Useful tips and tricks for secure circumcision

Ching-Wei Huang; Ta-Min Wang; Li-Chueh Weng; Hsiao-Wen Chen

doi:10.4103/UROS.UROS_114_18

ORIGINAL ARTICLE

Year : 2019 | Volume : 30 | Issue : 3 | Page : 136-139

Useful tips and tricks for secure circumcision

Ching-Wei Huang¹, Ta-Min Wang¹, Li-Chueh Weng², Hsiao-Wen Chen¹
¹ Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
² School of Nursing, Chang Gung University, Taoyuan, Taiwan

Date of Submission	23-Aug-2018
Date of Decision	14-Oct-2018
Date of Acceptance	22-Oct-2018
Date of Web Publication	20-Jun-2019

Correspondence Address:
Hsiao-Wen Chen
Division of Urology, Department of Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing St., Guishan Dist., Taoyuan City 333
Taiwan

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_114_18

Abstract

Introduction: The study aimed to find a secure procedure for circumcision, using monopolar diathermy with several key steps of technique to facilitate the surgical process and minimize the postoperative complications. Methods: Patients who underwent the secure technique for circumcision, due to different reasons, from 2012 to 2016 were retrospectively reviewed. A monopolar coagulator with a needle point probe with energy ranging from 10 to 15 W was used to perform the circumcision by following several key steps. In addition, tissue glue was applied to the wound to provide operative wound care. All data referring to patient demographics were recorded. The outcomes and complications associated with the secure technique for circumcision were assessed. Discussion: One hundred and ten children underwent this technique, carried out by a senior teaching staff member and several senior residents. All patients were followed with a mean of 29.5 ± 30.1 days postoperatively. All these patients were satisfied with the operation and had no major complications, and no second revisions were needed during the follow-up period. Two patients (1.8%) had a minor wound infection, which was resolved with oral antibiotics within 1 week. However, the study limitations included its retrospective nature and the heterogeneity of the study population. Conclusion: Modified diathermy circumcision with the secure technique protects the penile phallus and urethra, and it is associated with a low rate of complications, as hemostasis can be simultaneously ensured. The technique is feasible, simple, and easy to learn. In addition, tissue glue was proved to facilitate postoperative wound care.

Keywords: Circumcision, diathermy, electrocoagulator, tissue glue

How to cite this article:
Huang CW, Wang TM, Weng LC, Chen HW. Useful tips and tricks for secure circumcision. Urol Sci 2019;30:136-9

How to cite this URL:
Huang CW, Wang TM, Weng LC, Chen HW. Useful tips and tricks for secure circumcision. Urol Sci [serial online] 2019 [cited 2023 May 28];30:136-9. Available from: https://www.e-urol-sci.com/text.asp?2019/30/3/136/260777

Introduction

Circumcision is still one of the most popular surgical procedures performed in male populations regardless of medical, religious, or sociocultural reasons.^[1] It is still controversial whether patients benefit from circumcision. Several meta-analyses demonstrated that the benefits from circumcision can outweigh those of noncircumcision in terms of controlling urinary tract infections and their associated sequelae. The benefits can be extended throughout the entire life, such as prevention of sexually transmitted infections, including HIV; a lower incidence of the penile or prostate cancer; and decreased rate of cervical cancer in partners, which outweigh the risks of circumcision and justify providing access to this procedure to families who choose it.^{[2],[3],[4],[5]} However, considerable postoperative complications varying in severity, such as urethral fistula, partial amputation of the glans or penile shaft, and wound bleeding or hematoma, still occur. A postoperative parental assessment from a large series of patients who underwent circumcision showed that 52.3% and 47.7% of patients' parents were dissatisfied and satisfied with the outcome, respectively.^{[6],[7],[8],[9],[10]} Here, we reported a circumcision technique using diathermy and several key steps to facilitate the whole procedure and minimize the complication rate, and we present a review of the hindsight outcomes.

