Glue is our current technique of choice in adult circumcision wound closure

Sutureless circumcision using 2-Octyl cyanoacrylate (glue) results in more rapid and less painful procedures with excellent cosmetic satisfaction

Introduction

Circumcision is the most common surgical procedure in male children in the world and is performed because of cultural, religious or medical reasons. Traditionally, interrupted sutures are used to close the wound, but 2-Octyl cyanoacrylate (2-OCA) tissue glue can be used as an alternative method to close the circumcision wound.

Objectives

To compare the use of 2-OCA with absorbable sutures in circumcision wound closure in prepubescent patients in terms of operative time, complication rate, postoperative pain and cosmetic results.

Study design

We retrospectively evaluated 662 circumcision procedures using sutures and 609 procedures using 2-OCA for wound closure in prepubescent boys. All circumcision procedures were performed by 2 surgeons in a single centre. Operative time was collected from the hospital surgical software system. 62% of the patients in the suture group and 59% of the patients in the 2-OCA group presented for a postoperative check-up 6 weeks after the circumcision. Data regarding postoperative pain, need for analgesia, cosmetic satisfaction and the ease of wound care were collected through questionnaires completed by 25% of the boy's parents in the suture group and 53% of the parents in the 2-OCA group.

Results

Mean operative time was significantly shorter in the 2-OCA group (13 min) than in the suture group (17 min). Complications were comparable and mostly minor. Reintervention was only required in 3 cases. According to the parents, the degree of postoperative pain and the postoperative need for analgesics was significantly lower in the 2-OCA group. Wounds closed with 2-OCA were easier to care for. The cosmetic results after 1 day, after 1 week and after 1 month in the 2-OCA group were significantly superior than in the suture group, according to the parents' evaluation.

Discussion

The use of 2-OCA in circumcision wound closure has been reported before. Previous studies with mainly limited patient numbers report less pain, shorter procedure times and a higher surgeon satisfaction in terms of cosmetic results. This study is the largest study comparing the use of 2-OCA and interrupted sutures in circumcision wound closure.

The retrospective character of the study, the lack of a validated questionnaire tool for the cosmetic evaluation and the use of the parent's evaluation are the limitations of this study.

Conclusion

The use of 2-OCA in circumcision wound closure results in a shorter operative time, in less postoperative pain, in easy postoperative wound care and in excellent cosmesis when compared to interrupted absorbable sutures. 2-OCA is our current technique of choice in circumcision wound closure.

Report from AZ St Lucas, Department of Urology, Groenebriel 1, 9000 Ghent, Belgium

Sources: Journal of Pediatric Urology, Volume 11, Issue 3, June 2015, Pages 147.e1–147.e

THE COMPARISON OF POSTOPERATIVE COMPLICATIONS OF PARTIAL AND TOTAL CIRCUMCISION IN CHILDREN

PURPOSE

To compare the rate and types of complications in boys who underwent partial and total circumcision for pathological phimosis. 

MATERIAL AND METHODS

We retrospectively reviewed the records of patients under 18 years of age operated for phimosis from 2009 to 2012. Out of 347 patients included in the analysis, 273 underwent partial (group P) and 74 total (group T) circumcision. The complications were divided into short-term (within the first month), long-term, mild and severe with the need of re-operation.

RESULTS

The age distribution in groups P and T was similar with the mean 6.5 and 5.7 years, respectively. The short-term complication rate was significantly higher in P compared to group T (23 to 11%, p-value 0.02) and also higher in the long-term (22 to 9%, p-value 0.013), making the overall complication rate 36 to 19%, p-value 0.005. Of all the complications 97% were mild (painful swelling, scarring, adhesions, infection and haemorrhage). They all resolved during the follow-up 0.2 to 47.3 months (the mean 2.7 months). 3% were severe, all in group P (scarring 8x, paraphimosis 2x, poor cosmesis 1x).

