Male Circumcision Complications - A Systematic Review, Meta-Analysis and Meta-Regression

Penile skin necrosis: A case report of a rare complication associated with simultaneous circumcision utilizing a disposable circumcision suture device and genital beading surgery

RATIONALE

Male circumcision is a widely performed procedure globally and is generally safe. However, penile skin necrosis is a rare but serious complication. To our knowledge, this is the first case report describing the management of complications arising from circumcision using a disposable circumcision suture device (DCSD) performed simultaneously with a genital beading procedure.

PATIENT CONCERNS

A healthy 37-year-old man underwent circumcision using a DCSD and a genital beading procedure by an unlicensed practitioner.

DIAGNOSES

Wound infection with skin necrosis over the penile shaft.

INTERVENTIONS AND OUTCOMES

The patient required surgical debridement and single-stage reconstruction with a local flap. After appropriate surgical intervention and antibiotic treatment, the wound healed well. No structural or functional abnormalities were noted during outpatient follow-up. Ethical approval was waived due to case report only. Informed consent was given.

LESSONS

Although the DCSD offers benefits such as reduced operative time and improved cosmetic outcomes compared with conventional circumcision, combining the procedure with genital beading is not recommended due to the increased risk of complications. There are many techniques for reconstructing penile skin loss including split-thickness skin grafts, spiral flap, rotational skin flaps, pedicled skin grafting with vascular anastomosis, etc. Complex reconstruction is not always necessary; single-stage reconstruction with a local flap is a relatively simple but effective approach in certain situations.

Parents' knowledge, attitude and practice regarding childhood circumcision: a cross-sectional study in the central region of Sichuan, China

Introduction

This cross-sectional study aimed to explore parents' knowledge, attitudes, and practices (KAP) regarding male circumcision (MC) for their children.

Methods

A cross-sectional study was conducted among parents of male children under 18 years old in the central region of Sichuan, China, between September 2023 and January 2024 Questionnaires were distributed to collect demographic information and KAP scores.

Results

A total of 497 valid questionnaires were collected. The average knowledge score was 6.66 ± 2.34 (range: 0-10), attitude score was 38.04 ± 4.52 (range: 12-60), and practice score was 24.81 ± 3.49 (range: 6-30). Parents demonstrated highest awareness regarding the positive effects of MC on penis health, but showed lowest understanding of MC benefits for children with redundant prepuce or phimosis. Notably, 75% of parents indicated a willingness to have the procedure performed in the future. Multivariate analysis identified knowledge, attitude, and residence as independent factors associated with consent for childhood circumcision. Path analysis revealed positive influences from knowledge to attitude, knowledge to practice, and attitude to practice.

Conclusions

The study highlights the importance of targeted educational interventions to enhance parental understanding and decision-making regarding childhood MC. Educational programs can empower parents to make well-informed decisions considering both cultural and medical contexts.

Post-circumcision entrapped penis: A case report and literature review

INTRODUCTION AND IMPORTANCE

Circumcision represents the most common voluntary surgical intervention for male patients, characterized by the surgical excision of the foreskin. Among the potential post-operative complications, a notable condition is the surgically-induced retracted penis, wherein the phallus becomes concealed within the adjacent pubic tissue despite maintaining its standard anatomical dimensions. This clinical presentation typically emerges from medical interventions, including surgical techniques that involve excessive tissue resection, suboptimal surgical approaches, or subsequent scarring that impedes normal penile positioning.

CASE PRESENTATION

We report a case of an 11-year-old boy who experienced significant urogenital complications subsequent to an unprofessional circumcision performed at age five. Throughout the subsequent years, the patient's parents noted progressive challenges, including persistent hygiene management issues, recurring urinary tract infections, and micturition-related discomfort. A comprehensive medical assessment revealed extensive dermatological scarring and tissue adhesions circumscribing the penile region, with minimal visibility of the glans.

CLINICAL DISCUSSION

The comprehensive management approach for this complex case centered on strategic surgical reconstruction to restore penile functionality and anatomical integrity. The surgical intervention employed a meticulously planned approach that included precise scar tissue excision, comprehensive adhesion release, and advanced reconstructive techniques.

CONCLUSION

Complications can arise during circumcision procedures, with excessive removal of skin tissue or incorrect surgical methods potentially leading to penile confinement issues. Swift identification of these complications and appropriate corrective surgery performed by qualified medical professionals is essential for achieving favorable patient outcomes.

Efficacy of triamcinolone acetonide combined with recombinant bovine basic fibroblast growth factor in preventing scar formation after adult circumcision using a stapler device: A randomized controlled trial

BACKGROUND

This randomized controlled trial aimed to investigate the potential benefits of local application of triamcinolone acetonide combined with topical recombinant bovine basic fibroblast growth factor in promoting wound healing and reducing scar formation after circumcision using a stapler device.

