WHOLE1.indd ABSTRACT Background: Plastibell circumcision complications can be life-threatening. Objective: The aim of this paper is to review the complications of Plastibell circumcision reported in the literature and in our own patients to determine the safety of the proce- dure. Method: A retrospective study of 7 neonates circumcised in Sultan Qaboos University Hospital over a 4-year period from 997 to 2000. Results: Minor complications occurred in 4 (2.3 %) of circumcisions. Two cases were converted to formal circumcision due to bleeding and failure to introduce the bell respectively. One had delayed passage of urine for 24 hours and in one neonate, the parents were concerned about inadequate removal of foreskin. Conclusion: Plastibell circumcision is a safe technique in experienced hands. The risk of complications with this procedure is increased eight-fold when performed by nurses compared to surgeons. Keywords: Plastibell, circumcision, neonates. Pla stib ell Ci rc u mci sion: How S afe i s it? Experience at Sultan Qaboos University Hospital *Mohammed S Al-Marhoon1, Said M Jaboub2 SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL JUNE 2006 VOL 6, NO. 1 SULTAN QABOOS UNIVERSITY© CIRCUMCISION IS PROBABLY THE MOST COM-MON surgical procedure in children world-wide. The practice of circumcision is thought to be at least 15,000 years old.1 Cave drawings dated to paleolithic age show illustrations of circumcised men. There are reports of royal mummies who were circum- cised. The role of circumcision owes its origin from the circumcision of Abraham when he was circumcised at age of 99 years as a covenant with God. Muslim tra- dition dates the ritual to the circumcision of Ishmael, Abraham’s eldest son who was circumcised at age of 13 years with his father.2 During World War II tropi- cal diseases of foreskin in American servicemen led to an increase in the trend towards routine neonatal cir- cumcision. Neonatal circumcision as a routine proce- dure underwent a phase of controversy in non-Islamic countries. A report issued in 1975 by the committee on the fetus and newborn of the American Academy of Pediatrics stated that there was no absolute medical indication for routine circumcision of the newborn.3 In Islamic countries circumcision is a must for all males for religious reasons, but the issue here is whether to do neonatal circumcision or operate at older age. The natural history of the foreskin was described in 1949. In newborn males the foreskin is fully retract- able in 4%, the glans can be retracted to the urethral meatus in 54% and the tip of the glans cannot be seen in the remaining 42%. The foreskin is retractable in 25% of children at 6 months of age, 50% at one year, 80% at two years and 90% by four years.2 1 School of Biomedical Sciences, University of Leeds, UK & Department of Surgery, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman, 2 Department of Surgery, Army Force Hospital, Muscat, Sultanate of Oman *To whom correspondence should be addressed. Email: almarhoon@hotmail.com O R I G I N A L S T U D Y سالمتها؟ مدى :(Plastibell ) بواسطة الذكور ختان السلطان قابوس جامعة جتربة مستشفى (Plastibell) بواسطة اخلتان مضاعفات استعراض إلى الدراسة هذه .تهدف احلياة تهدد عملية اخلتان قد تترتب على التي الهدف: املضاعفات امللخص: ثم ١٧١ وليدا االستعادية الدراسة هذه الطريقة: ضمت هذه العملية. مثل خطورة مدى للتعرف على هنا التي حصلت وتلك في األدبيات املسجلة في بسيطة مضاعفات النتائج: ظهرت .٢٠٠٠ ١٩٩٧ إلى من للفترة سنوات أربع خالل قابوس السلطان جامعة مستشفى في الطريقة بتلك ختانهم وكانت هناك حالة واحدة تأخر فيها خروج . اجلرس إدخال في والفشل النزيف بسب وذلك إصالحي ختان إلى حتويلها مت اثنتان ، اخلتان حاالت من (٪٢٫٣) ٤ املذكورة الطريقة بواسطة الذكور اخلالصة: ختان كاملة. بصورة اجللد إزالة عدم قلقني بسب الطفل والدا كان حالة أخرى وفي ، ٢٤ ساعة ملدة البول باجلراح. مقارنة قبل املمرضات من أجريت إذا ٨ مرات الطريقة هذه مضاعفات تزداد وقد كفوءة أيدي بواسطة أجريت إذا سليمة تقنية M O H A M M E D S A L - M A R H O O N , S A I D M J A B O U B 18 The indications for circumcision in Oman are mainly for religious reasons, besides the medical in- dications of phimosis, paraphimosis, recurrent bala- noposthitis and recurrent urinary tract infections. A variety of clamp methods were developed including the Gomco clamp in the 1930’s and the Plastibell in the 1960’s. They are the most commonly used devices in newborn circumcisions. The aim of this paper is to review the complica- tions of Plastibell circumcision reported in the litera- ture and to review our own complications in Sultan Qaboos University Hospital (SQUH) and to emphasis the need for skilled surgeons to perform the procedure to make it free of the serious complications. M E T H O D This study included 171 neonates who underwent Plas- tibell circumcision. They were operated on by one sur- geon over 4 years period from 1997 to 2000 at SQUH. The data, including complications of the technique, were collected retrospectively by going through the patients’ files including emergency visits. A policy of preoperative genital examination, consent-taking and full explanation to the parents is used. All neonates with jaundice, hypospadias and small size penis were not circumcised. The procedure was performed as follows: The baby is identified and restrained. The penis is pre- pared with an antiseptic solution and local anesthesia provided by 1% Lignocaine as penile block. The prep- utial ring is dilated with a hemostat and the urethral meatus definitely identified. The foreskin is grasped with hemostats at 10 and 2 o’clock positions. A dorsal slit is made after crushing the skin for 5 seconds. The