International Urology and Nephrology

, Volume 40, Issue 2, pp 377–381

Circumcision with a new disposable clamp: Is it really easier and more reliable?

Authors

    • Department of UrologyAtatürk Teaching and Research Hospital
  • Murat Çakan
    • Department of UrologyDışkapı Teaching and Research Hospital
  • Berk Burgu
    • Department of UrologyDışkapı Teaching and Research Hospital
Original Article

DOI: 10.1007/s11255-007-9275-x

Cite this article as:
Aldemir, M., Çakan, M. & Burgu, B. Int Urol Nephrol (2008) 40: 377. doi:10.1007/s11255-007-9275-x

Abstract

Purpose

To compare the results of a new disposable clamp (SCD) used for routine circumcision in our department, compared with the conventional dissection tecnique (CDT) in infants and children.

Methods

The SCD and CDT were evaluated prospectively, in terms of the duration, complication rate and postoperative pain assesment. The cosmetic result and parents' satisfaction were evaluated after 6 weeks. A total of 200 boys were included in the study (with a median age of 4.45 years).

Results and conclusions

The median operative duration was 10 min less for the SCD (18 vs 8 min; P < 0.001). There was no difference in complication rates for both groups. The cosmetic results assessed by a blinded urologist were better for the SCD group (P < 0.001). The parents' satisfaction score for the procedure was similar in both groups, as 8 out of a scale up to 10 filled in by the parents. Circumcision with the SCD is quicker and leads to a better cosmetic results than with the CDT, without increasing morbidity.

Keywords

CircumcisionClampMorbidityCosmetic resultPatient satisfaction

Abbreviations

SCD

Smart Clamp Device

CDT

Conventional dissection technique

IQR

Interquartile range

Introduction

Male circumcision is one of the oldest surgical procedures and is performed in about one out of six men in the world [1]. In Turkey, most circumcisions are performed under local anaesthesia either in hospitals by surgeons or outpatient procedures by general practitioners. This study evaluates the safety and results of circumcision technique using a new disposable clamp [Smart Clamp Circumcision Device (SCD); Hengelo, The Netherlands; Fig. 1] in our department.
https://static-content.springer.com/image/art%3A10.1007%2Fs11255-007-9275-x/MediaObjects/11255_2007_9275_Fig1_HTML.jpg
Fig. 1

The SCD consists of an inner tube and an outer ring with measuring device

Materials and methods

A total of 130 SCD and 70 conventional dissection technique (CDT) procedures were performed with a mean age of 4.7 (2–9 years) and 3.9 (2–7 years) respectively. Circumcisions were performed by three urologists from the same institution. Parents were informed about both techniques and children involved in the groups according to the parents' prefence after informed consent. The study protocol was approved by the hospital's ethical committee.

Surgical technique

Local anaesthesia was obtained by subcutaneous injection with a small-diameter needle (25 G) of 0.2 ml/kg (<5 ml) lidocaine 1% at the base of the penis. After disinfection, the physiological adhesions between the glans penis and the inner mucosal layer of the foreskin were removed with a sterile sponge.

For the CDT, the surgical procedure utilized was the conventional sleeve technique. The inner mucosal layer is trimmed to 3 mm above the corona. After meticulous haemostasis is obtained by unipolar electrocautery (maximum power 25 W), the skin edges are approximated using absorbable suture (Chromic catgut 4/0; Toptex, Klettgau, Germany).

For the SCD technique, the level of circumcision is marked preoperatively on the skin side of the prepuce with a surgical pen, just proximal to the corona. By selecting one circular hole of the measuring card, with a diameter just large enough to encircle the glans penis at the level of the corona, the correct clamp is chosen from four sizes with diameters of 10–21 mm. After stretching with a straight clamp, the foreskin is pulled over the rim of the inner tube and positioned inside the outer ring to the level previously marked. If the orifice is too narrow, a dorsal slit is made. Just before the clamp is locked by pushing the two levers inwards, the frenulum is pulled up through the clamp with a suture, thereby stretching the urethra to prevent postoperative urinary retention and pain during voiding. Then the foreskin is cut circumferentially 1–2 mm distal to the outer ring, with the inner tube protecting the glans. The clamp is left in place and the boy is able to urinate through the open end (Fig. 2). After 4 days, the connection between the inner tube and the outer casing is cut and removed. The inner tube is left to fall off spontaneously in the following days (Fig. 3).
https://static-content.springer.com/image/art%3A10.1007%2Fs11255-007-9275-x/MediaObjects/11255_2007_9275_Fig2_HTML.jpg
Fig. 2

Postoperative fourth day (before the removal of the clamp)

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Fig. 3

Postoperative fourth day (after the the removal of the clamp)

The parents were instructed by an information leaflet to shower or bathe the wound daily and to apply fusidic-acid cream twice a day to the wound edge. In case of pain, the parents were advised to administer oral acetaminophen or as suppositories. Enough medication for the first 5 days was given to all parents. Both the duration of the procedure, e.g. the time elapsed after injection of local anaesthesia until wound care, and operative or postoperative complications, were recorded. Bleeding was defined as the necessity for re-exploration and suturing for haemostasis. Infection was defined as erythema with pus only. On the fourth day after operation, the parents were interviwed during removal of the SCD. The postoperative pain and pain during voiding was measured by Proxy, as scoring these items on a scale of 1 to 5. (Turkish version Verbal Rating Scale: 1 = no pain; 2 = mild pain; 3 = moderate pain; 4 = considerable pain; 5 = unbearable pain) [2, 3]. The parents were also asked for the days their son required analgesics or experienced a bad night’s rest, and after how many days he recovered fully to normal daily home activity. After a minimum of 6 weeks, the boys were evaluated again, and the parents’ evaluation for the cosmetic result and a score on a scale of 1 (very bad) to 10 (extremely good) for the entire procedure were obtained [4]. Furthermore, the appearance of the penis was blindly evaluated by one of the authors as to the covering of the glans by the residual prepuce, and the length of the inner mucosal layer was measured.

