Fall 2012 - 08.pdf 700 | Adult Male Circumcision Performed with Plastic Clamp Technique in Turkey Results and Long-Term Effects on Sexual Function Ferda M. Senel,1 Mustafa Demirelli,2 Fatih Misirlioglu,3 Tezcan Sezgin4 Purpose: To evaluate the long-term results of adult circumcisions performed by plastic clamp Materials and Methods: A total of 186 adult males with the mean age of 21.2 ± 2.8 years who presented to our clinic for circumcision between February 2007 and January 2010 were included in the study. Safety and acceptability of circumcision with plastic clamp technique as well as its (range, 12 to 52 months). Results: The mean duration of circumcision and removal of the clamp were 3.1 ± 1.1 minutes and 16 ± 7 seconds, respectively. The total complication rate was 2.15%. Wound dehiscence (1.07%), infection (0.54%), and bleeding (0.54%) were the encountered complications. Complete wound healing was observed at a mean of 25.5 ± 4.6 days. We did not encounter any penile deformity or - - tion improved following circumcision. Conclusion: Circumcision performed by plastic clamp technique in adult males had a low early functions. We suggest the utilization of this technique as an easy and a safe way of circumcising adult males. Keywords: Corresponding Author: Ferda M. Senel, MD Department of Pediatric Urology, Dr.Sami Ulus Women’s and Children’s Hospital, Ornek Mahal- lesi, Babur Caddesi, No.44, Altindag, Ankara, Turkey Tel: +90 312 305 6418 Fax: +90 312 3170353 E-mail: mfsenel@yahoo. com.tr Received September 2011 Accepted February 2012 1Department of Pediatric Urology, Dr.Sami Ulus Women’s and Children’s Hospital, Ankara, Turkey 2Elif Circumcision Clinic, Ankara, Turkey 3Department of Anes- thesiology, Dr.Sami Ulus Women’s and Children’s Hospital, Ankara, Turkey 4Department of Urology, Bitlis Government Hospital, Bitlis, Turkey MISCELLANEOUS Miscellaneous 701Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L Circumcision with Plastic Clamp | Senel et al INTRODUCTION M ale circumcision is the oldest surgical procedure with a history of at least 15000 years and has been described in ancient Egyptian papyri dat- ing 4000 BC.(1) Currently, it is estimated that one out of three males worldwide is circumcised.(2) Circumcision is mainly performed for religious reasons in our country to every Mus- lim male at an average age of 7 years.(3) At some rural areas of Turkey, children may not have the opportunity to get cir- cumcised until their adulthood due to low socio-economic status as well as the lack of adequate number of health pro- fessionals. Adults are usually circumcised during the military service or local mass circumcision campaigns. In the current study, the results of male circumcision per- formed by a medical team utilizing plastic clamp technique in our country were analyzed, and the early and late com- function were investigated. MATERIALS AND METHODS Subjects A total of 186 adult males with the mean age of 21.2 ± 2.8 years who presented to our clinic for circumcision be- tween February 2007 and January 2010 were included in the study. Males with history of bleeding disorder, severe allergy, and genital anomalies, such as hypospadias, micro- from each participant. A questionnaire, including patients’ characteristics, such as age, marital status, education level, and the city they live, - ual function (Table 1). Additionally, a pain scale chart and a questionnaire regarding the daily activities and satisfac- tion from the procedure were asked to be completed by the circumcised males. The advisability of the procedure to uncircumcised males was accepted as the main criteria for overall satisfaction from the circumcision. Males were called for weekly follow-up visits for 6 weeks postopera- tively in order to observe the status of wound healing. All of the 186 circumcised males were invited for a follow- up visit between January and March 2011 to investigate the - - penis, and skin bridge between the glans and the penile shaft. Furthermore, males were asked to complete a ques- Technique All the males were circumcised with the plastic clamp technique using Alisklamp, which consists of an inner tube and an outer ring