foreskin is freed off the entire glans and completely retracted to expose the whole glans, then the correct size Plastibell is selected by testing it directly on the glans. The foreskin is pulled over the Plastibell which is stabilized by a hemostat clamping the skin to the handle of the Plastibell. The tie is applied on the Plas- tibell groove using a surgeon’s knot for the first throw. The foreskin is excised just past the outermost edge of the Plastibell taking care not to damage the glans. Final checking for bleeding, meatal opening and cor- rect position of the tie was performed at the end of the procedure. The parents are advised to watch for complications and strongly encouraged to come back to the hospital in case of any problems and they were given contact numbers for any queries. Figure 1. Plastibell sizes (cm) used in the circumcision of 171 babies. Table 1. Complications observed in 4 cases out of 171 cases. Complication Number of cases (%) Not passing urine for 24 hours 1 (0.58) Inadequate removal of foreskin 1 (0.58) Conversion to formal circumcision 2 (1.17) P L A S T I B E L L C I R C U M C I S I O N : H O W S A F E I S I T ? 19 R E S U L T S The commonest Plastibell ring size used was 1.3 cm with sizes ranging from 1.1 to 1.7 cm [Figure 1]. Most circumcisions were performed in the neonatal age group (158 cases (92 %)). The majority of circum- cised babies (93.6 %) had birth weights ranging from 2.5 to 4 Kg. Preoperative examination of the infants revealed 2 babies with congenital hydroceles, one with left undescended testis, one with umbilical hernia, and one with glandular hypospadias. The complications observed, shown in Table 1, included one child who was unable to pass urine for 24 hours. He was brought to the emergency department where he passed urine with no intervention. One child who was brought by his father to the outpatient clinic because he was concerned about inadequate removal of foreskin, but the circumcision was deemed adequate. Two cases were converted to formal circumcision. The first was converted in the same sitting due to excess dorsal slit which made no room for the bell to fit in. The second was converted due to bleeding within 24 hours. This child had a very adherent prepuce with difficulty in re- leasing it, which had created raw oozing areas. D I S C U S S I O N Plastibell circumcision is a simple technique for neo- natal circumcision. However, the complications of this technique can sometimes be life-threatening. The re- ported complications of plastibell circumcisions range from very minor ones to serious ones as shown in Ta- ble 2. Complications of concern that have been report- ed in the literature include proximal migration of the bell on to the distal penile shaft causing circumferen- tial compression; denution of penile skin or persistent disfigurement of the glans penis;4 two cases of necro- tizing fasciitis;5 one case of rupture of bladder due to urinary obstruction by the Plastibell.6 The complication rate of Plastibell circumcision performed by trained nurses in Bradford Hospital in UK7 [Table 3] was 18.5 % (31 out of 168 cases) com- pared to, only 2.3 % (4 out of 171 cases) in this study and 2.4 % (5 out of 205 cases) in the Jamaican study.8 The low complication rate in the present study and the Jamaican study may be attributed to the procedures being performed by experienced surgeons. Therefore we strongly support that this procedure is performed by surgeons or trained doctors rather than nurses. Al- though Plastibell circumcision is a simple technique and can be easily learnt, it is not to be taken lightly as serious complications like necrotizimg fasciitis and rupture of bladder have been reported. R E F E R E N C E S 1. Darby R. “Where doctors differ”: the debate on circum- cision as a protection against syphilis. Soc Hist Med, 2003; 16: 57-78. 2. Anderson G. Circumcision. In: TM H, ed. Ashcraft KW. 2 ed. WB Saunders Company: Paediatric Surgery, 1993; 715-719. 3. Rose V. AAP Updates its Recommendations on Cir- cumcision: American Academy of Pediatrics, 1999; 59: 2918-2923. 4. Cilento BG, Holmes NM, Canning DA. Plastibell Com- plications Revisited. Clin Pediatr 1999; 38: 239-242. 5. Bliss DP, Healey PJ, Waldhausen HT. Necrotizing Fas- ciitis after Plastibell Circumcision. J Pediatr 1997; 131: 459-461. 6. Jee LD, Millar AJ. Ruptured Bladder Following Circum- cision Using the Plastobell Device. Br J Urol 1990; 65: 216-217. Table 3. Summary of the 31 children out of 168 with complications after plastibell circumcision5 Complications Number of cases (%) Bleeding 7 (4.2) Ring tracking back in penile shaft after separation 6 (3.5) Early separation of ring 12 (7) Wound infection 4 (2.3) Post-op pyrexia 1 (0.6) Inadequate removal of foreskin 1 (0.6) Table 2. Complications of plastibell circumcision Some of the reported complications of Plastibell circumcision Wound infection Bleeding Inadequate removal of foreskin Penile adhesions Phimosis Excess removal of foreskin Necrotizing fasciitis Sepsis Urinary retention Meatal ulceration/Meatal stenosis/Meatitis Bladder rupture Penile hematoma(due to local anaesthesia) Failure of plastibell to separate Plastibell ring too tight Migration of plastibell to midshaft M O H A M M E D S A L - M A R H O O N , S A I D M J A B O U B 20 7. Shah T, Raistrick J, Taylor I, Young M, Menebhi D, Ste- vens R. A Circumcision Service for Religious Reasons. Br J Urol 1999; 83: 807-809. 8. Duncan ND, Dundas SE, Brown B, Pinnock-Ramsaran C, Badal G. Newborn Circumcision Using the Plastibell device: An Audit of Practice. West Indian Med J 2004; 53: 23-26.