METHODS

A total of 192 patients with phimosis or redundant prepuce were randomly assigned to either the observation group (n = 96) or the control group (n = 96). Both groups underwent circumcision using a stapler device. Postoperatively, the observation group received wet dressings of 2 mg/mL triamcinolone acetonide solution combined with topical recombinant bovine basic fibroblast growth factor until complete wound healing. The control group received saline wet dressings and standard postoperative wound care. Outcome measures included: postoperative edema, time to resolution of swelling at the incision edges, wound exudate, healing time, staple removal time and rate, scar formation, and patient satisfaction with penile cosmesis.

RESULTS

The observation group demonstrated significantly faster healing times and lower incidence of edema from the seventh postoperative day compared to the control group (P < .05). Furthermore, the observation group exhibited superior outcomes in terms of complete staple removal time, staple detachment rate, scar hypertrophy, and cosmetic scores using the modified Stony Brook Scar Evaluation Scale (P < .05). Patient satisfaction with penile cosmesis was also significantly higher in the observation group (P < .05).

CONCLUSION

This study underscores the principle of "prevention over treatment" in scar management following stapler circumcision. The findings suggest that the combined use of triamcinolone acetonide and recombinant bovine basic fibroblast growth factor may be beneficial in reducing postoperative edema, improving scar formation, and enhancing patient satisfaction. However, further research is warranted to validate these findings, establish optimal treatment protocols, and ultimately assess the long-term efficacy and safety of this combined therapy.

Retrospective analysis of clinical outcomes and early complications of conventional circumcision techniques and thermocautery-assisted circumcision

This study compared various circumcision techniques, specifically the dorsal slit (DS), sleeve resection (SR), and forceps-guided (FG) techniques, which fall under the category of conventional circumcision techniques, with the thermocautery-assisted circumcision (TAC) technique. The aim was to investigate the safety and efficacy of these circumcision methods by focusing on clinical outcomes and early complications, categorizing the associated complications using the Clavien-Dindo classification system (CDCS). A total of 7041 circumcised patients were retrospectively analyzed and grouped according to the applied techniques: DS, SR, FG, and TAC. Factors such as age, duration of the procedure, bleeding, edema, infection, recovery time, and local anesthetic technique parameters were compared. Complications were classified according to the modified CDCS. The duration of the procedure was 4.7 min (range 4.5-5.2), and bleeding (hematoma) was significantly lower in the TAC group with seven cases (0.3%) (p < 0.001). The recovery time of 5 days (range 5-7 days) and the incidence of edema were longer in TAC compared to other techniques (p < 0.001). Additionally, the recovery time in the SR group was shorter than that of the FG and DS groups (p < 0.001). After adjusting for confounding factors such as age, duration of the procedure, and local anesthetic techniques, the likelihood of perioperative bleeding was observed to statistically significantly increase in the FG (odds ratio [OR] = 61.663, 95% confidence interval [CI] 42.764-88.913, p < 0.001), DS (OR = 59.249, 95% CI 39.382-89.141, p < 0.001), and SR (OR = 161.952, 95% CI 96.100-272.930, p < 0.001), in that order, compared to the TAC group. Furthermore, compared to the TAC group, the likelihood of severe edema statistically significantly decreased in the FG (OR = 0.010, 95% CI 0.004-0.027, p < 0.001), DS (OR = 0.040, 95% CI 0.017-0.092, p < 0.001), and SR (OR = 0.043, 95% CI 0.015-0.124, p < 0.001) groups, in that order. There was no significant difference between the surgical techniques according to the CDCS evaluation. TAC demonstrated advantages over the remaining techniques in terms of less bleeding and shorter duration of the procedure. However, it also presented with disadvantages such as postoperative edema and longer recovery time.

Circumcision-Associated Penile Papules: A Novel Complication With Unclear Etiology

OBJECTIVE

To report six patients with penile papules after circumcision to attract the attention of clinicians and patients to the complication associated with circumcision.

METHODS

We reported several clinical cases presenting with these papules following circumcision. Cases were reassessed for clinical characteristics, histopathological features, and potential risk factors.

RESULTS

A series of six adult male cases were identified, with papules appearing asymptomatically months to years after circumcision. The papules were larger, exhibited uneven distribution, and lacked the typical arrangement of pearly penile papules, posing a cosmetic concern and a risk of misdiagnosis as genital warts.

CONCLUSION

This study presents a previously unreported complication of circumcision with significant implications for patient care. Further investigation is warranted to understand the etiology and develop strategies for prevention and management.

Comparing Penile Problems in Circumcised vs. Uncircumcised Boys: Insights From a Large Commercial Claims Database With a Focus on Provider Type Performing Circumcision

OBJECTIVES

To compare penile problems in circumcised relative to uncircumcised boys, and to determine which providers performing the circumcision have fewer post-circumcision problems.

