Circumcision
Circumcision is among the most commonly performed urologic surgeries. Historically, it is also one of the oldest and at times controversial procedures. Indications include religious rite, social habit, and medical treatment and prophylaxis. The latter category includes phimosis, paraphimosis, hygiene, and reducing the relative risks for urinary tract infections (UTIs) and sexually transmitted infections.
Removal of the prepuce exposes the tip of the penis and results in a change in the microenvironment of the glans. The glanular epithelium changes from a moist glabrous transitional tissue to a dry tough squamous layer. Changing the surface has been suggested to reduce the risk for UTI by eliminating an otherwise favorable sanctuary for urinary tract pathogens. The tough keratinized surface has recently been shown in a series of randomized controlled studies to have increased the relative resistance to infection by human immunodeficiency virus in adult men.
When planning circumcision in babies, a careful physical examination is necessary to ensure that there are no congenital conditions that preclude circumcision, notably hypospadias. An intact foreskin, a straight shaft with equal ventral and dorsal penile shaft skin length, and a defined penoscrotal junction should all be present. Any irregularities should cause one to reconsider performing the procedure. A careful history should be obtained, with particular attention given to bleeding problems. Informed consent should be obtained, and the possibility of finding a megameatus should be discussed so that there are no surprises.
The genitals are prepped with an iodine-based solution. Anesthetic is administered. In infants, penile block using 1 mL of 1% to 2% lidocaine without epinephrine or 0.25% bupivacaine hydrochloride can be administered using a tuberculin syringe and a fine 26-gauge needle. Topical lidocaine–prilocaine and the cream EMLA have been also used in infants but require application for 15 to 30 minutes for full effect, and the tip of the glans and inner prepuce may not be as fully anesthetized. In older boys and adolescents, general anesthesia is usually preferable. For adult men, local, spinal, and general anesthesia have all been successfully used. Tourniquets may be used in adult patients to assist in hemostasis, but they usually are not necessary.
Sleeve (Double-Incision) Technique
The sleeve incision technique is used in adults and children older than infants.
Retract the foreskin. If the foreskin is fibrotic and does not retract easily, make a dorsal slit. Next take down any adhesions and clean out any accumulated smegma deposits. Using a blunt-tipped curved hemostat and a gauze soaked with iodine prep solution frees up most adhesions without tearing the surface of the glans. Carefully examine the glans and the position of the meatus. At this point, anomalies (e.g., megameatus, true hypospadias with a complete foreskin) can be detected before any incision is made on the shaft or near the glans. This is an important step functionally and from a medical legal standpoint. Completely free and reprep the glans down to the preputial sulcus with iodine prep solution. To divide the frenulum, pass a fine curved Jake clamp underneath the frenulum to create a potential space. Then pass the clamp across the frenulum and clamp for 10 seconds to crush the tissue and achieve hemostasis. Divide the crushed tissue sharply or using electrocautery on a cut setting. Be especially careful when taking down the frenulum not to come too close to the ventral glans. Replace the foreskin. Using a fine-tipped marking pen, trace out the path of the outer incision. It should be at the level of the coronal sulcus.
Retract the prepuce and mark the second inner incision about 0.5 to 1 cm from the edge of the glans. Follow the curve of the glans when marking. A common error is to drift too close to the glans when marking.
Incise along the marked lines using a #15 blade. It does not matter whether the inner incision or the outer one is made first. Use a fresh blade and stretch the skin taut with a dry gauze. Check for hemostasis and control any significant bleeders. Avoid incising the skin too deeply on the ventral surface and injuring the urethra ( Fig. 120.1 ).
A collar of skin should now be isolated between the two incisions. Divide the skin to convert the collar into a long strip of skin ( Fig. 120.2 ). This can be done sharply with a knife or scissors. Electrocautery, if used carefully, can be effective in splitting the skin while minimizing blood loss.
Pick up the edges of the skin and free the skin from the underlying dartos layer. Sharp dissection using scissors or electrocautery can be used to take down these connections. Again establish good hemostasis with judicious use of electrocautery or suture ligature of 5-0 or 6-0 absorbable suture.
