Journal of Pediatric Urology (2020) 16, 493.e1e493.
e6
Department of Surgery, Faculty
of medicine Umm Al-Qura
University, Makkah& King Faisal
Specialist Hospital & Research
Centre, Saudi Arabia
* Correspondence to: Osama A
Bawazir, Department of
surgery, Faculty of medicine in
Umm Al-Qura University at
Makkah, P.O.box 715, Makkah,
21955, Saudi Arabia. Tel.:
þ966125270000x4125
** Correspondence to:
Abdulaziz M Banaja, King Faisal
Specialist Hospital & Research
Centre, Dept. of surgery, Saudi
Arabia.
obawazir@yahoo.com, oaba-
wazir@uqu.edu.sa (O.A.
Bawazir)
Azizbanaja@hotmail.com (A.
M. Banaja)
Keywords
Male circumcision; Sutureless
technique; Interrupted suture
technique
Received 30 March 2020
Revised 17 June 2020
Accepted 20 June 2020
Available online 25 June 2020
https://doi.org/10.1016/j.jpurol.2020.06.025
1477-5131/ª 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
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Sutureless versus interrupted sutures
techniques for neonatal circumcision; a
randomized clinical trial
Osama A. Bawazir *, Abdulaziz M. Banaja **
Summary
Introduction
and objective: Male circumcision is a common pro-
cedure all over the world; in Saudi Arabia, circum-
cision is the most frequent elective surgical
procedure performed on males. The use of sutures
for neonatal circumcision may decrease bleeding;
however, it may lead to skin sinus formation. The
objective of this study was to compare the suture-
less to the interrupted sutures technique for
neonatal circumcision with Gamco clamp.
Patients and methods
We performed a randomized controlled clinical trial
between 2017 and 2018. The study included 182
newborns assigned into two groups. Group 1 (n Z 94)
included neonates who had sutureless circumcision,
and group 2 (n Z 89) included neonates who un-
derwent circumcision using interrupted absorbable
6/0 sutures. Study endpoints were bleeding, wound
gaping, skin tunneling or sinus, and cyst formation.
Results
There was no significant difference in patients’ age
and weight between groups. The procedure was
significantly longer in group 2 (12.24  2.17 vs.
6.54  1.42 min; p < 0.001). There was no differ-
ence in bleeding between both groups (4 (4.26%) vs.
Summary Table Comparison between duration of the procedure, early and late complications.
Group 1 (n Z 94)
Bleeding 4 (4.26%)
Wound gaping 8 (8.5%)
Skin tunnel/sinus 0 14 (15.91%)
Cyst formation 2 (2.13%)
Procedure duration (minutes) 6.54  1.42
2 (2.27%) in groups 1 and 2, respectively, p Z 0.683).
Cyst formation was significantly reduced in group 1
(2 (2.13%) vs. 13 (14.77%); p Z 0.002) and skin sinus
formation increased in group 2 (14 (15.91%) vs. 0 in
group 2 and 1, respectively; p < 0.001).
Discussion
Circumcision can be performed with several tech-
niques, and the superiority of one approach over the
other is still debated. Many surgeons use interrupted
sutures to oppose the skin edges, and in some re-
ports, tissue glue was used for skin edges re-
approximation with acceptable cosmetic results. In
our study, the mean time taken for sutureless
circumcision was about 7 min, and for the suture
circumcision, it took around 11 min. In addition, the
formation of a skin tunnel or sinuses rate was high
despite the use of very thin sutures.
Conclusion
Male circumcision is a common and safe technique
with minor and treatable complications. Risks of
bleeding and sinus track formation are low with the
sutureless method. The sutureless technique is rec-
ommended after Gamco circumcision as the stan-
dard technique for male circumcision in the
newborn.
Group 2 (n Z 88) P-Value
2 (2.27%) 0.68
1 (1.14%) 0.02
<0.001
13 (14.77%) 0.002
12.24  2.17 <0.001
493.e2
Introduction
Circumcision is the most frequent elective surgical pro-
cedure performed on males in Saudi Arabia, with circum-
cision rates for newborn boys around 99% [1]. We perform
neonatal circumcision for social, cultural, personal, and
religious reasons [2]. Male circumcision is common all over
the world, and in 2009, 54.5% of boys in the USA were
circumcised [3,4]. Neonatal circumcision has several po-
tential benefits, and according to the American Academy of
Pediatrics, it could decrease the incidence of urinary tract
infection and carcinoma of the penis [5,6]. The procedure
is relatively safe, and complications depend on the expe-
rience of the operator and the available equipment and
supplies [7]. The objectives of circumcision are to remove
the shaft skin and inner preputial epithelium enough to
uncover the glans and to prevent phimosis and render the
development of paraphimosis impossible [8]. The Gomco
clamp is commonly used for neonatal circumcision, which
provides a bloodless procedure, in addition to the accepted
cosmetic results [9].
Many research agreed that normal penile anatomy was
associated with good outcomes of neonatal circumcision
[10]. Parents wish to get excellent wound healing with no
complications and the best cosmetic results. For decades,
circumcision has been performed without sutures with
acceptable results. One of the significant concerns about
the use of sutures in neonatal circumcision was the devel-
opment of stitch sinus, especially with the use of larger
sutures, and there is a strong belief in our community
against the use of sutures for neonatal circumcision
because of this belated sequel. We hypothesized that the
rate of sinus and cyst formation is different between
sutureless and interrupted sutures technique for neonatal
circumcision. Therefore, the objective of this study was to
compare the sutureless to the interrupted sutures tech-
nique for neonatal circumcision with Gamco clamp.
Patients and methods
Design
The research is a randomized controlled clinical trial that
included all newborn scheduled for circumcision in our
clinic between January 2017 and January 2018. The study
was conducted at the Pediatric Surgery Clinic, Jeddah,
Saudi Arabia. The Ethics Committee approved the study
(protocol number 051) and written informed consent was
obtained from the parents or guardians before randomiza-
tion. Both techniques were equally performed in our insti-
tution, and there was no preference for either technique.
Randomization and blinding
Simple randomization was used to assign patients into
either group. Closed envelopes were made containing both
treatments prior to commencing the study. The patients
were blindly assigned into either treatment groups, and the
nurses who collected the data, and the biostatistician were
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O.A. Bawazir, A.M. Banaja
not aware of group allocation. Parents were not aware of
the circumcision technique at the time of the procedure.
Patients
A total of 286 newborn boys were screened for possible
inclusion in the study. We excluded 101 patients; 47 were
older than four weeks, 53 refused randomization, and one
patient had hypospadias. We allocated the patients into
two groups according to the circumcision technique. Group
1 (n Z 96) included newborns who underwent sutureless
circumcision, and Group 2 (n Z 89) included the patients
who underwent circumcision using interrupted sutures. We
used absorbable 6/0 polyglactin suture (Vicryl, Ethicon Inc,
Bridgewater, NJ, USA) in all patients.
After randomization, three patients were excluded
because of loss for follow-up (2 in group 1 and one patient
in group 2). One-hundred eighty-two patients had per-
protocol analysis (94 patients in group 1 and 88 patients in
group 2). Three patients were lost for follow-up in both
groups and were excluded from the analysis. The loss of
follow-up was completely missing at random; therefore,
the exclusion was an appropriate option. We excluded pa-
tients older than four weeks (n Z 47), patients with
congenital anomalies (n Z 1), and patients who refused to
be enrolled (n Z 53). Fig. 1 shows the study flowchart.
Study endpoints
The primary endpoint was cyst/sinus formation. Short-term
secondary outcomes were postoperative bleeding, infec-
tion, wound gaping, and urinary retention. Long-term sec-
ondary outcomes were foreskin adhesions, redundant
foreskin, and buried penis, and incomplete circumcision.
Sample size calculation
We designed the study to include two groups of indepen-
dent cases and controls with 1:1 allocation. If the rate of
cyst and sinus formation in the interrupted suture tech-
nique is 0.14 and their rate in the sutureless method is 0.01,
we will need to study 78 cases assigned to each group to be
able to reject the null hypothesis with probability (power)
0.8 and the Type I error probability associated with this test
of this null hypothesis is 0.05.
Surgical technique
Physical examination was performed before circumcision to
identify congenital anomalies and exclude patients not
fulfilling the study criteria (age less than four weeks).
Paracetamol drops (15 mg/kg) were used as a pre-
medication, and anesthetic cream was applied locally.
Well-trained pediatric surgeons performed all circumcisions
using a circumcision board and Gomco clamp. Local anes-
thetic cream was used. The procedure commenced with
freeing the glans from the inner prepuce and cleaning the
smegma with chlorhexidine solution. We performed a dor-
sal slit to expose the glands. Prepuce was held at 12 and 1’
O’clock position with two artery forceps. An appropriate
size metal bell was introduced between the two artery
Sutureless versus interrupted sutures circumcision 493.e3