METHODS

CPT codes in the 2011-2020 MarketScan database were used to identify boys who had a circumcision. Uncircumcised control subjects of the same age, state of residence, and insurance type were selected. The primary outcome was a penile problem, defined as penis-specific infection, inflammation, and urethral stricture/stenosis, among others. The secondary outcomes were procedure-related complications limited to 28 days after circumcision, and whether post-circumcision problems varied by the clinician performing the procedure. ICD-9/10 diagnostic codes were used to identify these problems.

RESULTS

We identified ∼850,000 cases and ∼850,000 matched controls. Overall, the rate of penile problems within the first five years of life was 1.7% in circumcised boys versus 0.5% in uncircumcised boys (p < 0.05). Multivariable regression models showed that the risk of penile problems was 2.9-fold higher among circumcised compared to uncircumcised males (95%CI [2.8-3], p < 0.001). Compared to males circumcised by pediatricians, those circumcised by surgeons had 2.1-fold higher penile problems in the year after circumcision (95% CI [2-2.3], p < 0.001). Procedure-related complications within 28 days of circumcision were infrequent (0.5%), with the most common being penile edema (0.2%).

CONCLUSIONS

Penile problems are very infrequent in boys in the first five years of life. However, when they occur, they are 3x more likely to occur in circumcised boys relative to uncircumcised boys. Penile problems are more likely to occur in boys circumcised by surgeons.

LEVELS OF EVIDENCE

Level II.

TYPE OF STUDY

Prognosis study.

Glans ischaemia after circumcision in adult males: A two-patient case series and a narrative review of the literature

INTRODUCTION

Glans necrosis after circumcision is an exceedingly rare complication among adult males, with only a handful of cases being reported in the literature.

MATERIALS AND METHODS

We present here two cases of glans ischaemia observations after circumcision in both a 19-year-old and a 26-year-old patient; both were managed with oral medications in the outpatient setting, with complete restitutio-ad-integrum. A narrative review of the literature was also performed to better describe the possible predisposing factors; the treatment/management options; and the typical outcomes among the adult males experiencing with this complication.

RESULTS

Penile dorsal anaesthetic blocks, monopolar cautery usage and compressive wound dressing are all reported to play a role as co-factors for glans ischaemia after circumcision, hence their adoption should be mindful. There is no consensus on the management of ischaemia of the glans after male circumcision.

CONCLUSIONS

The favourable outcomes being reported for most of the literature cases of glans ischaemia after circumcision among adults despite the adoption of diverse empirical therapeutic strategies suggest that the role of the proactive management may be questionable.

Replantation following complete penile amputation: Summary of perioperative experience and treatment strategies

INTRODUCTION

To date, there are only case reports of penile amputation, a rare urological emergency with a low-treatment successful rate, and there are still no advanced, detailed surgical or perioperative treatment plans. Effective treatments for these rare diseases are urgently needed.

METHOD

The researchers summarized the perioperative experience of 20 patients who underwent replantation after complete penile amputation at several hospitals over the past 5 years and shared experience in detail.

RESULTS

Only 1 of the 20 surgeries failed, and both urinary and erectile functions were successfully restored in other cases, indicating that the surgical methods and perioperative treatments summarized by researchers are feasible and highly successful for replantation following complete penile amputation.

CONCLUSION

Researchers have summarized the method and perioperative plan for replantation following penile amputation based on a summary of 20 cases, thereby providing guidance for urologists and andrologists.

The Effect of Therapeutic Play on Children's Pain, Anxiety and Mothers' Anxiety during Pre- and Postcircumcision Period

PURPOSE

The study was conducted to determine the effect of the therapeutic play method implemented on the pre- and postcircumcision pain and anxiety levels of children and mothers' anxiety levels in the pediatric surgery clinic.

DESIGN

Prospective, randomized clinical trial.

METHODS

The study consisted of children between the ages of 3 to 6 admitted to the pediatric surgery clinic and their mothers (N = 120; Therapeutic playgroup = 60, Control group = 60). As a therapeutic play method the children and their mothers used play dough during the structured conversation for about 10 minutes before and after the operation. A questionnaire, the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale, the Children's Emotional Manifestation Scale (CEMS) anxiety scale, and State-Trait Anxiety Inventory-S (STAI-S) anxiety scale for parents were used to collect data.

FINDINGS

In the pre- and postcircumcision period, the pain and anxiety levels of children and mothers' anxiety levels in the therapeutic playgroup were statistically lower compared to the control group (P < .05). In the postoperative period, a positive and significance correlation was found between anxiety levels of the mothers and pain and anxiety levels of children in the control group (P < .05).

CONCLUSIONS

The therapeutic play method was effective in reducing the pain and anxiety levels of children and mothers' anxiety in the pre- and postcircumcision period.