CONCLUSIONS

Partial circumcision (excision of the distal fibrotic ring) is preferred due to cultural habits in our country. The boys and their parents should be warned about the high rate of expected complications that is the double compared to total circumcision.

Source: European Society of Paediatric Urology (ESPU) 2016 Harrogate, Yorkshire UK

Reported by Motol University Hospital, Charles University in Prague, Paediatric Surgery, Prague, CZECH REPUBLIC dated 23 June 2016

Comment by Dr Khan:  Partial circumcision has a high rate of expected complications that is the double compared to full circumcision according to this report

A Cross Sectional Study of the Prevalence of Preputial and Penile Scrotal Abnormalities among Clients Undergoing Voluntary Medical Male Circumcision in Soweto, South Africa.

The high prevalence of preputial and penile scrotal abnormalities observed suggests a need for Voluntary Medical Male Circumcision sites to provide for both open surgical and devices methods in the provision of Voluntary Medical Male Circumcision services. This is especially so among young male subjects presenting themselves for Voluntary Medical Male Circumcision services at the various sites being developed in sub Saharan African countries.

Reported recently during the review, 6861 circumcisions were conducted and 37.1% (n = 2543) were 8–13 year olds. Median age was 15 years (IQR: 12–23 years). Fifteen percent (n = 1030) had preputial abnormalities or major penile scrotal abnormalities. 

After Adult Circumcision: What happens next?

A typical post-operative correspondence between a patient and surgeon.

Adult in his 30s

The following is the text and telephone conversations between Patient and Dr. Khan  

Before the circumcision

Patient:  if I am going to abroad (which is 20 degree) next week, Potentially Monday – would be OK.

Dr. Khan: Traveling will be fine after 5 days if everything is OK after the circumcision.

Patient: what will be best tight or loose underwear?

Dr. Khan:  It is helpful to wear the tight underwear for 2-3 days. It helps to decrease the pain and swelling. I will discuss further before the op.

Patient: Thank you for your response Dr. I will need to speak to you about the pain as I do not really take pain killers, but we can talk about that tomorrow. Very nervous!

Day 1

Patient: Good morning Dr. Just to update you that I had several erections last night which were very uncomfortable but bearable. No blood this morning until just recently I went to the toilet and noticed a bit of blood on the tissue from the underside of the penis (where the frenulum was removed). It doesn't seem like a lot so far but just wanted to be sure.

Dr. Khan: Please put small bandage on where there was a spots of bleeding. As frenulum was exposed because it was very high near the opening and bleeding may be due to erection. It should stop itself, use ice if erecting penis is causing significant problem.

Patient: It has already stopped already which is a relief so I think it may be best to leave it be unless it starts again and I will go and buy a new bandage. When will the pain from erections reduce? Also are they damaging the area?

Dr. Khan: It will take a few days to reduce the pain. Please take pain killers if you wish.

Patient: Thank you Dr. It only hurts so far when I have those erections at night so I will hold off until I need them. I have bought coconut oil as my penis head looks very dry so I can apply some on there after my shower tonight.

Patient: Hi again, just a quick one. I'm worried about the sensitivity when I take my bandage off. Would it be OK to keep it on just for tonight?

 Dr. Khan: You can keep it unless you keep the bandage dry.

Day 2 

Patient: Afternoon Dr. As an update I have just taken my bandage off which was very hard as the dried blood had made everything stick so I had to soak it in the shower before very slowly taking it off. A bit scabby, hard, bruised and sensitive down there but I'm guessing that's normal. Got some tight underwear on which I will continue to keep doing for a few more days until I land in-----(abroad)

Patient: Also there is some seepage happening, I am not worried as it doesn't seem like a lot, I just notice every time I wipe after I go for a pee and can also see some residue on my underwear. Can you please confirm it is normal?

Dr. Khan: I will call u later (I have given a reassurance him that everything will be fine )

Patient: OK thanks

Day 3

Patient: Hi Dr. Quick one, should I be showering everyday with soap on it?

