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  • Circumcision in the adult

    About the authors: Timothy Byler, MD and Oleg Shapiro, MD

    Oleg Shapiro, MD

    Dr. Oleg Shapiro completed his medical education and residency at SUNY Upstate Medical University, Syracuse, NY where he stayed on as staff. His primary focus is the treatment of urologic cancers and stone disease.

    Link to Dr. Shapiro’s website page at Upstate Medical University

    Surgeon Oleg Shapiro MD performs circumcision in the adult male.

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    Urology Book editorial

    We are grateful for Dr. Shapiro and Byler’s submission of this chapter to Urologybook.com. While adult circumcision is on the less complex end of the spectrum in technical difficulty, it is one of the more common urologic procedures performed.

    Introduction

    Circumcision has been a part of human life for centuries.  Perhaps the oldest known definitive reference comes from ancient Egypt hyroglyphics1.  In the US, neonatal circumcision rates fluctuate but have been consistently between 55-65% of male live births for the past 20 years2.  The World Health Organization estimates that 30% of the world’s male population is circumcised3. While the most common indication remains personal preference2, whether it is religious or personal, there has been recent data to support circumcision for extended medical indications.

    Medical Indications

    Classically, medical indications for circumcision include balanitis, phimosis, tumor of the foreskin and paraphimosis.  Recent data supports extended indications which are still controversial.  Penile cancer is often linked to hygiene and occurs almost exclusively in uncircumcised men4.  There have been no randomized data to support circumcision to prevent this rare carcinoma.Three randomized controlled studies conducted in Africa all showed decreased HIV transmission among circumcised men5,6,7.  The incidence of febrile urinary tract infection is ten times higher in uncircumcised infants8.

    Contraindications

    The main contraindications are congenital penile anomalies.  The hypospadias complex should always be evaluated prior to any circumcision.  If a patient has a displaced urethral meatus or chordee, the prepuce may be used as preputial flap to repair the defect.  Active infection and bleeding disorders should be sought prior to any intervention.

    Patient Position  

    Supine

    Procedure Steps for adult circumcision

    After appropriate antibiotic coverage and surgical prepping, the procedure begins with incision marking.

    To stimulate an erection, pressure is applied to the base of the penis and the corona is marked 1 – 1.5 centimeters through the foreskin circumferentially.  The penis is then used as a backboard applying gentle pressure to place tension on the incision line.  This facilitates easy separation of the skin layers as the incision is made.  This dissection is carried down through the dermis and into the connective tissues until separation of the skin edges is obtained.  It is our preference to use gauze to retract these edges to obtain a better grip while incising the tissue.

    Once the outer layer is incised, the foreskin is retracted to reveal the skin proximal to the glans.  Another marking line is made 1cm below the corona.  An incision is then made through the dermis with careful attention not to violate the underlying corporal body or urethra.  At this point, a sleeve has been formed that needs separation from its underlying connective tissue.  Four clamps are used to grasp the sleeve dorsally.  The sleeve is then transected between these clamps and electrocautery is used to separate the remaining connective tissue from the foreskin.  Meticulous control of bleeding is then controlled by picking up each bleeding area and applying electrocautery.

    The skin is then approximated with a 4-0 vicryl or chromic suture.  It is our preference to place a horizontal mattress suture at the frenulum for hemostasis.  Anapproximation stitch is then placed dorsally to aid in closure.  These can be left longer and clamped to aid in suturing.  Two running sutures are placed between the two anchoring sutures.   When placing these stitches, it is important to watch for rolling of the skin under the running suture which can be prevented by taking smaller amounts of tissue on the skin edge.   A frenuloplasty will often be evident at this point and overlapping skin on the frenulum should be excised for cosmesis.   Several interrupted sutures are placed at the frenulum to approximate it and stop any bleeding.

    A dorsal block can be performed before or after the procedure for pain control.  A needle is passed through the suspensory ligament at the base of the penis toward the dorsal penile nerves.  Aspiration to confirm a non-intravascular location should be done with subsequent injection.  It is our preference to also do a ring block by infiltrating the skin at the base of the penis circumferentially with local anesthesia as well.  The suture line is then covered in bacitracin and a Vaseline gauze dressing.  A loose fitting circumferential bandage is then applied.

    The 1 inch Kerlix wrap of the area is left loosely on for 2 days.  During this time, the patient should not let the area get wet.  Sexual intercourse should be avoided for at least 2 weeks.

    Complications

    The most common complications include post-operative bleeding and infection.  In a recent meta-analysis of 5, 228 circumcisions, these complications both occurred at roughly 1.5% of the cohort9.

    In review of the South African complications, an overall complication rate of 3.6% was found with the most common being pain followed by bleeding5.  Other complications include wound breakdown, delayed healing, penile damage, removal of too much or too little foreskin, difficulty voiding and undesirable cosmesis.  The rare but serious complications include penile amputation, glans injury and damage to the penile shaft.

     

    References

    1.  Smith GE.  Circumcision in Ancient Egypt.  Br Med J. 1910 January 29; 1(2561): 294.

    2.   Circumcisions Performed in U.S. Community Hospitals, 2012.  Statistical Brief # 126.Healthcare Cost and Utilization Project.  February.

    3.  World Health Organization/UNAIDS.  Male Circumcision:  Global trends and determinants of prevalence, safety, and acceptability.  2008.  Geneva, World Health Organization.

    4.  Wein A, Kavoussi L, Novick A, Partin A, and C Peters.  Campbell-Walsh Urology.Nineth Edition.Philadephia:  Saunders Elsevier; 2007.  Chapter 31, Tumors of the Penis; p 965.

    5.  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 Nov;2(11):e298

    6.   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 Feb 24;369(9562):643-56.

    7.  Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007 Feb 24;369(9562):657-66.

    8.  Rushton HG and M Majd.  Pyelonephritis in male infants:  how important is the foreskin?  J Urol 1992 Aug; 148, 733-736.

    9.  Perena CL, Bridgewater FHG, Thavaneswaran P, and GJ Maddern.  Safety and Efficacy of Nontheraputic Male Circumcision:  A Systematic Review.  Annals of Family Medicine 8; January/February 2010; 64-72.