Does the addition of hyaluronidase to betamethasone in topical treatment of phimosis improves results? - A randomized double-blind clinical trial

INTRODUCTION

Phimosis is defined as the inability to retract the foreskin, preventing partial or complete exposure of the glans.

OBJECTIVES

To compare the efficacy of topical treatment with betamethasone alone and in combination with hyaluronidase, evaluate systemic absorption of cortisol, and identify factors that predispose the success of topical treatment of phimosis in children aged 3-10 years.

METHODS

This randomized double-blinded clinical trial involved 152 participants (3-10 years old) with phimosis. The children were divided into two groups: betamethasone associated with hyaluronidase (betamethasone valerate 2.5 mg + hyaluronidase 150 UTR; Group A) and betamethasone (betamethasone valerate 2.5 mg; Group B). Parents were instructed on how to use the ointment (twice a day, after hygiene, for 60 days) and on collecting salivary cortisol measurements at 11pm and 9am, before and after treatment. Participants were evaluated after 30 and 60 days. Fisher's exact test and paired t-test were used to analyze the data.

RESULTS

Ninety children (69.77%) were successfully treated with the proposed treatment, with the success rate for Group A being 75.38% versus 64.06% for Group B, p = 0.18). Systemic absorption evaluated by salivary cortisol did not show differences after the intervention (p > 0.05), indicating that there was no systemic absorption when using ointments with or without hyaluronidase. The factors of age (OR = 0.98 - CI: 0.97-1.00), adherence (OR = 1.49 - CI: 0.53-4.16), balanoposthitis (OR = 1.85 - CI: 0.47-7.19), and previous use of corticosteroids (OR = 1.21 - CI: 0.53-2.72) also did not show influenced results CONCLUSION: Topical therapy for true phimosis with betamethasone 0.2% + hyaluronidase, despite showing no differences when compared with betamethasone 0.2% alone, for a period of up to 60 days, proved to be safe, effective, and with good results. The variables analyzed could not predict the expected clinical response.

REBEC

RBR-76bhgyb.

Evaluating Safety of Ring Versus Clamp Devices in Neonatal Circumcision: A Meta-Analysis

BACKGROUND

While device-based circumcision is considered non-inferior to traditional dissection, there is no consensus on the efficacy and safety of ring devices in comparison with clamp devices. We aimed to compare the safety outcomes of ring-based versus clamp-based circumcision techniques in neonates.

METHODS

MEDLINE, EMBASE, Scopus, and CINAHL were searched following the Cochrane collaboration (PRISMA guidelines), without language restrictions, to identify relevant randomized controlled trials. Adverse events, bleeding events, infection events, and procedure time were extracted and analyzed from the selected studies.

RESULTS

From 1661 citations, seven trials were included, encompassing 3390 patients. These studies compared ring-based to clamp-based circumcision devices in neonates. No significant difference was found in overall adverse events between the two groups. However, ring devices showed significantly fewer bleeding events compared to clamp devices. Infection events and procedure time were similar for both groups.

CONCLUSIONS

Both ring and clamp devices have similar safety profiles, with ring devices potentially offering a reduced risk of bleeding. A comprehensive understanding of ring-specific complications and cosmetic outcomes is necessary for a more complete evaluation of these circumcision techniques. Our analysis is limited from a lack of detailed examination of ring-specific complications and their impact on cosmetic results. The included studies varied in quality, and some exhibited a risk of bias.

LEVEL OF EVIDENCE

Level IV Treatment Study.

Glanular Ischemia Following Circumcision: A Rare But Perilous Complication

Circumcision is a commonly performed surgical procedure both in childhood and in adults. Acute ischemia of the glans penis after circumcision is a rare but hazardous complication. If left untreated, it can lead to severe consequences such as blackish discolouration due to ischemia, necrosis, or rare organ loss. Herein, we report a case of a 30-year-old male who underwent circumcision for phimosis, following which, he developed ischemia of the glans penis that was managed with timely diagnosis, topical application of warm saline, and oral pentoxifylline. We report the need for a prompt diagnosis and early intervention and also highlight the possibility of dreadful sequelae if left undiagnosed or untreated.

Efficacy and safety of two disposable circumcision suture devices for circumcision in adults: a prospective comparative multicenter study

The objective of this study was to evaluate and compare efficacy and safety of two different Disposable circumcision suture devices (DCSDs). A prospective comparative non-randomized multicenter study was performed between November 2019 and February 2023. Patients underwent circumcision using a DCSD (CircCurerTM or the ZSR® device) according to the surgeon preference and device availability. A total of 378 patients were circumcised; 184 using CircCurerTM and 194 patients using ZSR®. No differences in baseline characteristics were observed. CircCurer and ZSR Groups showed similar rates of operative time (7.7 ±2.1 vs 7.3 ±2.0 min), surgical site infection (1.1% Vs 1.5%), edema (13% Vs 8.2%), hematomas (2.7% Vs 1.1%), and postoperative pain (2.5 Vs 2.0 points). ZSR Group had a significantly higher rate of clip fallout (62.9% Vs 38%, p < 0.001). At 2 months, patients of both groups reported a median satisfaction of 9 (8-9) points. Main limitation consist in non-randomized study. DCSDs seem to be effective and safe, with short operative times, uncommon and mild complications, and high patient satisfaction. ZSR® device has a higher rate of spontaneous staple dropout.