Sew the edges of the shaft skin to the new preputial collar using fine absorbable sutures ( Fig. 120.3 ). For infants and children, use a 6-0 suture. For older children and adults, consider 5-0 suture. To prevent torsion of the penile skin, place the first suture dorsally at the 12 o’clock position and the second suture at the 6 o’clock position. Leave the tails long and apply mosquito clamps to help position the penis. In older boys, a second set of stay sutures at the 3:00 and 9:00 o’clock positions can be used, but two stay sutures are usually sufficient. Careful attention to suture placement and try to incorporate some of the underlying subcutaneous tissue to help line up the skin edges and to prevent the possibility of suture tracks. Alternatively, 5-0, 6-0, or 7-0 absorbable sutures may be placed in an interrupted subcuticular fashion to avoid suture tracks. A sutureless technique can be achieved by aligning the skin edges with fine toothed forceps and approximating with application of a surgical skin adhesive such as 2-octyl cyanoacrylate. This technique allows the procedure to be completed more efficiently and affords improved cosmesis. Sutureless circumcision should be avoided in peri- and postpubertal patients because of increased risk of wound dehiscence associated with erections.
A variety of dressings can be applied. Some practitioners apply only bacitracin ointment to the tip of the penis. Others apply Telfa, Tegaderm, gauze, or a skin glue coating.
Alternative Techniques
An alternative technique can be used in small boys and in those whose prepuces cannot be easily retracted.
After anesthesia has been induced and the penis has been prepped, mark the shaft to the level of the coronal sulcus with the prepuce into place. Pick up the prepuce and make a dorsal slit down to the level of the mark ( Fig. 120.4 ). Reprep the glans with iodine prep solution and clear away any smegma and adhesions. Take care not to cut too close to the inner preputial collar.
Work around from the dorsum to the ventrum, taking care at the frenulum to achieve good hemostasis. Reapproximate the edges as described previously.
For families and patients with a medical indication but who wish to keep the foreskin, there are two alternatives. A medical approach uses a steroid ointment such as betamethasone. In mild cases (when the phimotic ring is loose enough to allow the meatus to be visible), steady daily application of a thin coating of the ointment for about 2 weeks can loosen it to the extent that full retraction is possible. Continued use beyond 2 weeks is not recommended because of a lack of efficacy and risk of systemic absorption. If the ointment is not successful or the phimotic ring is simply too tight, a dorsal slit or preputioplasty may be considered.
Gomco Clamp Technique
The Gomco device is one of the oldest and most commonly used devices for neonatal circumcision. Before starting, be sure that all the necessary equipment is available and in good operating condition. Carefully disassemble the Gomco clamp. Check that the baseplate, nut, and bell are in good condition with no sharp edges and that the size marked on the baseplate matches that of the bell.
To minimize pain, the infant may be premedicated 20 to 30 minutes before the procedure with 10 mg/kg of oral acetaminophen and topical EMLA applied to the prepuce and covered with a small Tegaderm dressing to the diaper from absorbing the ointment. After securing the baby in a papoose restraint, prep the genital area with an iodine prep solution and drape in a sterile fashion. Place a local anesthetic block using 1 mL of 1% to 2% lidocaine without epinephrine. Use a 26-gauge needle to infiltrate a ring block around the base of the penis. Always check by aspirating before injecting to avoid accidental intravascular injection. Examine the penis carefully. Most infants will need a 1.1- or a 1.3-cm diameter Gomco bell. Have additional sizes (1.45 cm, 1.6 cm) on hand in case they are needed. Create a dorsal slit, retract the prepuce, and clear away any smegma collections. Be sure the entire coronal margin is visible.
Select the bell large enough to fit over the glans but no larger ( Fig. 120.5, A ). After the bell has been positioned, replace the foreskin over the bell. Be sure that the penile shaft skin is symmetric and even ( Fig. 120.5, B ). Apply the baseplate, drawing the foreskin up evenly through the opening. Be sure that the skin is symmetric and that there are no twists or folds. Applied a clamp and tighten the nut down on the screw. Brace the baseplate when applying the nut so that the penile skin does not twist ( Fig. 120.5, C ).
