Blackwell Science, LtdOxford, UKIJUInternational Journal of Urology0919-81722005 Blackwell Publishing Asia Pty LtdMarch 2005123374377Original ArticleTissue glue in circumcisionKU

Ozkan
et al.

International Journal of Urology (2005) 12, 374–377

Original Article

Wound approximation with tissue glue in circumcision

KERAMETTIN UGUR OZKAN,1 MURAT GONEN,2 TAYFUN SAHINKANAT,2
SEFA RESIM2 AND MUSTAFA CELIK3
Departments of 1Pediatric Surgery, 2Urology and 3Family Medicine, Kahramanmaras
Sutcuimam University Medical Faculty, Kahramanmaras, Turkey

Abstract Background: To assess the feasibility of using tissue glue in the approximation of circumcision
wounds in children.
Patients and methods: A prospective randomized trial was carried out on 30 boys (age, 1–10 years)
admitted to the Kahramanamaras Sutcuimam University Medical Faculty, Turkey. The results of
wound approximation in circumcision with cyanoacrylate tissue glue and suturing with interrupted
5/0 plain catgut were compared. The operations were carried out by the same surgeon using an
identical technique. The wounds were assessed 1 day, 3 days, 1 week and 1 month postoperatively.
Results: There was no difference between the two groups in the rates of wound inflammation,
infection, bleeding and dehiscence, although cosmetic appearance was better in the tissue glue group.
The operation time was also shorter in this group.
Conclusion: Using tissue glue for wound approximation in circumcision is a feasible alternative.

Key words circumcision, tissue glue.

Introduction Patients and methods

Circumcision is one of the most common surgical pro- Between June 2003 and August 2003, 30 healthy boys
cedures in the world. Absorbable suture materials have (age, 1–10 years) admitted to the Kahramanamaras Sut-
been traditionally used for wound approximation in cir- cuimam University Medical Faculty, Turkeyfor elective
cumcision. The only disadvantage of these sutures is circumcision were included in the present study. These
that they may leave stitch marks along the suture line. boys were randomized into two groups. Parents were
Recently, tissue glue application for wound closure has informed of the study and consent was obtained. An
been reported as a new alternative for circumcision.1–4 identical surgical technique was performed by the same
Although some investigators stated that tissue glue has surgeon. Control of bleeding was carried out by using
no extra advantage to suturing,4 others believed tissue ligature and cauterization was not used. All boys were
glue has a superior cosmetic results.3,5 operated under general anesthesia with caudal block. In
The purpose of this prospective randomized study the control group (group 1), 5/0 chromic catgut suture
was to assess the feasibility of using the tissue glue in was used for wound approximation. In the testing group
approximation of circumcision wounds in children. (group 2), mucocutaneous approximation was per-
formed by n-butly cyanoacrylate (INDERMIL) tissue
glue. To protect the external meatus from accidental
tissue glue contact, the glans was covered with sterile
Correspondence: Keramettin Ugur Ozkan MD, Kahraman- gauze. Wound edges were approximated by using for-
maras Sutcuimam Universitesi, Tip Fakultesi Cocuk Cerra- ceps or skin hooks and a thin layer of tissue glue was
hisi AD, 46050-Kahramanmaras, Turkey.
Email: ozekan@hotmail.com applied. The wound edges were held together until the
Received 10 December 2003; accepted 21 September glue dried (Fig. 1). The wounds of all the boys were
2004. assessed on days 1, 3, 7 and 30 after the operation.
 Tissue glue in circumcision 375

Fig. 1 Penis, following tissue glue aplication.

Wound inflammation, infection, dehiscence, bleeding

and cosmetic appearance were assessed. After 1 month,
evaluation of cosmetic appearance categorized in to
mild, good and excellent results was also performed by
a plastic surgeon who was blinded to the study (Fig. 2).
Cosmetic appearance is categorized according to stitch
marks and neatness of mucocutaneous line. Patients
without any stitch marks and with a neat mucocutaneous
line were categorized as excellent, patients with less
than three stitch marks and/or minimal irregularity in
the mucocutaneous line were categorized as good and
patients with more than three stitch marks and/or with
significant irregularity in the mucocutaneous line were
categorized as mild. The Mann–Whitney U-test and the
c2 test were used to analyze the results. P-values less
than 0.05 were considered to be significant.