Phimosis in Adults: Narrative Review of the New Available Devices and the Standard Treatments

BACKGROUND

Phimosis is the inability to completely retract the foreskin and expose the glans. The treatment of phimosis varies depending on the age of the patient and the severity of the disease; a great number of conservative or surgical treatments are currently available.

AIM

To provide the first review summarizing the available options for the treatment of adult phimosis.

METHODS

A PubMed, Cochrane and Embase search for peer-reviewed studies, published between January 2001 and December 2022 was performed using the search terms "phimosis AND treatment".

RESULTS

A total of 288 publications were initially identified through database searching. Thirty manuscripts were ultimately eligible for inclusion in this review. Conservative treatment is an option. and it includes topical steroid application and the new medical silicon tubes (Phimostop™) application for gentle prepuce dilation. Concerning the surgical approach, the gold-standard treatment is represented by circumcision in which tissue synthesis after prepuce removal can be also obtained with barbed sutures, fibrin glues or staples. Laser circumcision seems to be providing superior outcomes in terms of operative time and postoperative complication rate when compared to the traditional one. Several techniques of preputioplasty and use of in situ devices (which crush the foreskin and simultaneously create haemostasis) have been also described. These in situ devices seem feasible, safe and effective in treating phimosis while they also reduce the operative time when compared to traditional circumcision. Patient satisfaction rates, complications and impact on sexual function of the main surgical treatments are presented.

CONCLUSION

Many conservative and surgical treatments are available for the treatment of adult phimosis. The choice of the right treatment depends on the grade of phimosis, results, complications, and cost-effectiveness.

A prospective randomized controlled trial measuring satisfaction and parents stress after Gomco and Plastibell infant circumcision

PURPOSE

To compare the physician and parental satisfactions between the two types of circumcision maneuvers used in our units, Gomco and Plastibell circumcision.

METHODOLOGY

This study was performed from 2019 to 2021. A total of 190 children were circumcised either by Gomco or Plastibell procedure. Each child was evaluated during the procedure, immediately after the operation, and 1, 2, and 3 weeks after the procedure. Data were collected, statistically analyzed using SPSS version 25.

RESULTS

A total of 190 children underwent circumcision from 2019 to 2021. Of the total 190, 98 children (51.6%) underwent circumcision by Gomco, while 92 (48.4%) underwent circumcision by Plastibell. Bleeding was significantly higher in Plastibell method, while excess skin was significantly higher in Gomco method (p value 0.048). Physician evaluation results show no significant difference between both methods in late physician evaluation. 23/92 (28%) of parents were not satisfied after Plastibell circumcision, compared to 8/98 (8.2%) of parents who were not satisfied with the results of Gomco circumcision (p value 0.002).

CONCLUSION

Gomco needs a longer operative time, and Plastibell circumcision is less preferable by parents. There is no significant difference in physician satisfaction between the two procedures, but parents are less satisfied with Plastibell circumcision.

Type 2 diabetes mellitus increases the risk of circumcision among men aged between 30 and 69 years using a nationwide population-based dataset in Taiwan: a five-year follow-up study

BACKGROUND

Diabetes is an important factor in the development of penile inflammation. We studied whether type 2 diabetes (DM), with/without hypertension and hyperlipidemia increased the risk of circumcision among men aged between 30 and 69 using a population-based dataset in Taiwan during a 5-year follow-up period.

METHODS

The research data in this study were obtained from Taiwan's National Health Insurance Research Database between 1997 and 2010. We identified 23,197 patients who had a new diagnosis of DM and randomly matched 115,985 subjects as controls. We observed whether circumcision was the treatment after a new DM diagnosis. The initial step involved analyzing the data using Poisson regression analysis. To address potential confounding factors, this study employed propensity score matching based on three variables. Additionally, a Cox regression with a Gamma frailty was utilized to compare outcomes between different groups.

RESULTS

Poisson regression analysis showed that DM (RR = 1.75, 95CI = 0.10 ~ 1.22), but not hypertension (RR = 1.14, 95CI=-0.44 ~ 0.70), hyperlipidemia (RR = 0.94, 95CI=-0.66 ~ 0.53), or age (RR = 0.83, 95CI=-0.43 ~ 0.62), had an impact on circumcision treatment. Cox regression with a frailty model found that DM was a risk factor associated with circumcision (HR = 2.31, 95% CI = 1.74 ~ 3.06, p-value < 0.01), whereas no significant difference was noted between circumcision and hypertension (HR = 1.10, 95% CI = 0.80 ~ 1.51), hyperlipidemia (HR = 1.05, 95% CI = 0.79 ~ 1.40), or age (HR = 1.00, 95% CI = 0.99 ~ 1.02).

