PDF-1002.pdf 423Vol. 9 | No. 1 | Winter 2012 |U R O LO G Y J O U R N A L Pediatric Sutureless Circumcision With- out Using Skin Closure Adhesives A New Technique for Poor Setting Seyyed Alaeddin Asgari,1 Mandana Mansur Ghanaie,1 Siavash Falahatkar,1 Hassan Niroomand,1 Elham Iran-Pour,2 Mohammad Reza Safarinejad2 Keywords: penis, circumcision, sutures, hemorrhage, child INTRODUCTION ircumcision is one of the most common procedures performed worldwide. Neonatal circumcision is mostly done due to social, cultural, personal, and religious reasons.(1) - cised.(2,3) World Health Organization has introduced medical male circumcision as a human (4) Nevertheless, inadequate funding and concerns about the safety of the surgical procedure, as well as diverse - tance to circumcision. Many various methods can be used for circumcision, but the two commonly used are the sleeve technique and use of the Plastibell® device. With the sleeve tech- nique, the skin edges are approximated by interrupted stitches using non-absorba- ble suture materials. The main disadvantage of this method is unsatisfactory cos- mesis.(5,6) On the other hand, proximal migration of the Plastibell® ring, due to use of an inappropriate size, may occur causing serious penile injury.(7) For the skin closure in sleeve technique, the long chain derivatives of cyanoacr- toxicity and good bonding strength.(6,8) Corresponding Author: Mohammad Reza Safa- rinejad, MD P.O. Box 19395-1849, Tehran, Iran Tel: +98 21 2245 4499 Fax: +98 21 2245 6845 E-mail: mersa_mum@ hotmail.com Received May 2011 Accepted November 2011 1 Urology Research Center, Guilan University of Medi- cal Sciences, Rasht, Iran 2 Private Practice of Urol- ogy and Andrology, Tehran, Iran Point of Technique 424 | Point of Technique available in every community. Furthermore, cost USD for each patient. Technique of sutureless circumcision, compared to the standard closure using interrupted sutures, has - ter postoperative appearance, parental satisfaction, diminished operative time.(6,9-11) To promote large population-based circumcision syndrome, an easy, safe, cost-effective, and cos- metically acceptable technique can be helpful. To the best of our knowledge, there have been no re- ports of pediatric sutureless circumcision without auxiliary measure for the skin closure. CASE REPORT children were circumcised by the same surgeon. The indication for circumcision was ritual causes and none of our subjects had phimosis or other conditions, such as urinary tract infection or repeti- tive balanoposthitis. The study was approved by the Medical Ethics - ences and all the parents of the children involved signed an informed consent allowing their child to participate. TECHNIQUE Seventy-one surgeries were performed under gen- eral anesthesia, due to parental preference, and 55 children underwent local anesthesia with dor- foreskin was completely retracted, freeing the ad- hesions from the glans. Thereafter, the skin was marked circumferentially with a surgical pen to af- ford a suitable tissue apposition. Mosquito forceps were applied to the tip of the foreskin ventrally and dorsally, and the foreskin was protracted. A straight Figure 2. The foreskin is incised below the forceps using a scal- pel blade through the skin and dartos fascia to the inner mucosa. Figure 1. A straight forceps has been applied over the marked line above the glans. Figure 3. A dorsal slit is made through both layers of the pre- puce back to the incision line of the skin. 425Vol. 9 | No. 1 | Winter 2012 |U R O LO G Y J O U R N A L Sutureless Circumcision | Asgari et al forceps was applied over the marked line above glans was not caught within the forceps. The fore- skin was incised below the forceps using a scalpel blade through the skin and dartos fascia to the in- ner mucosa (Figure 2). Thereafter, a dorsal slit was made through both layers of the prepuce back to the incision line of the skin, and inner mucosa was trimmed with scissors, leaving an adequate mu- cosal cuff (Figure 3). electric cauterization. Furthermore, meticulous he- mostasis was secured with electric cauterization or - sels if necessary. Particular attention was paid to provide complete hemostasis at the frenulum. The incision was then cleansed, and the skin edges were aligned by upward moving of the penile shaft skin from its usual place below the incision to ap- pose the distal mucosal collar. The edges of inci- sion were not closed with sutures, and tissue–glue was not applied (Figure 4). No dressing was used. - vent the raw and sensitive tissue from sticking to clothing. To prevent the repair from adhering to the glans or penile shaft skin, antibiotic ointment was applied to the wound for 1 week. Parents whose boys were still in diapers were instructed to leave the penis exposed at convenient times. The chil- dren were allowed to bathe after 72 hours as their usual habit after discharge from the hospital. The duration of the circumcision