Patient: Also can I send a picture of the top and bottom of it to make sure you're happy?

Dr. Khan: You can take shower regularly. It is not essential. Please DO NOT send the picture due to patient confidentiality. Internet or email is not safe to send these photos. I am happy to speak and advise you if there is any problem.

Patient: Ok, maybe a quick 1 minute call about the swelling to make sure it is safe. Thanks Dr

Patient: Just to say that I will be home all night packing so I shall keep my phone next to me when you are able to call. Thanks again

Day 5

Patient: Morning Dr. As a concern/update, everyday is getting easier and less swollen bit by bit. I had a good look at it today and noticed that on the top the swollen skin underneath looks like it is stuck to the top skin, however around the frenelum the skin looks like it is separate. Both stitches are still in so I am not too worried but what do you think?

Patient: Dr. Just to say that I am now certain that a part of the skin to the left of the frenulum has come away or unstuck, as the rest of the area around the pe is is stuck to the inner skin and this part has small traces of blood under it and has movement. Is this going to be a problem or greatly increase the recovery time? As a note, I haven't touched, forced or played with any part of that, just realised after my daily check today. I am leaving everything alone like you've said

Day 6

Patient: Ok I will buy some tomorrow and put on morning and evening. No shower for 2-3 days either. I will let you know if I am concerned and if you think I should come back to London so you can see me then let me know.

Day 10

Patient: Hi Dr. Just an update. The skin wasn't coming away, it was all the dried blood on the glue which looked like it was part of the skin, it is half hanging off now so I'm going to start having showers again to loosen it all up and keep it clean. What are the timescales for the glue and 2 stitches to come out, by next week?

Dr. Khan:  Glue will come off in next a few days. Stitches will takes 2-3 weeks. Bruising and swelling will go in 10-15 days.

Day 11

Patient: Thanks for that Dr. I am usually very active so was wondering when you would say it is safe for me to start working out again? When I say safe I mean that there is no chance of me damaging anything or increasing my recovery time.

Dr. Khan:  3-4 weeks. If the wound is healed in 3 weeks time. It is OK to start gym.

Patient: OK, I'll call you when I'm back in the country next week to see my progress and ask a couple more time benchmark questions - thanks for the support Dr!

Day 14

Patint: Hi dr is it ok if we speak tomorrow. I am back in the country now so got a few questions regarding one of the stitches and progress. Thanks

Dr. Khan: I will call you in the morning.

Patient: Thank you. Have a nice evening

Day 22

Patient: Morning Dr. Just to say that all the stitches are out and glue is off. A few scabs left on the underneath which will hopefully go soon. Had a trace of blood from that area that didn't close properly this morning which is probably because I was a bit rougher with it than usual after my shower. I'm sure it is more of a surface cut now but is there anything I should be worried about? Also I was hoping to see a girlfriend next weekend - that should still be possible right?

Dr. Khan: Avoid any sexual activity for 6 weeks from day of operation. Nothing else to worry.

Patient: I thought it was 4 weeks?

Dr. Khan: If you have still blood, it is better 6 weeks. I am happy to see you on next Wednesday if you like.

Patient: OK, what time could you see me on Wednesday?

Dr. Khan: 4 pm

Patient: OK I will see you at the same hospital (clinic)

Dr. Khan: Your appointment is booked at 4.30pm at LEYTON Healthcare, 4th floor. Leyton, London E10 5 LG

Day 28

Patient: I am in the waiting room

Dr. Khan: (I have seen him in the clinic. He has an excellent outcome)

Day 30

Dr Khan:  Please leave feedback on following link: http:/iwgc.net/eezh4

Day 50

Patient: Dr Khan sorry it took me so long but I have now submitted a great review for you.

Dr. Khan: Thank you. Much appreciated.

Note: Name of the patient was removed to protect patient confidentiality and this correspondence was published with patient's written consent.