Methods

This retrospective study was approved by the Institutional Review Board of the Ethical Committee. Between 2012 and 2016, the charts and database of 110 children who underwent the secure technique with different indications were retrospectively reviewed. All circumcisions were performed under general anesthesia using conventional procedures with a sterile drape over the genitalia. The foreskin was fully retracted by the hands. In patients, the distal preputial skin was tightly wrapped, a dorsal-splitting incision was made, and the glans was exposed by retraction of the bivalved prepuce. Secondary betadine sterilization was applied over the glans and preputial skin. A monopolar coagulator was used as a substitute for a scalpel with a needle point probe with energy ranging from 10 to 15 W. The upcoming incisional rim was marked with dots circumferentially 5–10 mm proximal to the coronal sulcus with the coagulator [Figure 1] and [Figure 2]a, Step 1]. Then, the subcutaneous layers were divided deep onto the superficial plane of Buck's fascia [Figure 1] and [Figure 2]b, Step 2]. The second incisional line was marked with dots using the electrocoagulator beneath the narrowing ring or the smallest circumference of the preputial skin (i.e., phimotic band), and the tip of the distal preputial skin (keratinized) was retracted by a hemostat and pulled up by the index and middle fingers with moderate pressure. Moreover, the glans and urethra underneath the prepuce were pressed downward with the rest of the fingers to avoid injury [Figure 1], Step 3], then the foreskin was finally dissected off of the penis by the electrocoagulator from the outer (keratinized) to inner (nonkeratinized) layer of the preputial skin; this was performed carefully to prevent injury to unnecessary tissue [Figure 2]c and [Figure 2]d. Then, each end/edges of the incised preputial skins were approached in a parallel manner to measure the length difference; usually, the circumference of the distal edge of the preputial skin (nonkeratinized) after the first incision is wider than the proximal edge of the preputial skin (keratinized) after the second incision, if so, dorsal spitting incision was carried out on the midline of the proximal end of the preputial skin (keratinized) to extend the circumference according to the discrepancy of the girth between both ends of the distal and proximal prepuce; meanwhile, the slits of the dorsal preputial skin or dog ears were trimmed well in coaptation with the opposite preputial skin; finally, hemostasis was ensured. Both edges of the incised preputial skins were approximated with 5–0 Vicryl Rapide-interrupted sutures for the entire layers. Once circumcision was completed, tissue glue (Histoacryl, n-butyl-2-cyanoacrylate) was applied to the wound to cover the suture line circumferentially [Figure 2]e and [Figure 2]f. The occlusive wound dressing was essentially not needed, except the principles of postoperative wound care were explained to the parents or family after the circumcision was completed. Ibuprofen (4–10 mg/kg) or acetaminophen (7–15 mg/kg) was given for relieving pain postoperatively. Postoperative outcomes were based on the chart reviews which included wound bleeding, hematoma, infection, keloid formation, or whether there was a need for secondary surgery during the follow-up period.

Figure 1: The key steps of circumcision with diathermy

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Figure 2: (a). Electrodivision of the subcutaneous layers which deepen to the plane of the Buck's fascia with length from the tip of the glans to the coronal sulcus (b). The distal end of the prepuce was retracted; meanwhile, the glans and the penile phallus underneath the prepuce were pressing downward (c). The distal end of the prepuce was finally dissected off the penis by the electocoagulator (d). The distal end and proximal edge of prepuce were approximated with 5–0 Vicryl Rapide sutured interruptedly in the whole layers; the wound was applied with the tissue glue coverage on the sutured line circumferentially (e and f)

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Results

The patients' characteristics and the postoperative outcomes are presented in [Table 1]. Patients' mean age was 6.9 ± 3.7 years. Among these patients, surgical indications for circumcision included 78 with phimosis, 11 with balanitis/posthitis, 14 with paraphimosis, 3 with religious reasons, and 4 with other reasons. All patients underwent the procedure in an outpatient fashion, except eight patients who were already hospitalized due to another concomitant procedure. All patients underwent the operation with general anesthesia, and the mean operation time was 29.2 ± 5.3 min. All operations were performed by the teaching staff members and several senior residents who had been trained in this skill before. All patients were followed for a minimum of 6–224 days with a mean of 29.5 ± 30.1 days postoperatively. Occlusive dressing of any type was not needed, either during early postoperative wound care or follow-up, and the glue that was applied spontaneously peeled off within 1–2 weeks postoperatively; the patients had no major complications such as postoperative bleeding and no revision or any second procedure was needed during the follow-up period. Two (1.8%) patients had a minor wound infection, which was resolved with oral antibiotics within 1 week. However, the 11 patients with balanitis or posthitis before the operation did not show wound infection after the circumcision.