in various sizes (Figure 1). Initially, the an appropriate size of inner plastic tube was placed. The retracted foreskin was then pulled over the inner tube, and the second outer plastic ring was placed over the foreskin and locked. The foreskin which was squeezed between the A to C). The apparatus was safely removed without any complica- tion after a mean of 5 ± 1.1 days following the circumci- sion. The mean duration of circumcision procedure and removal of the clamp were 3.1 ± 1.1 minutes and 16 ± 7 seconds, respectively. Analysis The analysis of the early complications, such as bleeding, wound infection, and wound dehiscence was performed on 186 males. Of the 186 circumcised males, 142 (76.3%) came to the late follow-up visit in 2011, and the remain- Figure 1. Alisklamp consists of an inner tube which is placed over the glans penis and an outer ring placed over the tube. Depending on circumference of the glans, clamp sizes vary between 20 to 34. 702 | Miscellaneous - fore, the analysis of late complications and assessment of (4) The BMSFI scores obtained before and after circumcision were com- pared by paired t - cepted as P < .05. RESULTS The total complication rate was 2.15%. Wound dehiscence, the most common complication, which occurred in two (1.07%) men. Bleeding was encountered in one (0.54%) and wound infection in one (0.54%) man. Complete wound and total appearance of the incision line, was achieved at a mean of 25.5 ± 4.6 days (Figure 3). Of the 186 men, 86% reported little or no disruption of sleep at the night of circumcision. After 7 days following circumcision, there was no disruption of the sleep reported by any of the men, and normal daily activities with no dis- ruption were achieved at a rate of 99.5%. Of the 186 men, 181 (97.63%) stated that they would recommend plastic clamp method to the uncircumcised men. The mean follow-up period was 30.4 months (range, 12 to Figure 2. A) Foreskin is retracted completely to expose the glans, and an appropriate size of inner plastic tube is placed. Follow- ing the placement of the inner tube, retracted foreskin is pulled over the inner tube; B) Second outer plastic ring is placed over the foreskin and locked; C) Adequate amount of the foreskin is squeezed between the inner tube and the outer ring, then ex- cised with a surgical blade. A B C Figure 3. Complete wound healing is defined as disappearance of the crusts and total appearance of the incision line. 703Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L Circumcision with Plastic Clamp | Senel et al 52 months) for the 142 men who came to the visit in Janu- ary 2011 (Table 1). During the follow-up period, there was a slight difference in the marital status. Of the 142 men, 14 (18.3%) were married at the time of circumcision. During the follow-up period, 3 were devorced and 15 got married. The number of married men was 26 (24.6%) at the end of the study (Table 1). Among the 142 men, we did not encounter any penile de- formity or any long-term complications, such as urinary and ejaculatory functions adversely. It was observed that long-term post-circumcision BMSFI scores for erection, problem assessment, and overall satisfaction rates were sig- DISCUSSION The popularity of adult male circumcision has remarkably increased following a study conducted in Africa, which (5) Following this report, various studies mainly held in Africa were conducted to assess the safety of adult male circumci- sion. Complication rate as high as 35.2% was reported in a study where circumcisions were performed by traditional prac- titioners utilizing the conventional dissecting technique. (6) In another study performed in Africa where all circum- cisions were performed by general practitioners at their reported among HIV-negative and HIV-positive males.(7) In our previously reported study, we have also obtained a complication rate of 10.4% in those who were circumcised by conventional dorsal slit technique.