wrap to ointment alone.

METHODS

Boys ≤18 years of age who underwent circumcision at a tertiary children's hospital were retrospectively reviewed between 2017 and 2018. Postoperative bleeding was defined by phone calls, clinic or Emergency Department visits, or return to the operating room. Outcomes were examined by univariate association and multivariable modeling.

RESULTS

Of 681 boys undergoing circumcision, 503 (74%) patients received a wrap dressing and 178 (26%) only ointment. There were 28 (4%) patients who had a postoperative bleeding event: 14/503 (2.7%) among wrap dressings and 14/178 (7.8%) among ointment alone (p < 0.01). The majority of events were phone calls related to bleeding (75%). Univariate analysis demonstrated no association between postoperative bleeding and surgeon specialty (p = 0.72), age at circumcision (p = 0.44) or technique type (p = 0.09). After controlling for age, technique type, and surgeon specialty, dressing type remained significantly associated with postoperative bleeding (OR = 2.81, p < 0.01).

CONCLUSION

This single-center, retrospective review found circumferential wrap dressings are associated with a decrease in bleeding events after circumcision.

LEVEL OF EVIDENCE

III - retrospective case-control study.

Reintroducción de la circuncisión como una técnica quirúrgica reconstructiva

La circuncisión es una cirugía practicada frecuentemente en urología. Sin tener en cuenta los principios básicos de la cirugía reconstructiva, puede generar procesos de cicatrización anómalos, con resultados estéticos y funcionales inadecuados, fimosis secundaria, cicatrización hipertrófica, queloide o “pene enterrado.” El objetivo de este video es recordar la importancia de operar con las directrices de una cirugía reconstructiva, resaltando el cuidado de los tejidos y el uso de suturas de bajo calibre, para prevenir complicaciones y resultados insatisfactorios, resaltando la preservación de las zonas postuladas por Firlit. Se sospecha que las complicaciones de este procedimiento son subestimadas por los especialistas. El manejo cuidadoso de los tejidos, el uso de suturas de bajo calibre y los puntos subcuticulares con poca tensión, son medios para optimizar el proceso de cicatrización, evitando la isquemia y las cicatrices hipertróficas, basados en el fundamento de que esta es una cirugía no solo funcional, sino reconstructiva y estética. La circuncisión es un procedimiento que debe conservar la funcionalidad y estética del pene, por lo que debe ser realizado bajo las directrices de una cirugía reconstructiva.

Histology and immunohistochemical evaluation of phimotic prepuce: The role of steroid therapy

Phimosis is one of the most frequent andrological diseases in paediatric age. Steroids are useful to treat phimosis. Through a retrospective study of histological and immunohistochemical analysis, we evaluated the effectiveness of topical steroid treatment in patients undergoing circumcision. Cases of patients treated for phimosis were selected during the two-year study period. All patients underwent circumcision and were divided into four groups: groups A (religiously circumcised patients), B (phimotic patients not undergoing steroid treatment), C (phimotic patients who do not respond to cortisone treatment) and D (hypospadic patients undergoing urethroplasty). An histological evaluation of the degree of fibrosis and an immunohistochemical evaluation of collagen IV and tenascin were carried out. Study results demonstrate that the grade of fibrosis is age-related. On histological and immunohistochemical evaluation, fibrosis was found to be lower in patients receiving steroids; higher degrees of fibrosis were found in older patients (p < .05). Different degrees of fibrosis have also been found in hypospadic patients. We can conclude that study results correlated with the clinical history of the patients. The success rate of medical therapy seems to be age-related.