was recorded by the circulating nurse, since the penile block or fore- skin retraction until the covering was done. After the operation, the children were sent home with a prescription of acetaminophen every 6 hours on the day of the surgery and on the following days only if necessary. Parents were told to return to the hospital at any time if anything unusual occurred. and at 12 months after the surgery. The following parameters were addressed: wound infection, de- hiscence, hemorrhage, and cosmetic appearance. All parents completed a non-validated satisfaction survey (Appendix). Data were expressed as mean ± standard deviation. RESULTS The mean age of the children was 36 ± 11 months (range, 4 months to 6 years). The mean operating Figure 4. The edges of incision have not been closed with sutures, and tissue–glue has not been applied. Figure 5. Six-month post-operative result. 426 | - dren, after excision of the prepuce, the skin edges (penile shaft skin and distal mucosal collar) were not apposed spontaneously without traction, and a standard sutured repair was carried out. One-hundred and nine (91.6%) parents were “very - ance and with the operation being carried out as a - dehiscence at ventral aspect 2 to 3 days after sur- - - tory to both patients and surgeons. Other complications included minor postoperative bleeding in 8 (6.7%) subjects, which were man- aged by compressive dressing, and meatal steno- sis in 4 (3.4%), which might be due to extensive diathermy used near the frenulum. Hematoma or bleeding requiring additional intervention did not and abnormal scarring did not happen in any chil- dren, and nearly all the subjects had very good or excellent cosmetic results. Figure 5 shows post- operative condition after 6 months. Parents of 111 (93.3%) children wanted their next son undergo this operation as well. DISCUSSION - quently performed operations with some poten- tial complications. Many surgeons use interrupted chromic or plain catgut sutures to appose the skin edges reapproximation has demonstrated accept- able cosmetic results.(6,12,13) advantages of tissue glue versus sutures for cir- cumcision were compared in 152 boys.(9) Glue was reported a superior cosmetic result following tissue glue approximation, which did not reach statisti- circumcision with tissue glue approximation, there were two postoperative complications of wound dehiscence.(9) The authors concluded that the su- tureless circumcision technique should be reserved for boys under the age of 12 years due to the in- creased risk of wound dehiscence following penile erection. underwent circumcision with tissue glue and 46 boys underwent circumcision with suturing; the age range of the patients was 1 to 11 years. The cosmetic results of the two groups were compa- rable. Furthermore, the incidence of bleeding and infection was similar.(12) - dian length of surgery with tissue glue application was longer than conventional suturing; however, this has not been reported in other studies. most recent systematic literature review, Lane and associates concluded that sutureless circumcision the standard closure technique, using interrupted sutures.(11) including bleeding, infection, dehiscence of the wound, meatal stenosis, cosmetic failure due to abnormal scarring, penile injury, such as glanular necrosis and glans and penis amputation, and ure- (14-16) Bleeding can occur at a variety of points during circumcision and typically happens at the frenulum as apposed to the preputial excision line. This com- plication can be reduced by adequate hemostasis during surgery using bipolar electrocautery and su- ture ligature. The reported rate of bleeding as the early complication of circumcision was between (17) - ported acute bleeding after circumcision in 24% of their patients.(18) However, Wiswell and colleagues Point of Technique 427Vol. 9 | No. 1 | Winter 2012 |U R O LO G Y J O U R N A L reported excessive bleeding in 3 out of 478 boys who underwent circumcision beyond the neonatal period.(19) With this technique, meticulous hemo- stasis has outmost importance, because bleeding can be worrisome for parents and the child may require re-operation. To avoid the bleeding, we bleeding occurred in 8 (6.7 %) patients within few hours after the operation and all of them were man- aged by compressive dressing. Tissue adhesives have some complications, es- circumcisions using tissue glue, meticulous skin edges apposition is important, since insertion of tissue glue into the skin edges can slow the heal- ing process and may result in a foreign body re- action. tissue glue can be challenging and may result in unwanted adherence of the incision to the glans or penile shaft.(6) releasing, it is mandatory to take away any forceps prior to polymerization of tissue adhesives. Us- ing tissue glue in children with hidden penis, even partial, can lead to unwanted complications.