Ó Springer 2006
International Urology and Nephrology (2006) 38:599–601 DOI 10.1007/s11255-005-0249-6
Window technique on circumcision Halil Basar, Erdal Yilmaz, Mehmed Murat Basar, Ertan Batislam & Devrim Tuglu Department of Urology, Faculty of Medicine, University of Kirikale, Kirikkale, Turkey
Abstract. Objective: To remove the preputium by using a simple, quick and safe method without damaging glans, frenulum and urethra as well as with a good cosmetic result. Patients and methods: The procedure, remind the guillotine technique at first, but completely different from it. Basically, a long haemostat is applied onto preputium and skin and subdermal tissue were incised; a small window is opened at dorsal of preputial mucosa and it is excised, while observing glans and frenulum. Results: The circumcisions were performed in a quick, safe and pretty bloodless way. There was no case with glans amputation, frenulum short cut or urethral damage, even if a clamp includes the foreskin with a part of glans or excess frenulum unnoticedly. Conclusion: This technique is simple, quick, relatively bloodless operation with cosmetically good result. Morever it is quite safe against to amputation of glans, frenular short cut or urethral fistula formation. Key words: Alternative, Circumcision, Technique, Window
Introduction Circumcision is one of the most commonly performed operation in the world [1–3]. It has been estimated that approximately one-third of the male population has been circumcised. It’s known that circumcision prevents urinary tract infection in infants, and sexually transmitted diseases, balanithis-balonoposthitis, and cervical and penile cancer for adults, in spite of controversies [4, 5]. Although, those proposed benefits of the circumcision, the incidence of procedure is mostly affected by religion, customs, rituals and cultural factors as in the Islamic and Jewish people. In the Muslim country like Turkey, all of the boys should have gone circumcision before puberty, because of religious custom. Circumcision can be done by using one of the primary circumcision techniques such as dorsal slit, sleeve resection, squeeze and guillotine [6–8]. The main purpose of various circumcision techniques is to remove the preputial tissue without damaging glans and frenulum as well as urethra, and also to minimise the bleeding together with the
good cosmetic result. Because of some occasional problems with any procedure, several minor modified techniques have been reported both to minimise surgical complications and to simplify the procedure with good cosmetic result [9, 10]. The ‘‘guillotine technique’’ is a simple, quick and relatively bloodless operation with good appearance. There has not been any need to use a specific device such as gomco, plastibell or tarakilamp as in the squeeze technique. The risk of clamping the preputium with glans is the main handicap of this procedure and it might result in glans laceration, amputation, phrenular short cut or even urethral fistula [11]. This is possible, especially in younger and fatty children because of the tinny glans. Although the exact incidence of this severe complications are unknown, due to its awful consequences, surgeons hesitate to use it [11, 12]. Herein, we describe a new circumcision method which is remind the guillotine technique but completely different from it. Circumcision can be done still in a simple and quick manner with safe by our technique.
600 Patients and methods The procedure is as follow: a. After the marking of cut level of preputial skin on the coronal sulcus, a straight-haemostat is loosely applied onto preputium at 6–12 o’clock position just above the glans, while preputial skin is pulled up and degloving of glans. b. The preputial skin and subcuticular tissue is incised by scalpel proximally to the haemostat (Figure 1a). c. A small window (approximately 7–12 mm in diameter) at the dorsal midline on preputial mucosa is opened by scalpel, while the preputium is retracted backward by straight-haemostat, like a tent (Figure 1b and c). d. Seeing the glans, preputial mucosa is transected through this window by scissors to the frenulum in both sides (Figure 1d). e. Frenular tissue is excised with caring of frenular short cutting. f. Mucosal trimming is done.
Frenular vessels are controlled, and other bleeders are ligated. The wound edges are approximated with interrupted sutures of 4/0 chromic catgut. We use an initial dressing and take it out in the first day of operation. All of the circumcision operations were performed as day cases. We advise the parents to give acetaminophen orally to relieve of pain in first 24 hours, and to apply fusidic-acid cream twice a day to the wound edge for the first 48 hours, routuniley.