Leave the clamp on for about 5 minutes to achieve good hemostasis. Do not hurry this step. This time limit is mentioned in the original paper of the device but is often ignored by some practitioners today to their regret. Using a fresh scalpel blade, cut the foreskin against the pole of the bell at the point where it emerges from the baseplate. Use a firm, steady stroke and avoid sawing.
Disassemble the device. Use a curved blunt-tipped hemostat to gently push the crushed hemostatic edge from the bell. Control any bleeding and apply a dressing of copious bacitracin ointment. A surgical adhesive may be applied if desired but is usually not necessary. Never use electrocautery with the Gomco clamp.
Plastibell Technique
The Plastibell method is used exclusively for infants. Obtain informed consent from the guardians. Before beginning the procedure, check that all of the instruments and supplies are available and ready. Oral and topical analgesics may be administered (see section on the Gomco technique ). Carefully place the baby in a papoose restraint. Prepare the glans with iodine prep solution and drape in a sterile fashion. Be fastidious about maintaining asepsis. Place a local anesthetic block in the similar fashion as described earlier in the Gomco section. Mark the level of the coronal sulcus on the shaft of the skin. Dilate the prepuce with a hemostat and check that the urethral meatus is normal. Using a straight hemostat, clamp the prepuce in the dorsal midline about halfway down the corona ( Fig. 120.6 ). Leave the clamp on for about 10 seconds. Divide the crush groove with a fine sharp scissors. This should allow the prepuce to be retracted. Free up any adhesions and clean away any smegma collections using a fine-tipped blunt curved hemostat or a flexible probe. The entire corona should be visible.
Select the correct size Plastibell from the available models. Choose one whose bottom edge of the bell completely covers the corona. Note the location of the groove that will hold the hemostatic ligature ( Fig. 120.7, A ). Draw back the prepuce over the bell and glans. Apply tension using forceps so that the skin mark is at the level of the groove on the bell ( Fig. 120.7, B ).
Tie an absorbable suture (5-0 plain gut) tightly in the groove of the bell. Use a surgeon’s knot to achieve a tight square knot. Cut the prepuce isolated distally with scissors or a scalpel just past the outer groove. Do not use electrocautery. Break off the handle. The remaining ring should naturally fall off in a few days. Otherwise, the parents must contact a physician for urgent removal. In this situation, divide the ring using a bone cutting forceps. Have the guardians apply bacitracin ointment to the tip for 2 weeks.
Revision Circumcision
Residual foreskin : Take down any adhesions and scar bands. Using a pen, carefully mark out the redundant skin and excise in the manner described for the sleeve incision technique.
Concealed or buried penis : Consider approaching this situation like a hidden penis (see Chapter 122 ). Usually this is a result of a dense cicatrix covering over the penis. After exposing the glans, deglove the penis and allow the penis to straighten out. Redistribute the skin to cover the ventral and dorsal shaft. Try to align the suture lines to maintain symmetry and to allow the scar to resemble the natural raphe and skin creases. These situations have to be individualized given the availability of skin.
Shaft and prepuce disparity: Sometimes the original circumcision was uneven and there is marked disparity of the shaft skin and glans. When this occurs, try degloving the penis and redistributing the skin. Place the first few sutures dorsally and ventrally and work the excess tissue laterally where it can be trimmed away and closed. When the ventral side is shortchanged, perform a vertical cut on the dorsal shaft skin to allow enough skin to rotate ventrally, as in the creation of Byars flaps for hypospadias repair. Another method is to make a careful transverse or inverted V incision at the penoscrotal junction. Deepen and fully mobilize the skin edges and then close it in a vertical fashion. This Heineke-Mikulicz approach can free up another 1 to 2 cm of ventral length and will redefine the penoscrotal junction.
Phimosis postcircumcision : A dorsal slit is the simplest and most expedient procedure, but it is often simpler to remove the constricting skin and just revise the circumcision. Be suspicious, however, of patients with unusual scarring after surgery. They may have an unappreciated skin disorder such as balanitis xerotica obliterans.