CONCLUSIONS

Type 2 diabetes mellitus, but not hypertension, hyperlipidemia or age increases the risk of circumcision in men aged between 30 and 69 years.

Comments by opponents on the British Medical Association's guidance on non-therapeutic male circumcision of children seem one-sided and may undermine public health

The British Medical Association (BMA) guidance on non-therapeutic circumcision (NTMC) of male children is limited to ethical, legal and religious issues. Here we evaluate criticisms of the BMA's guidance by Lempert et al. While their arguments promoting autonomy and consent might be superficially appealing, their claim of high procedural risks and negligible benefits seem one-sided and contrast with high quality evidence of low risk and lifelong benefits. Extensive literature reviews by the American Academy of Pediatrics and the United States Centers for Disease Control and Prevention in developing evidence-based policies, as well as risk-benefit analyses, have found that the medical benefits of infant NTMC greatly exceed the risks, and there is no reduction in sexual function and pleasure. The BMA's failure to consider the medical benefits of early childhood NTMC may partly explain why this prophylactic intervention is discouraged in the United Kingdom. The consequence is higher prevalence of preventable infections, adverse medical conditions, suffering and net costs to the UK's National Health Service for treatment of these. Many of the issues and contradictions in the BMA guidance identified by Lempert et al stem from the BMA's guidance not being sufficiently evidence-based. Indeed, that document called for a review by others of the medical issues surrounding NTMC. While societal factors apply, ultimately, NTMC can only be justified rationally on scientific, evidence-based grounds. Parents are entitled to an accurate presentation of the medical evidence so that they can make an informed decision. Their decision either for or against NTMC should then be respected.

Primary syphilis, an extremely uncommon cause of acute-onset phimosis

We present a case of phimosis in the context of primary syphilis with a preputial chancre. An accurate diagnosis after an appropriate examination and patient history allowed conservative treatment with antibiotics and the avoidance of circumcision in this patient.

Age-incidence and prevalence of HIV among intact and circumcised men: an analysis of PHIA surveys in Southern Africa

The study investigates the statistical relationship between male circumcision and HIV prevalence in Africa, in the context of the Voluntary Medical Male Circumcision (VMMC) campaigns in place since 2008. Data from the Population-based HIV Impact Assessment (PHIA) surveys conducted in African countries in 2017-2018 were utilized. Six countries with high HIV prevalence, low traditional circumcision and large VMMC programs were selected: Eswatini, Lesotho, Malawi, Namibia, Zambia, Zimbabwe. The statistical analysis investigated the relative risk (RR) of HIV prevalence by circumcision status (circumcised vs intact) among men age 20-59, and the age-incidence of HIV in the two groups among men age 20-49, defined as the linear-logistic slope of the relationship between prevalence and age. Results show that the standardized RR was not different from 1 at older ages (50-59): RR = 0.923, 95% CI = 0.769-1.108, P = 0.390. Furthermore, the age-incidence was at least as high or higher among the circumcised groups than among the intact groups. The standardized RR was lower than 1 at younger ages, and this could be explained by selection biases. HIV prevalence at age 40-59 (27.3%) was also the same in the four groups of circumcision status (intact, traditional, medical, unknown). Results matched earlier observations made in South Africa that circumcised and intact men had similar levels of HIV infection. The study questions the current strategy of large scale VMMC campaigns to control the HIV epidemic. These campaigns also raise a number of ethical issues.

[Development of circumcision rates in Germany since the approval of ritual circumcision : A population-based analysis from 2013 to 2018]

INTRODUCTION

The religious and cultural circumcision of male infants in Germany is controversially discussed. After the passing of the religious circumcision bill in 2012, an increase of infant circumcisions without medical indication was feared. The aim of this study was to analyze the development of the circumcision case numbers.

MATERIALS AND METHODS

We used the research database of the German Institute for Applied Health Research with a representative anonymous sample of 4.9 million insured persons to estimate the annual circumcision numbers in Germany from 2013-2018. We stratified the data according to age (< 18 vs. ≥ 18 years). The number of male adolescents in the study period was taken from the database of the German Federal Statistical Office.

RESULTS

In the study period, 673,819 circumcisions were performed. From 2014, there was a significant decrease in the number of cases across all age groups (p = 0.049). Thereby, circumcisions in minors significantly increased (p = 0.002) and procedures in adults significantly decreased (p = 0.01) during the entire study period. The number of male minors increased by 4% from 6,709,137 (2013) to 6,992,943 (2018). The corresponding population-based number increased from 7.5 circumcisions per 1000 minors in 2013 to 8 in 2018 (p = 0.037).

