Circumcision device makes the cut in paediatric procedures

A modified disposable circumcision suture device (DCSD) facilitates simpler and faster procedure in children, with a relatively lower complication rate and better cosmetic results compared with the conventional dorsal slit technique, according to a recent study.

Traditional methods, such as forceps-guided, dorsal slit, and sleeve resection, are considered the gold standard in most male circumcision programmes. [Photomed Laser Surg 2013;31:422-427; Int J Surg 2017;43:17-25; Urology 2015;85:799-804]

“However, [such] procedures are time-consuming and have some drawbacks, including bleeding, wound infection, pain, and unsatisfactory cosmetic results. In order to overcome these problems, many newer devices … have been developed,” the investigators said.

The study assessed the surgical outcomes and complications of a modified circumcision using DCSD (n=144) against those of a conventional dorsal slit procedure (n=140) in boys aged 7–16 years. There was no difference in patient age or indications between the groups (p>0.05).

Compared with the conventional method, DCSD led to a significantly shorter operation time (mean, 7.4 vs 21.3 minutes; p<0.001) and less blood loss (mean, 2.6 vs 5.6 ml; p<0.001). Intraoperative and postoperative pain scores were also lower with DCSD (p<0.001). [Urology 2020;doi:10.1016/j.urology.2020.06.018]

Patients in the device vs conventional group had faster incision healing time (mean, 12.2 vs 14.2 days; p<0.001) and higher satisfaction rate of penile cosmetic appearance (99.3 percent vs 92.8 percent; p<0.01).

In terms of safety, DCSD outdid the dorsal slit method, being associated with a significantly lower complication rate (4.3 percent vs 12.3 percent; p<0.05) and less frequent occurrences of severe oedema (0.7 percent vs 5.8 percent; p<0.05). There were no between-group differences seen in the rates of bleeding, infection, and wound dehiscence.

A downside of common circumcision devices is that physicians, especially beginners, cannot observe the condition of inner foreskin layer when performing removal of foreskin. This results in either too much or too little skin removed. [Zhongguo Nan Ke Xue 2016;30:33-36; Zhonghua Nan Ke Xue 2018;24:404-408]

In the current study, the investigators redesigned the operating procedures for circumcision by combining the advantages of traditional dorsal slit method and DCSD technique. Specifically, they marked the inner foreskin layer incision at 0.5–1.0 cm proximal to the coronal sulcus before removing the prepuce via DCSD.

“In [that] way, the DCSD made an even and symmetrical incision and avoided too much or too little skin removed, keeping the lengths of the edges on the inner and outer skin of the prepuce consistent, thereby improving the penile cosmetic appearance,” they pointed out.

The investigators also emphasized the importance of selecting an appropriate DCSD size for preventing intraoperative and postoperative complications. The circumcision device used in the current trial was chosen properly based on the penis circumference in the flaccid state, abiding by the principle of “larger rather than smaller.”

“With increased experience, we have observed [that] a slightly larger DCSD maintains a certain tension of the foreskin and avoids poor incision alignment, ensuring better aesthetic results postoperatively. If DCSD is too large, too much foreskin will be removed,” they stated.

In light of the findings, the modified DCSD circumcision represents an attractive alternative to the conventional technique for children, having the potential to be used around the world, according to the investigators.