(3) These data show that the conventional surgical technique carries high risk of practitioners. Results of the current study show that the overall complica- tion rate is reduced to 2.15% when a plastic clamp tech- nique is utilized. Furthermore, we did not encounter any penile deformity or any long-term complications with this technique. Plastic clamp method is shown to simplify the circumcision, shorten its duration, and reduce the compli- cation rate by eliminating the need for suturing and dress- ing. Easy application and short duration are very important advantages, especially if large number of men are planned to be circumcised. Bleeding and infection are considered as uncommon com- plications of the plastic clamp technique while they are sig- to a rate of 5%.(3) In the current study, bleeding occurred Table 2. Brief male sexual function inventory scores of 142 men before and after circumcision. Parameters Before After p Sexual drive 7.2 ± 0.8 7.4 ± 0.6 .2 Erection 9.5 ± 0.7 10.3 ± 0.4 .01 Ejaculation 6.9 ± 0.8 7.1 ± 0.5 .45 Problem assessment 10.1 ± 0.4 11.5 ± 0.8 .02 Overall satisfaction 3.1 ± 0.2 3.9 ± 0.6 .01 Table 1. Background characteristics and follow-up periods of 142 men included in the late follow-up survey. Variable n % Age, y 18 to 20 69 (48.6) 21 to 23 46 (32.4) ≥ 24 27 (19) Mean 21.2 Education level Primary School 28 (19.7) High School 82 (57.8) University 32 (22.5) Marital Status Married 26 (18.3) Non-married 116 (81.7) Location Ankara 114 (80.3) Outside the city 28 (19.7) Follow-up period, mo 1 to 24 35 (24.6) 25 to 36 47 (33.1) 37 to 48 49 (34.5) > 48 11 (7.8) Mean 30.4 704 | Miscellaneous in one man within 24 hours following the removal of the clamp, which was conservatively managed. Infection after circumcision is an important concern, especially if per- formed outside the hospital, reaching to a rate of 10%.(8) Infection rate was found to be 2.7% in a study where 700 men were circumcised during a 5-day period by a medi- cal team utilizing conventional method.(9) In our study, the infection rate was 0.54%, which is remarkably lower than the previously reported rates. The low bleeding and infec- tion rates observed after plastic clamp technique make this technique a safe procedure for circumcising large number of adult males. Plastic clamp technique appears to have remarkably lower complication rates compared to other minimally-invasive circumcision devices. Among the similar devices, common- ly used plastibell apparatus is not removed and is let to fall off spontaneously. The mean fall-off duration is 8.7 days among infants whereas after 12 months age, the fall-off pe- riod goes up to 13.4 days.(10) Due to this reason, plastibell is generally not recommended above the age of one year. The most commonly observed complication with the plastic clamp technique observed in our study was wound dehis- cence which occurred at a rate of 1.07%. However, this is remarkably less then the reported rate of wound dehiscence, which was 3% among the 534 adult males circumcised by using another minimally-invasive device consisting of two concentric plastic rings.(11) In the current study, the distance of wound edges was less than 4 mm and no bleeding was - tion. The lower incidence of wound dehiscence observed in our study can be contributed to the anatomically adjusted design of the clamp. The inner plastic tube is well-adjusted to the curve of the penile glans; thus, leaving more skin and mucosa on the ventral part, which reduced the tension on the skin during erection. A similar minimally-invasive circumcision apparatus consisting of an inner tube and an outer ring has also been reported to enable circumcisions safely and easily.(12) However, high risk of adverse events related to use of this apparatus has been reported, and a strong caution against the use of this method on young adults has been suggested.(13) In our study, normal daily activities were achieved at a rate of 89% even on the 1st post-circumcision day. Our data show that the Alisklamp technique seems to be a safe alternative to other current minimally-invasive circumcision devices. Results of our study showed that circumcision did not - sulted in improvement in erection, problem assessment, and overall satisfaction. In a study which investigated the was mailed to 123 men and responses were received from only 43.