CONCLUSIONS

After the passage of the circumcision bill in 2012, there was a significant increase of circumcisions in the age group of < 18 years in Germany. A major limitation of our study is that presumably many ritual circumcisions might not be provided within the health care system.

Foreskin restorers: insights into motivations, successes, challenges, and experiences with medical and mental health professionals - An abridged summary of key findings

Demographically diverse surveys in the United States suggest that 5-10% of non-voluntarily circumcised American males wish that they had not been circumcised. Similar data are unavailable in other countries. An unknown proportion of circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth investigation into foreskin restorers' lived experiences. An online survey containing 49 qualitative and 10 demographic questions was developed to identify restorers' motivations, successes, challenges, and experiences with health professionals. Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust. Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by medical and mental health professionals.

Does using a laser improve outcomes of conventional circumcision in adult and children populations? Results from a systematic review and meta-analysis

BACKGROUND

Male circumcision is a well-known old surgery, and several recently developed techniques have been scaled up, including the introduction of laser technology, as alternative approaches to overcome morbidity of conventional surgery scalpel/suture method OBJECTIVES: We aimed to perform a systematic review and meta-analysis of studies comparing laser circumcision versus conventional circumcision technique in terms of perioperative outcomes and efficacy (complications, unacceptable appearance, reoperation rate) both in children and adults.

MATERIALS AND METHODS

This review was performed following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Continuous variables were analyzed using the inverse variance of the mean difference with a random effect, 95% confidence interval (CI), and p-value. The incidence of complications, unacceptable appearance, and reoperation rate were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and reported as odds ratio (OR), 95% CI, and p-value. Significance was set at p-value ≤0.05 and 95%CI.

RESULTS

Seven studies were included. In comparison to the conventional circumcision, laser circumcision shoved lower visual analogue score at 24-h, and 7 days after surgery, a lower rate of overall complication rate (OR 0.33, 95% CI 0.24-0.47, p < 0.001), scarring (OR 0.09, 95% CI 0.02, 0.41, p = 0.002), and unacceptable appearance (OR 0.09, 95% CI 0.05, 0.15, p < 0.001). We found no statistically significant difference in surgical time, and incidence of bleeding, infection, wound dehiscence, and reoperation rate.

DISCUSSION AND CONCLUSION

Our review infers that laser-assisted circumcision is certainly a safe and strong contender as the procedure of choice in both children and adult populations.

Circumferential full-thickness skin grafting: An excellent method for the treatment of short penile skin in adult men

Objective

Short penile skin due to excessive circumcision is a complex condition requiring surgical care. The study aims to investigate the effect of full-thickness skin grafting (FTSG) in treating short penile skin.

Methods

A retrospective analysis was performed on 24 patients with insufficient penile skin. The included patients underwent full-thickness skin grafting from the scrotum and the groin region in the Genital Plastic Surgery Center between February 2014 and September 2021. Morphology of the penis, length of the penis, complication, and donor area healing status was observed by the authors. Additionally, the International Index of Erectile Function Questionnaire (IIEF-5) and the patient's evaluation of penile appearance were investigated.

Results

An aesthetically pleasing appearance of the penis was obtained by FTSG in 24 patients. The length of penis was improved after surgery (5.70 cm ± 1.24 cm vs. 6.05 cm ± 1.33 cm, P value < 0.05). All patients had good healing of the penile area without serious complications. Only 2 cases showed minor partial necrosis and recovered soon after proper treatment. A high patient's evaluation of penile appearance was received (4.08 ± 0.71, mean ± SD) and the scores of IIEF-5 increased significantly after surgery (18.38 ± 2.24 vs. 21.08 ± 1.79, P-value < 0.05).

Conclusions

FTSG from the scrotum and inguinal skin provides good aesthetic and functional results for treating short penile skin. FTSG, particularly the scrotum-derived skin graft, offers a great supplement to penile skin. It could be suggested as a promising method of treating insufficient penile skin, which meets both functional and aesthetic needs.