Table 1: Patient demographics and outcomes of circumcision

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Discussion

Several techniques for circumcision have been widely used, including sleeve resection, the dorsal slit procedure, and auxiliary devices (e.g., forceps for guiding, the Gomco and Mogen clamp, and the plastic bell clamp or Shang Ring). These are easily learned and practiced; however, the choice of modality varies according to the individual's experience and preference.^[11],[12] Literature regarding postoperative satisfaction varies. A perspective study with a large number of patients showed that the rate of postoperative bleeding was significantly associated with the surgeon's skill and experience.^[9] However, wound bleeding is the most common adverse event after the procedure, and the complication rate ranged from 0.2% to 9.2% in large series published in the last decade ^{[13],[14],[15],[16],[17]} [Table 2]. Using diathermy with a cutting current set at 25 W and a coagulation current at 6 W in routine pediatric penile procedure with sufficient hemostasis has been reported by Peters and Kass.^[18] However, the technique was not popular, and it did not prevent the potential risk associated with total or partial penile ablation during the excision of the prepuce with electrocautery.^[19],[20] Despite this, the use of diathermy enables a virtually clear and dry operating field while enabling surgeons to perform tissue dissection and ensure hemostasis. By using monopolar diathermy as a substitute for a scalpel in our practices, we have found no tissue necrosis; the power is controlled under 15 W in the constant voltage output mode, which is lower than that reported in previous reports; and the electrical current is concentrated on the tip of a needle point probe, which prevents further injury from the current energy. In theory, bipolar electrodissection may be more or less harmful in terms of thermal trauma, as it transmits the current at a much lower rate than it flows in a closed circuit with a limited thermal area using forceps.^[21] However, in a large series of 11,617 patients who underwent circumcision, there was no significant difference between bleeding controlled by monopolar and bipolar electrocautery in patients who returned for a bleeding complication.^[22] Compared with the conventional procedure, small vessels either on the cutting edges or the frenular artery during undermining can be simultaneously fulgurated; hence, the time required to assess bleeding can be shorter, and the steps for using a scalpel can be omitted by using monopolar diathermy; these reasons may explain the low postoperative complication rate (e.g., hematoma) in this series. Another main factor of this procedure is not using auxiliary devices by following our key steps for protecting the penile phallus and urethra; moreover, the entire procedure can be conducted with the hands of only one surgeon, as other techniques usually require more than one pair of hands, which may be helpful in the operation room with shortage of manpower. In addition, postoperative wound dressing was an important factor, as late bleeding at the surgical site may occur when conventional dressings such as Telfa/Tegaderm or gauze are removed. We attempted to apply tissue glue on the surgical site to minimize operative bleeding and ensure easy care of the wound. Tissue glue is a surgical tissue adhesive with a cyanoacrylate base that has been historically used to control bleeding during sclerosation of the esophageal varices or for wound closure during an intra-abdominal operation.^[23],[24] Based on our experience, the antibacterial film of the glue protects the circumcision wound from infection, and it is a remedy to prevent late wound bleeding; in our cases, the tissue glue spontaneously peeled off within 5–10 days; thus wound care was convenient for patients.

Table 2: Surgical complication rate from different circumcision techniques in literatures

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Circumcision is a historically common and popular procedure among senior and junior surgeons. The classical excision technique is commonly used, and the procedure is usually performed by clamping the prepuce, which is followed by making guillotine-like incisions. The techniques of circumcision have been mostly taught by having learners see the technique performed step by step, and they are associated with inherent hazards such as hematoma and glanular or urethral injuries when performed by inexperienced personnel. Studies on preventing complications due to circumcision are rare; thus, we have emphasized several aspects of the technique when performing circumcision to avoid major complications such as penile amputation, urethral injury, postoperative bleeding, or hematoma. However, the study limitations include its retrospective nature and the heterogeneity of the study population, such as the postoperative satisfaction of surgeons and patients/parents. However, we believe that the simplicity and safety of this surgical fashion should be adopted as the alternative option for circumcision.