(14) The authors concluded that adult circumcision sensitivity. On the other hand, a prospective study compar- ing BMSFI scores before and after circumcision concluded function.(15) In a recent study that assessed the pudental evoked potentials in adults before and at least 12 weeks af- ter the circumcision, it was concluded that the circumcision evoked potentials latency.(16) The ejaculatory latency time in a study performed on 42 adults.(17) In our previous study and quality of erection as well as status of libido, erectile function was intact in all adults following circumcision.(18) The mean follow-up period was short (10 days) and none of the patients initiated intercourse within this period. were assesed seperately in a prospective design. Further- more, current study included larger number of men and considerably longer follow-up period compared to our pre- - regarding erection, problem assessment, and overall satis- faction in the current study. The lower socio-cultural level of the men, which caused from follow-up could be limitations of our study. Neverthe- less, our study still seems to bear one of the largest sample size among studies investigating the long-term effects of 705Vol. 9 | No. 4 | Fall 2012 |U R O LO G Y J O U R N A L Circumcision with Plastic Clamp | Senel et al CONCLUSION Circumcision with plastic clamp technique did not adverse- improvement in erectile function and overall satisfaction. The ease of application, low early complication rates, ab- scence of long-term complications, and high satisfaction ratio make the Alisklamp technique an acceptable, safe, and important alternative for adult male circumcision, especial- ly for the regions where large number of males are planned to be circumcised. CONFLICT OF INTEREST None declared. REFERENCES 1. Bhattacharjee PK. Male circumcision: an overview. Afr J Paediatr Surg. 2008;5:32-6. 2. WHO/UNAIDS. Neonatal and child male circumcision: a global review; ISBN 978 92 9 3. Senel FM, Demirelli M, Oztek S. Minimally invasive circumci- sion with a novel plastic clamp technique: a review of 7,500 cases. Pediatr Surg Int. 2010;26:739-45. 4. O'Leary MP, Fowler FJ, Lenderking WR, et al. A brief male sexual function inventory for urology. Urology. 1995;46:697-706. 5. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a ran- domised controlled trial. Lancet. 2007;369:643-56. 6. Bailey RC, Egesah O, Rosenberg S. Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya. Bull World Health Organ. 2008;86:669-77. 7. 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. 8. Williams N, Kapila L. Complications of circumcision. Br J Surg. 1993;80:1231-6. 9. Ozdemir E. Significantly increased complication risks with mass circumcisions. Br J Urol. 1997;80:136-9. 10. Samad A, Khanzada TW, Kumar B. Plastibell circumcision: a minor surgical procedure of major importance. J Pediatr Urol. 2010;6:28-31. 11. Peng YF, Cheng Y, Wang GY, et al. Clinical application of a new device for minimally invasive circumcision. Asian J Androl. 2008;10:447-54. 12. Schmitz RF, Abu Bakar MH, Omar ZH, Kamalanathan S, Schulpen TW, van der Werken C. Results of group-circumci- sion of Muslim boys in Malaysia with a new type of dispos- able clamp. Trop Doct. 2001;31:152-4. 13. Lagarde E, Taljaard D, Puren A, Auvert B. High rate of ad- verse events following circumcision of young male adults with the Tara KLamp technique: a randomised trial in South Africa. S Afr Med J. 2009;99:163-9. 14. Fink KS, Carson CC, DeVellis RF. Adult circumcision out- comes study: effect on erectile function, penile sensitivity, sexual activity and satisfaction. J Urol. 2002;167:2113-6. 15. Collins S, Upshaw J, Rutchik S, Ohannessian C, Ortenberg J, Albertsen P. Effects of circumcision on male sexual func- tion: debunking a myth? J Urol. 2002;167:2111-2. 16. Senol MG, Sen B, Karademir K, Sen H, Saracoglu M. The effect of male circumcision on pudendal evoked potentials and sexual satisfaction. Acta Neurol Belg. 2008;108:90-3. 17. Senkul T, Iser IC, sen B, KarademIr K, Saracoglu F, Erden D. Circumcision in adults: effect on sexual function. Urology. 2004;63:155-8. 18. Senel FM, Demirelli M, Pekcan H. Mass circumcision with a novel plastic clamp technique. Urology. 2011;78:174-9.