# Circumcision Complications Associated with

Authors: Seyed Abdollah Mousavi; Ebrahim Salehifar
Journal: Advances in Urology
 (2008)

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## Abstract

Conventional dissection surgery (CDS) or using the Plastibell device (PD) is the method most frequently employed for circumcision. The aim of this study was to evaluate two methods in terms of the incidence of complications in infants of ages up to 12 months. In a prospective study, 586 infants equal to or less than 12 months were studied from 2002 to 2008, and complications between the two groups were assessed. The overall rates of complications in CDS and PD groups were 1.95% and 7.08%, respectively. In each group, the rate of complications was not different among children who had a normal weight, compared to those of a lower or upper (10%) weight. There was a significant positive correlation between the age and weight of subjects within the time of ring separation (P<.001). The results of this study suggest the PD method for neonates and low-weight infants with thin prepuce and the CDS for other infants.


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## Body

## 1. Introduction

Male circumcision has been performed for
more than 5000 years [1] as a way to remove the redundant foreskin in order to
expose the glands. About 25% of the total male population are circumcized, and
circumcision remains one of the most common operations performed all over the
world [2]. Over 60% of male newborns
were circumcized in USA in 1992 [3]. In our country, all Muslim boys are ritually circumcized between
the neonatal periods through the age of 4 to 5 years. The benefit of
circumcision has been described in numerous studies, such as in the reduction
risk of penile cancer [2], cancer of the cervix uteri [4, 5], urinary tract
infections (UTIs) [6, 7], sexually transmitted diseases (STDs), and lower HIV
prevalence [2, 6]. There are many
procedures for circumcision; conventional dissection surgery (CDS) or using the
Plastibell device (PD) is one of the methods most frequently employed for
circumcision. The technique of choice remains controversial as we found only
two published prospective randomized trials of circumcision in children,
comparing the PD to a conventional dissection technique [8, 9]. These trials
were performed 14 to 27 years ago, in which most children were older than
infantile. On the other hand, there exist several reports of complications
associated with the use of the PD in children circumcision [10, 11].The aim of this study was to compare the
various complications of two methods of circumcision in infantile age.


## 2. Materials and Methods

This study was conducted on 586 children
equal to or less than 12 months, who were brought by their parents for
circumcision in an outpatient clinic, between September 2002 and January 2008.
The study was approved by the Ethics Committee of Mazandaran University of
Medical Sciences. All participants were full-term healthy males without any
medical indication or urological anomaly, and had been operated on by one of
our pediatric surgeons.Informed consent was obtained from parents of eligible infants based on entry criteria.
Infants were randomly divided by one of two techniques: the Plastibell method or conventional dissection (sleeve
resection). We randomized infants in one of two groups unless the parents
insisted on a particular circumcision method. Consequently, the number of
subjects in Plastibell method was more than that of the conventional group.
Infants were not fed for 1-2 hours prior to
the procedure. After placing an infant on a circumcision restraint board, the
skin was prepared with povidone iodine (10%) solution. A dorsal nerve block was
administered using 0.2 mL/kg of 2% lidocaine, with a 27-gauge needle.
Regardless of the technique, four minutes were allowed to elapse for all
infants before beginning of circumcision procedures. In Plastibell technique, a plastic protective
bell was placed over the glands and under the foreskin. A suture was placed
around the entire foreskin, which would eventually fall off, after necrosis
within several days. The parents of subjects
were informed to return if the time of bell separation exceeded more than 10
days.In the second group, a dissection
suturing technique was used. After a circumferential incision along the line of
the coronal sulcus, the foreskin was retracted to expose the glands. Then, a
second circumferential incision was provided 1.5 cm proximal to the coronal
sulcus. The foreskin was then carefully excised and the wound was closed with a
4/0 chromic. No dressing was applied in Plastibell method;
however, a mild compress dress was used to prevent bleeding in the conventional
dissection group.Acetaminophen drop was used as an analgesic for children in both operations. In addition,
parents were directed to do sits bath with soapy water twice per day, and also to
apply a liberal amount of ophthalmic ointment gentamicin to the operative site
for a period of ten days. All children were followed up until the wound was healed,
along with observing them for any associated complications. The complications
are, for example, infection, bleeding or
hematoma, excess mucosa, bell disposition (entrapping the ring), and delayed
falling.Data were analyzed by SPSS 11.5 software, andP-value of <.05 was considered
as a significant difference. The frequency of complications between two groups
was assessed by chi-square test. Correlations between age and weight of cases
with the separation time of the Plastibell method were investigated by Pearson
correlation test.