Conclusion

We described how to perform diathermy circumcision using key steps of the secure technique to protect the penile phallus and urethra. Hemostasis can be simultaneously ensured during the procedure. This technique is feasible because of its low complication rate, and it is simple and easy to learn. In addition, tissue glue was proved to facilitate postoperative wound care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Morris BJ, Bailis SA, Wiswell TE. Circumcision rates in the United States: Rising or falling? What effect might the new affirmative pediatric policy statement have? Mayo Clin Proc 2014;89:677-86.
2.	Tobian AA, Serwadda D, Quinn TC, Kigozi G, Gravitt PE, Laeyendecker O, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med 2009;360:1298-309.
3.	Morris BJ, Bailey RC, Klausner JD, Leibowitz A, Wamai RG, Waskett JH, et al. Review: A critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries. AIDS Care 2012;24:1565-75.
4.	Policy Statement. Circumcision policy statement. Pediatrics 2012;130:585-7.
5.	Morris BJ, Waskett JH. Circumcision reduces prostate cancer risk. Asian J Androl 2012;14:661-2.
6.	Ceylan K, Burhan K, Yilmaz Y, Can S, Kuş A, Mustafa G, et al. Severe complications of circumcision: An analysis of 48 cases. J Pediatr Urol 2007;3:32-5.
7.	Williams N, Kapila L. Complications of circumcision. Br J Surg 1993;80:1231-6.
8.	Osifo OD, Odion-Obomhense H, Osagie TO. Repair-oriented categorization of circumcision urethral injury in Benin City, Nigeria. J Pediatr Urol 2013;9:206-11.
9.	Feinberg AN, Brust RA, Walker TA. Bleeding at circumcision: Patient or operator issue? Clin Pediatr (Phila) 2010;49:760-3.
10.	Freeman JJ, Spencer AU, Drongowski RA, Vandeven CJ, Apgar B, Teitelbaum DH, et al. Newborn circumcision outcomes: Are parents satisfied with the results? Pediatr Surg Int 2014;30:333-8.
11.	Hargreave T. Male circumcision: Towards a world health organization normative practice in resource limited settings. Asian J Androl 2010;12:628-38.
12.	Peterson AC, Joyner BD, Allen RC Jr. Plastibell template circumcision: A new technique. Urology 2001;58:603-4.
13.	Plank RM, Ndubuka NO, Wirth KE, Mwambona JT, Kebaabetswe P, Bassil B, et al. A randomized trial of Mogen clamp versus plastibell for neonatal male circumcision in Botswana. J Acquir Immune Defic Syndr 2013;62:e131-7.
14.	Wang R, Chen WJ, Shi WH, Xue YF. Shang Ring, Sleeve and Conventional circumcision for redundant prepuce and phimosis: A comparative study of 918 cases. Zhonghua Nan Ke Xue 2013;19:332-6.
15.	Horowitz M, Gershbein AB. Gomco circumcision: When is it safe? J Pediatr Surg 2001;36:1047-9.
16.	Palit V, Menebhi DK, Taylor I, Young M, Elmasry Y, Shah T, et al. A unique service in UK delivering plastibell circumcision: Review of 9-year results. Pediatr Surg Int 2007;23:45-8.
17.	Sinkey RG, Eschenbacher MA, Walsh PM, Doerger RG, Lambers DS, Sibai BM, et al. The GoMo study: A randomized clinical trial assessing neonatal pain with Gomco vs. Mogen clamp circumcision. Am J Obstet Gynecol 2015;212:664.e1-8.
18.	Peters KM, Kass EJ. Electrosurgery for routine pediatric penile procedures. J Urol 1997;157:1453-5.
19.	Gearhart JP, Rock JA. Total ablation of the penis after circumcision with electrocautery: A method of management and long-term followup. J Urol 1989;142:799-801.
20.	Stefan H. Reconstruction of the penis after necrosis due to circumcision burn. Eur J Pediatr Surg 1994;4:40-3.
21.	Taheri A, Mansoori P, Sandoval LF, Feldman SR, Pearce D, Williford PM, et al. Electrosurgery: Part II. Technology, applications, and safety of electrosurgical devices. J Am Acad Dermatol 2014;70:607.e12.
22.	Harty NJ, Nelson CP, Cendron M, Turner S, Borer JG. The impact of electrocautery method on post-operative bleeding complications after non-newborn circumcision and revision circumcision. J Pediatr Urol 2013;9:634-7.
23.	Caldwell SH, Hespenheide EE, Greenwald BD, Northup PG, Patrie JT. Enbucrilate for gastric varices: Extended experience in 92 patients. Aliment Pharmacol Ther 2007;26:49-59.
24.	Rosin D, Rosenthal RJ, Kuriansky J, Brasesco O, Shabtai M, Ayalon A, et al. Closure of laparoscopic trocar site wounds with cyanoacrylate tissue glue: A simple technical solution. J Laparoendosc Adv Surg Tech A 2001;11:157-9.