A Retrospective Taiwanese-Population-Based Clinical Study on Determining the Efficacy and Safety of Disposable Circumcision Anastomat

Traditional approaches for male circumcision are tedious and could lead to complications such as peri-/postoperative pain, bleeding, and infection. Thus, for the first time, we investigated the surgical outcomes of recently the discovered Disposable Circumcision Anastomat Type A (Dongguan ZSR Biomedical Technology Company Ltd., China), a disposable circumcision suture device (DCSD), in terms of the operation time, surgical complexity, safety, satisfaction, and aesthetic outcomes and most importantly the prognostic factors for postoperative infection. A total of 394 individuals were circumcised, with a mean age, body mass index (BMI), stretched penile length (SPL), and penile circumference of 30.1 ± 7.05 years, 25.47 ± 4.73, 10.12 ± 1.61, and 7 ± 0.73 cm, respectively. Associated comorbidities included diabetes mellitus (6.09%), hypertension (2.03%), gout (1.02%), end-stage renal disease (ESRD, 0.25%), and HIV (0.25%). The mean operation time, average postoperative bleeding, and wound infection rate was 31.4 ± 9.96 min, 2.54%, and 9.39%, respectively. The mean VAS postoperative pain scores at D0 and D1 were 4.4 ± 2.4 and 1.9 ± 1.6, respectively. Moreover, 1.27% of subjects required reoperation, and a 2.03% rate of instrument malfunction was noted. The significant factors associated with the post-operative infection group were age (p = 0.0313), BW (p = 0.0081), BMI (p = 0.0026), penile circumference (p = 0.0343), and DM (p ≤ 0.001). Multivariate analyses revealed only DM as a statistically significant factor (p < 0.001). Our box−whisker plot revealed no significant difference between the HbA1c level of infection (Hb1Ac = 7.77 ± 1.39) and non-infection groups (Hb1Ac = 6.92 ± 1.84). However, a trend of higher glycemic index in the infection group was observed. Conclusively, DSCD could be an effective and safe alternative to performing circumcision. However, in the population with advanced aging, phimosis, elevated BMI, and DM (HbA1C > 9%), users should be highly cautious due to the increased risk of infection, dehiscence, and hematoma.

The efficacy of tissue glue in pediatric circumcision wound approximation: A meta-analysis of randomized controlled trial

INTRODUCTION

Tissue glue has been examined extensively for its effectiveness in pediatrics, and the findings are good. The purpose of this research was to examine the effectiveness of tissue glue compared to absorbable sutures for wound approximation in pediatric circumcision.

METHODS

A systematic review and meta-analysis on children who had circumcision using tissue glue and absorbable suture were done in line with the PRISMA criteria. RevMan 5.4 was used to perform the meta-analysis. The mean differences for continuous and dichotomous data are determined using inverse variance, and the odds ratio is calculated using the Mantel-Haenszel technique.

RESULTS

The inclusion criteria were met by six trials containing a total of 817 patients. According to the analysis, tissue glue significantly reduces the duration of the operation (MD - 7.98; 95% CI -12.35, -3.62; p = 0.0003), pain severity (SMD -0.57; 95%CI -0.80, -0.32; p < 0.00001) and the duration of pain (MD - 2.33; 95% CI -2.57, -2.08; p < 0.00001) compared to absorbable suture. However, we found that there was no significant difference in the incidence of postoperative bleeding, infection, dehiscence, or overall complication when comparing tissue glue to traditional suture.

CONCLUSION

Our systematic review and meta-analysis using the most recent data suggest that tissue glue usage might reduce the operation time, as well as the intensity and duration of postoperative pain.

Can circumcision be avoided in adult male with phimosis? Results of the PhimoStopTM prospective trial

Background

Circumcision as surgical treatment of adult phimosis is not devoid of complications. Efficacy of alternative non-surgical options is unclear. PhimoStop^TM is a therapeutic protocol which involves the use of appropriately shaped silicone tuboids of increasing size to obtain a non-forced dilation of the prepuce. The aim of the study was to evaluate the efficacy and durability of results of PhimoStop^TM device for the treatment of adult male phimosis.

Methods

A prospective trial was conducted between 2018 and 2020 on 85 consecutive adult male patients affected by phimosis and with an indication for circumcision. Patients were treated with PhimoStop^TM protocol and they were evaluated at baseline and after treatment through a subjective (patient self-reported information on various domains of his sexual function) and an objective assessment (evaluation of phimosis severity grade according to the Kikiros scale pre- and post-treatment, re-assessment of indication for circumcision post-treatment and validated questionnaires scores). Primary endpoint was to avoid the scheduled circumcision in 33% of the patients enrolled.

Results

Seventy-one patients (84%) completed the device usage phase as per study protocol. Median duration of tuboid application was 60 days. Thirty-seven patients (52.1%) had no indication for circumcision after treatment. Even considering patients lost to follow-up as failures, primary endpoint was reached in 43.5% of cases. There was a significant reduction of the grade of phimosis after treatment (P<0.001). Moreover IIEF-5 showed a statistically significant improvement after treatment (P<0.001). Thirty/37 patients who met the primary endpoint (81%) still have a successful resolution of their phimosis avoiding circumcision at a median follow-up of 24 months.

Conclusions

PhimoStop^TM device is effective for the treatment of adult male phimosis of Kikiros grade ≤2. The results seem to be durable in most patients at a median follow-up of 24 months. Randomized clinical trials are necessary in order to confirm our results and assess cost-efficacy.