Continuous data are expressed as the median (interquartile range, IQR). For analysing differences between groups for continuous data, Student’s two-tailed t-test was used, and otherwise, if not normally distributed, a Mann–Whitney U-test was applied. The chi-square test, or if appropriate Fisher’s exact test, was used to compare proportions. An ANOVA for repeated measurements was used to compare Verbal Rating Scale scores of both groups in time; all reported P-values are two-tailed.

Results

A total of 200 boys (130 SCD, 70 CDT) were included from June to August 2006 in the study. The operative characteristics, morbidity and cosmetic results are shown in Table 1. The median operative duration was 10 min longer for the CDT. In one SCD procedure it was necessary to convert to the CDT, because the device disconnected spontaneously during the procedure. Two boys in the CDT group had to be re-operated on the same day because of bleeding. There was no bleeding in the SCD group when the clamp was in situ, but in three cases bleeding had to be controlled with a suture after the clamp was removed on the fourth day. No clamp was removed earlier than intended and most of the inner tubes fell off on the day when the clamp was disconnected. Three of the boys was given antibiotics to treat swelling and redness of the penile shaft in the SCD group.
Table 1

Operative characteristics, morbidity and cosmetic results

Variable

CDT

SCD

P

Number

70

130

 

Median (IQR) duration, min

18 (15–25)

8 (5–11)

<0.001

Conversion to CDT

1

 

Complications

    Bleeding

2

3

 

    Infection

2

3

 

    Urinary retention

0

0

 

Median (IQR) scores

    Pain with voiding

1 (1–2)

1 (1–3)

0.18

    Bad night’s rest (in nights)

0 (0–1)

1 (0–2)

0.03

    Use analgesics (in days)

2 (1–3)

3 (1–4)

<0.001

    Normal daily home activitya

1 (1–2)

0 (0–2)

<0.001

Cosmetic result

    Assessed by investigator

   

     Number

70

130

 

     Glans penis completely free

50 (71)

115 (88)

<0.001

    Corona

   

      Just covered

15 (22)

10 (8)

<0.001

      Half-covered

5 (7)

5 (4)

 

      Completely covered

0

0

 

Median (IQR) length of inner mucosal layer, mm

3 (3–7)

5 (4–7)

0.04

By parents' number

70

130

0.14

Happy, n (%)

60 (86)

120 (92)

 

Median (IQR) score of total

8 (8–9)

8 (7–9)

0.05

a0 = day of operation; 1 = first day after operation; 2 = second day after operation, etc

The postoperative pain was comparable in both groups, but the boys with the SCD had more disturbed nights and more analgesics were given (Table 1). However, they recovered earlier to normal daily home activity.

The cosmetic results were similar for both methods. The parents’ satisfaction score for the procedure, including the return for the removal of the clamp, was the same in both groups.

Discussion

In the twentieth century, many circumcision clamps were developed for a quicker and safer procedure [5]. Most of these are re-usable clamps in which the foreskin had to be crushed for several minutes before it was cut distally from the crushing zone. The only widely used disposable circumcision device is the Plastibell® device for neonatal circumcision. After the foreskin is pulled over this plastic bell, it is tied on the bell with a suture and subsequently cut. The bell is then snapped off, leaving the ring to slough off several days later. This technique is considered quick, easy and safe [6].

The advantages of SCD are speed and reliable haemostasis directly after the procedure. However, some minor bleeding may occur after removing the clamp and the control of bleeding with a suture was required in three of the cases, three older boys, aged 7, 9 and 11 years. It is probably advisable to remove the clamp in older boys 1–2 days later than usual. Although a frank infection with pus was rarely encountered, there was often an inflammatory response with erythema partially or totally on the penile skin and glans, when the clamp was disconnected. This was considered to be the result of a probable ischaemic injury or a possiblle foreign-body reaction. Similar findings were reported with the Plastibell [7].

Although postoperative pain was comparable in both groups, nocturnal pain was more frequent with the SCD, which is why analgesics were required for longer. Interestingly, less daytime discomfort was experienced in the SCD group, presumably because the clamp protects the wound while the boy is mobile. A disadvantage of the clamp is the postoperative check needed to remove the clamp, which could cause discomfort and anxiety to the boy and his family.

Circumcision with the SCD more often caused a completely uncovered glans penis, but insufficient removal of the foreskin, occurred more than SCD group (7% vs 4%) [8]. In a series of consecutive conventional circumcisions in Australia, Leitch found that 9.5% of operations had to be repeated because of inadequate skin excision during the initial procedure, but in a study in the UK only 1% were repeated [9, 10]. With a clamp circumcision it is essential to correctly mark beforehand the level of cutting (just proximal to the corona), as this decreases the risk of an incomplete circumcision. It may be wise to ask parents before circumcision about their preference for the length of the redundant prepuce. Although the inner mucosal layer was longer after the SCD, the parents did not qualify this as aesthetically unpleasent. Also, the absence of small scars from sutures, which are common after conventional surgery, was appreciated.

Conclusion

Circumcision with the SCD is simple, less traumatic and quicker. The technique even leads to better cosmetic results than CDT, without increasing morbidity. Disposable circumcision devices like the SCD can be used as a valuable tool for efficient and safe circumcisions. Omitting the need for most of the classical surgical equipment may potentially be proven to overcome the castration phobia and change the classical aproach to circumcision age.

Copyright information

© Springer Science+Business Media B.V. 2007