Results

There were no problems during clinical follow-up for

any patient. There were no significant differences in the Fig. 2 Penis, 1 month after circumcision. a) Mild cos-
two groups according to wound inflammation, wound metic result of cat-gut suture group. b) Excellent cosmetic
result of tissue glue group.
376 KU Ozkan et al.
Table 1 Complications and operation times
Groups n (mean age) Inflammation Infection
Group 1 15 (3.9 years) 1 2
Group 2 15 (4.1 years) 1 2
P-value – >0.05 >0.05
*Statistically significant.
Table 2 Cosmetic results
Groups Mild Good
n (%) n (%)
Group 1 (n = 15) 6 (40) 9 (60)
Group 2 (n = 15) 0 (0) 3 (20)
*‘Mild’ and ‘good’ colums were joined for appropriate c2 test. **Statistically significant.
infection, bleeding and wound dehiscence. Operation
time was significantly higher in the control group
(11.4 min versus 13.8 min, P < 0.01, Table 1).
After 30 days, patients in the tissue glue group had
superior cosmetic results than in the control group
(Table 2). In the suturing group, there were no excellent
results, but there were 12 excellent results in the tissue
glue group. This was statistically significant (P < 0.05).
Discussion
Cyanoacrylates were discovered in 1949. Ten years
later, these agents were started to be used as tissue
adhesives. Methly 2-cyanoacrylate was the most widely
used compound initially, but in 1970s its histotoxicity
was recognized. After this, longer alkyl chain derivates,
such as n-butly 2-cyanoacrylate and octlycyanoacrylate,
were developed. They were found to be superior to short
alkyl chain derivates with a smaller acute inflammatory
response and faster polymerization. Butlycyanoacry-
lates have been used successfully for topical skin clo-
sure in Canada and Europe since early 1980s with no
adverse reports.6–8 There have been no reports of toxicity
or carcinogenicity when these adhesives were used top-
ically.9 In 2002, the Food and Drug Administration
approved butylcyanoacrylates for external use and they
have started to be used in the USA with great interest.
The major limitation of butylcyanoacrylates is low early
breaking strength.10,11 Studies have shown wound break-
ing strength to be equal to that of suture repaired
wounds at 5–7 days, but at day 1, breaking strength is
only approximately 10% to 15% that of a wound closed
with 5/0 monofilament sutures.5 This restricts the use of
butylcyanoacrylates to low-tension areas.
Bleeding Dehiscence Operation time median (min–max)
0 0 13.8 (12–15.3)
0 0 11.4 (10.7–12.4)
>0.05 >0.05 <0.001*
Excellent c2* P-value
n (%)
0 (0) 20.0 0.000**
12 (80)
In the present study, there were no differences
according to wound inflammation, wound infection,
bleeding or wound dehiscence. There was no tissue reac-
tion to cyanoacrylate. In the cyanoacrylate group, cos-
metic appearance was found to be superior to suturing
group because there were no residual suture marks.
After circumcision, suture marks are seen more than
other wound closures, this may be related to edema of
penile mucosa. In circumcision, at the beginning of pro-
cedure, prepisium should be retracted and cleaned. This
may cause penile mucosal edema, especially in younger
children. Sutures planted into the mucocutaneous line
may cause stitch marks because of this edema. For this
reason, better cosmetic outcomes are obtained by clos-
ing the mucocutaneous line with tissue adhesives rather
than surgical stitches.
Moreover, the time taken for wound closure was sta-
tistically faster in tissue glue group than in the suturing
group. Recently, bacteriostatic and hemostatic effects of
cyanoacrylates have been reported.12 These effects may
also be advantages of tissue glue.
In conclusion, the present study has shown that the
use of tissue glue in circumcision has no extra advantage
in inflammation, infection, bleeding and dehiscence.
However, it shortened operation time with a superior
cosmetic result. Accordingly, we believe tissue glue
approximation in circumcision is a feasible alternative.
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