## 3. Results

The demographic characteristics of subjects are presented in Table1. The mean age
of both groups was less than 6 months. Considering the age and weight of the
children, more than 90% had a normal weight. There was no significant
difference between the two groups in terms of numbers of subjects who were in
the upper or lower 10th percentile curves for weight.Table 1
Demographic characteristics of subjects.
Conventional dissectionPlastibell Methodsurgery (n=205)(n=381)Age (m)4.4±3.23.1±2.8Weight (kg)6.6±2.35.6±1.9Upper percentile 102.9%2.6%Lower percentile 104.9%5.8%Complications of circumcision by CDS and
PD are presented in Table2. The overall complication rates in CDS and PD groups
were 1.95% and 7.08%, respectively.Table 2
Complications of circumcision by conventional dissection surgery and Plastibell
methods based on the weight percentile of subjects (chi-square analysis).
ComplicationsConventional dissection surgery (n=205)Plastibell method (n=381)P-value (surgery versus Plastibell)Upper 10%NormalLower 10%P-value*Upper 10%NormalLower 10%P-value*.051weightweightweightweightweightweight(n=6)(n=189)(n=10)(n=10)(n=349)(n=22)N%N%N%N%N%N%Infection000000.1620041.0500.935Bleeding0031.4610.490051.3100Hematoma0000000010.2600Excess mucosa0000000041.0510.26Disposition0000000020.5300Delayed falling00000010.2682.1010.26No complication62.9318690.7394.3992.3632585.3205.25*P-value of complications in each group based on their weight percentile.In conventional dissection group,
bleeding was the only complication. There were 6 infants who had continuous
oozing. Two of them were hemophilic, and thus they were excluded from this
study. The bleeding of four other infants stopped with compress dressing.In Plastibell method, delayed separation
of ring was the most common complication (2.6%) followed by bleeding, excess
mucosa, infection, disposition, and hematoma. There were 10 infants whose bell
did not separate after the 10th day; therefore, we removed the cup accordingly
by cutting the tie. Infection was a clinical diagnosis and was not confirmed by
culture. All subjects subsided without any adverse effects. Eight of subjects,
who had bleeding, hematoma, or disposition of ring, were managed by reoperation
and suturing.There was a trend for significant difference
regarding the rate of complications between PD and CDS (P=.051). In
each group, the rate was not different among children who had a normal weight,
compared to those who had lower or upper 10% weight.Correlation between the age and
weight of children in Plastibell group within the separation time of ring is
demonstrated in Figures1 and 2. There was a significant positive
correlation between the age and weight of subjects within the time of ring separation
(P<.001). This indicates that the ring separated faster in younger children.
Eventually, the average procedure time for CDS and PD methods (in spite of the
time needed for anesthesia) was 9.2 and 3.4 minutes (P<.01).Figure 1
Correlation between age of subjects and the bell separation time (Pearson
correlation = 0.24,P<.001).Figure 2
Correlation between the weight of subjects and the bell separation time
(Pearson correlation = 0.29,P<.001).