(6) El- more and associates recommended that tissue glue should not be used by those who depend on sutures to manage unsatisfactory skin edge apposition or for hemostasis.(6) Recent data stating that circumcision confers sig- raised considerable interest in the procedure.(21,22) - veloped countries, mainly in sub-Saharan Africa, where usually medical resources are very limited and the parents have to pay for circumcision. chromic suture costs about 7 USD. Furthermore, longer operating time is required for wound clo- the mean time taken for circumcision was about 7 minutes. Elmore and colleagues reported that of 7 minutes per case.(6) Therefore, it represents a operating time might reduce the circumcision cost. Therefore, cost-effectiveness, time savings, and acceptable results make this method very suitable in some communities. - naire to accurately evaluate parental satisfaction with circumcision results. However, the results from non-validated postoperative questionnaire used in the present study indicated very good or excellent parents’ satisfaction. was being performed by traditional method with- out suturing to appose the skin edges. Nowadays, in our country, there are millions of middle-aged men who have been circumcised with the above- mentioned traditional method with very good or excellent cosmetic results. This was the rational for performing the present study. To the best of our knowledge, sutureless circum- cision without using tissue glue has not been re- ported previously. Sutureless circumcision without wound closure appears to be a reliable, cost-ef- fective, and safe method of circumcision that sig- provides very good or excellent cosmetic results and can be recommended for some communities. CONFLICT OF INTEREST None declared. REFERENCES 1. Schoen EJ. The status of circumcision of newborns. N Engl J Med. 1990;322:1308-12. 2. Elder JS. Circumcision—Are You With us or Against us? J Urol. 2006;176:1911. 3. Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpa- tient sample. J Urol. 2005;173:978-81. Sutureless Circumcision | Asgari et al 428 | 20. Edmonson MB. Foreign body reactions to dermabond. Am J Emerg Med. 2001;19:240-1. 21. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007;369:643-56. 22. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005;2:e298. 4. WHO/UNAIDS technical consultation on male circumcision and HIV prevention: research implications for policy and programming. Mar, pp. 6–8. Available at: http://data.unaids. org/pub/Report/2007/mc_recommendations_en.pdf. 5. Petratos PB, Rucker GB, Soslow RA, Felsen D, Poppas DP. Evaluation of octylcyanoacrylate for wound repair of clinical circumcision and human skin incisional healing in a nude rat model. J Urol. 2002;167:677-9. 6. Elmore JM, Smith EA, Kirsch AJ. Sutureless circumcision using 2-octyl cyanoacrylate (Dermabond): appraisal after 18-month experience. Urology. 2007;70:803-6. 7. Bode CO, Ikhisemojie S, Ademuyiwa AO. Penile injuries from proximal migration of the Plastibell circumcision ring. J Pediatr Urol. 2010;6:23-7. 8. Kamer FM, Joseph JH. Histoacryl. Its use in aesthetic fa- cial plastic surgery. Arch Otolaryngol Head Neck Surg. 1989;115:193-7. 9. Subramaniam R, Jacobsen AS. Sutureless circumcision: a prospective randomised controlled study. Pediatr Surg Int. 2004;20:783-5. 10. Arunachalam P, King PA, Orford J. A prospective comparison of tissue glue versus sutures for circumcision. Pediatr Surg Int. 2003;19:18-9. 11. Lane V, Vajda P, Subramaniam R. Paediatric sutureless cir- cumcision: a systematic literature review. Pediatr Surg Int. 2010;26:141-4. 12. Cheng W, Saing H. A prospective randomized study of wound approximation with tissue glue in circumcision in children. J Paediatr Child Health. 1997;33:515-6. 13. Zafar F, Thompson JN, Pati J, Kiely EA, Abel PD. Sutureless circumcision. Br J Surg. 1993;80:859. 14. Harrison NW, Eshleman JL, Ngugi PM. Ethical issues in the developing world. Br J Urol. 1995;76 Suppl 2:93-6. 15. Ceylan K, Burhan K, Yilmaz Y, Can S, Kus A, Mustafa G. Se- vere complications of circumcision: an analysis of 48 cases. J Pediatr Urol. 2007;3:32-5. 16. Johnson PV. Childhood circumcision. Surgery. 2008;26:314- 16. 17. American Academy of Pediatrics, Task Force on Circumcision. Circumcision policy statement Pediatrics 1999;103:686-93. 18. Ben Chaim J, Livne PM, Binyamini J, Hardak B, Ben-Meir D, Mor Y. Complications of circumcision in Israel: a one year multicenter survey. Isr Med Assoc J. 2005;7:368-70. 19. Wiswell TE, Tencer HL, Welch CA, Chamberlain JL. Circum- cision in children beyond the neonatal period. Pediatrics. 1993;92:791-3. Point of Technique APPENDIX Non-validated parents’ questionnaire used at follow-up evalu- ation 12 months postoperatively. 1. Are you pleased with the results of the circumcision/surgery? Very satisfied Moderately satisfied Satisfied Dissatisfied Very dissatisfied 2. How would you evaluate this technique? Excellent Very good Good Fair Negative 3. Would you like your next son undergo this operation? Yes No