Postoperative Problems From Circumcision
The most important complication is failure to recognize hypospadias . Repair of hypospadias after the foreskin has been removed is more difficult and is an avoidable problem. Necrosis of shaft skin and the glans may occur if epinephrine is used when infiltrating a local block or if electrocautery is used injudiciously. Never use electrocautery when performing neonatal circumcision involving the Plastibell or Gomco devices. Always be sure that when using the Plastibell that the guardians bring the baby back within 1 week to be sure the ring has fallen off. If left on too long, the ring deforms the glans.
Laceration of the glans or amputation of the tip of the glans can occur if one of the older blind circumcision techniques is used. It is also seen as a complication of circumcision devices such as the Mogen clamp. Immediate reanastomosis of the glans is usually successful.
Bleeding can occur along the edge of the incised skin, from penetrating vessels on the shaft or from the frenulum. Direct pressure, suture ligature, and the very careful use of fine needle-point electrocautery should be able to control nearly all cases. Be suspicious of bleeding disorders when infants and young children have intra- or postoperative bleeding problems. When using the Plastibell or Gomco devices, be sure that the device is applied correctly. The Gomco clamp should be applied for at least 5 minutes for its full hemostatic effect.
Infections are rare. Localized infections can be treated with topical and oral antibiotics and drainage. Systemic infections, including Fournier gangrene, have been reported but fortunately are exceptionally rare. Aggressive therapy with parenteral antibiotics and debridement of necrotic tissue are needed.
Separation of the circumcision seam can occur but usually resolves well. When it occurs within the first week of life, it usually heals spontaneously with excellent cosmesis. The treatment is typically copious amounts of antibiotic ointment on the tip and careful observation. Skin grafting and surgery are not advised.
Redundant residual foreskin can occur when an insufficient or uneven amount of foreskin had been resected. Treatment is usually a revision circumcision.
Adhesions usually result from residual foreskin clinging to the lower edge of the glans. These can be either peeled back or resected as part of a revision circumcision. Skin bridges or bands can occur when a narrow web of skin grows from the circumcision seam onto the glans. These create pockets of dead space into which smegma and other debris can accumulate. Treatment involves sharply taking down these bands flush against the glans and penile shaft.
Penile torsion and chordee can occur if there is a disparity or twist in the shaft skin. The usual treatment is to take down the penile shaft skin and try to correct the imbalance. Glanular division can occur during the vertical slitting of the foreskin. Taking down preputial adhesions before cutting and awareness of this complication are the key points in prevention. Treatment is primary repair and closure over a catheter if the urethra is involved.
Inclusion cysts can occur when portions of the skin become entrapped during closure. The buried space lined with skin over time fills with smegma and debris. Treatment is excision of the cyst and its lining. Urethral injuries and urethrocutaneous fistula can occur when sutures used to control bleeding inadvertently catch the urethra or when the ventral incision is too deep and enters the urethra. Treatment is primary closure. When the fistula is close to the glans tip, it is preferable to split the glans down to the fistula and recreate the distal urethra using a hypospadias technique. Urinary retention can occur because of secondary phimosis or overly tight dressing. Suture tracks occur when the paths of the dissolving sutures do not collapse but become keratinized tunnels. The tracks fill with lint and other debris, giving the appearance of small dark spots and streaks. Treatment is unroofing these tracks sharply. To prevent the development of these tracks, inverted buried closure has been advocated. Meatal stenosis has been identified as a long-term possible complication of neonatal circumcision. Up to 7% of circumcised neonates later developed meatal stenosis.
Uncircumcision (Lynch and Pryor)
Make a circumferential incision along the base of the penis. Place four stay sutures symmetrically on the mid to upper penile shaft skin. Mobilize under the penile shaft skin. Deglove the penis in reverse; head toward the glans rather than the usual base. Make four small evenly spaced circumferential incisions and tag with marking sutures. These will define the new preputial opening. Using the stay sutures, pull the shaft skin upward, thereby creating a neoprepuce. Close the four small incisions vertically to help narrow the caliber of the opening. ( Fig. 120.8, A ). Elevate a midline full-thickness skin flap from the scrotum approximately the size of the defect on the lower shaft. Raise the flap keeping the dartos pedicle intact and wrap it around the base of the shaft. Place a urinary catheter for 1 week ( Fig. 120.8, B ).