Discussion Today, there are numerous techniques for circumcision described in the literature [7, 8, 12–14]. Although circumcision is a simple operation and may be done with one of these techniques, each of them has risk of some complications. These complications may range from the trivial to the
Figure 1. (a) Incision only of preputium by scalpel proximally to the haemostat. (b) Opening of a window on preputial mucosa by scalpel. (c) Opened window on preputial mucosa on the dorsal midline. (d) Excision of preputial mucosa by scissors through window, while observing glans.
601 tragic according to the surgical technique [5, 6, 9]. The guillotine technique on circumcision is a simple and quick operation. However, in this technique sometimes unnoticed clamping of preputium with glans might result with severe injury, even amputation of glans and urethral fistula formation. In addition, frenular band short cut and bleeding of frenular vessels may occur very often due to cutting preputial tissue very close to frenulum on ventral midline [9]. Although circumcision may be done easily by using guillotine technique, which described by Frank, the preputium is cut without seeing the glans and frenulum in this technique [13]. And it is not always possible to feel or palpate glans inferior to the haemostat, which applied at the level of corona) sulcus. Although the real rate of the complications such as too much skin removal, glans amputation, urethral fistula or frenular band short cut is not known, the awful consequence of this severe damage makes the surgeons reluctant on using of this technique [9, 14]. In our technique, which we recommend here, there is no risk amputation of glans or frenular band short cut, as well as urethral fistula since the preputial mucosa is already excised, while glans and frenulum are being observed. On the other hand, there is almost no bleeding of frenuler vessels. As a conclusion, window technique, which we described here is simple, quick and safe operation with least bleed. We strongly recommend to use this circumcision technique in the clinics, where this operation are doing oftenly. Acknowledgement We wish to thank Gu¨lsah Bademci, due to kindly help on drawing the figures.
References 1. Schoen EJ. The status of circumcision of newborns. N Engl J Med 1990; 322: 1308–1312. 2. Wiswell TE, Tencer HL, Welch CA et al. Circumcision in children beyond the neonatal period. Pediatrics 1993; 92(6): 791–793. 3. O’Brien TR, Eugenia MPH, Calle Eatlanta GA et al. Incidence of neonatal circumcision in Atlanta, 1985–1986. Southern Med J 1985; 88(4): 411–415. 4. Kochen M, McCurdy S. Circumcision and the risk of cancer of the penis. Am J Dis Child 1980; 134: 484–486. 5. Craig JC, Grigor WG, Knight JF. Acute obstructive uropathy-a rare complication of circumcision. Eur J Pediatry 1994; 153: 369–371. 6. Datta NS, Zinner NR. Complication from plastibell circumcision ring. Urology 1997; 9: 57–58. 7. Harahap M, Siregar AS. Circumcision: a rewiev and a new technique. J Dermatol Surg Oncol 1988; 14(4): 383–386. 8. Tucker SC, Cerqueiro J, Sterne GD et al. Circumcision: a refined technique and 5 year review. Ann R Coil Surg Engl 2001; 83(2): 121–125. 9. Kaplan GW. Complications of circumcision. Urol Clin North Am 1983; 10: 543–549. 10. Redman JF. Circumcision revision in prepubertal boys: analysis of a 2 year experience an description of a technique. J Urol 1995; 153: 180–182. 11. Yilmaz F, Sarikaya S, Yildiz S, Buyukalpelli R. Rare complication of circumcision:penile amputation and reattachment. Eur Urol 1993; 23: 423–424. 12. Sullivan DCO, Heal MR, Powell CS. Circumcision: how do urologist do it?. Br J Urol 1996; 78: 265–270. 13. Crawford DA. Circumcision: a consideration of some of the controversy. J Child Health Care 2002; 6(4): 259–270. 14. Trier WC, Drach GW, Ariz T. Concealed penis. Am J Dis Child 1973; 125: 276–277. Address for correspondence: Erdal Yilmaz, MD, Kirikkale Universitesi Tip Fakultesi, Uroloji AD, Sagalik Sokak, 71100, Kirikkale, Turkey E-mail:
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