## 4. Discussion

Routine neonatal circumcision can be a
safe procedure [10]. The overall complication rate of the procedure ranges
between 0.19% and 3.1% [12]; however, in a few studies, it was extremely high.
Upon a retrospective study, Linus reported 20.2% complication in infants [12]. The less complication rate (17.6%) was reported in
other randomized trials
of childhood subjects [9].Although many techniques for circumcision have
been studied extensively [7], there are few reports determining which surgical technique may be
associated with the least complications [8, 9].A number of studies proposed that
circumcision with PD is a simple method and complications including hemorrhage,
local infection, sepsis, metal ulceration, and poor cosmetic results are rare [10, 11, 13].
On the other hand, tragic complications such as traumatic amputation of the
glands and urethra-coetaneous fistula in CDS have been reported in other
studies [14–18].Mak et al. reported that the overall
complication rates (intra- and postoperative) were similar between the
conventional dissection and PD groups being 17.6% and 17.8%, respectively [9].In a randomized trial study, Fraser et al. compared these two methods in childhood and concluded that the PD procedure is a
satisfactory method for circumcising children [8].Although comparison of these two
circumcision methods has been reported in previously mentioned trials, as well
as known ones, our study is unique in terms of the number of subjects who were less than or equal to 12 months of age,
and the procedures for all subjects were performed by only one pediatric surgeon
[8, 9].PD is the most common technique used for
neonatal circumcision around the world [1]. However, in our country the
surgeons usually prefer conventional dissection methods. Fraser et al.had
shown that the PD was a satisfactory method for circumcision of children up to
the age of 8 years [8]. In our trial, we found that the overall complication
rate of conventional surgical method was less than that of the Plastibell method
(1.95% versus 7.08%). Although the P-value of complication comparison between
PD and CDS groups was a little more than .05, the hazard ratio is so high
(7.08/1.95 = 3.6).The main complication associated with
the PD in our study was the delayed separation of ring (2.6%). It should be
noted that the ring separates faster in younger children due to thin prepuce
and easier sloughing. Considering the lowest incidence of this complication in younger
and thin infants, it would be considered a satisfied method for them.There were eight cases whose bell was
separated by a surgeon as an emergency setting. Six of them had bleeding or
hematoma, while two cases had bell disposition.Choosing
the correct size of the Plastibell and close attention to ensure the ligature are sufficiently tied in order to
prevent bleeding. In our study, bleeding was the second most common
complication consisting of 18%. Lazarus et al. reported that bleeding was 44%
from their observed complication [10].The infection rate was 1% in Plastibell group,
while no infant in the other group had infection. This is significantly lower
than those reported by Mak et al. [9]
(13.7% in Plastibell and 14.9% in dissection group), Fraser [8] (4% with both
techniques), and Sorensen (5% with PD method) [19]. Since the criteria of
infection were only clinical in our study as well as other studies, it may be
underestimated. Although application of local antibiotics as prophylactic
agents needs to be confirmed [20], we used a topical ophthalmic antibiotic as a
lubricant and prophylactic agent. This may explain the lower rate of infection
compared to other mentioned studies.We had five cases (1.3%) of redundant
mucosa in Plastibell group that may be due to the inappropriately sized bell. The choice of a correctly sized bell is
important. If the bell is too small, it causes compression of the glands and
edema, thus leading to micturition difficulty. If the bell is too large,
proximal dislocation or distal dislocations can occur [9].Although the PD group had a diverse type
of complications, bleeding was the only complication of CDS group and it occurred
in 1.95% of subjects.As reported in other studies [8], an
obvious advantage of using the Plastibell was the short surgery time. Average
procedure duration with the PD group was 3.4 minutes, compared with 9.2 minutes
with the sleeve resection.There are a few
limitations for this study. First, a
variety of surgical methods are available for neonatal circumcision, and this
study assessed only two of them. In addition,
the higher complications with the PD compared to CDS should not be externalized
to other nonsurgical approaches (i.e., Gomco clamp). This study was not
a complete randomized trial. The cosmetic appearance and also the parent
satisfaction were not prospectively assessed.
We are planning to follow up with subjects in terms of possible long-term
complications, similar to other studies [1, 12, 21].


## 5. Conclusion

Based on results of this study, the overall complication rate of CDS is less than that
of the Plastibell method. The bell separation time directly correlates with the
age and weight of infants. We suggest the Plastibell method for neonates and low-weight
infants with thin prepuce, and the CDS for other infants.



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