Figure 1 The study flowchart.

clamps and was placed over glans, and the prepuce was
drawn through the ring of the plate. The clamp was
assembled so that the prepuce was maintained between
the ring and bell. As the nut of the clamp got tightened, the
crushing force was applied to the prepuce, and this was
maintained for 30 s to achieve hemostasis (Fig. 2). Prepuce
was excised with a surgical blade; then, the nut was
released. The clamp was removed carefully, and the pro-
cedure was completed. The difference between the two
groups was the technique of wound closure. Four-corner
interrupted sutures were used for wound closure using 6/
0 absorbable sutures. We observed all patients for 20 min in
the immediate postoperative period. Follow-up was
scheduled on the 7th postoperative day, then after one, six,
and 24 months postoperatively. Both groups had wound
dressing, which was removed after 24e48 h. We educated
the parents about the warning signs and instructed them to
have bathing from day three after surgery.
Statistical analysis
We presented the continuous variables as mean and stan-
dard deviation and categorical variables as number and
percent. Continuous data were compared using a t-test or
ManneWhitney test and categorical data using Chi-square
or Fisher exact test if the expected frequency was less than
5. A p-value of less than 0.05 was considered statistically
significant. Statistical analysis was performed with Stata 16
(Stata Corp- College Station- TexaseUSA).

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493.e4 O.A. Bawazir, A.M. Banaja

Figure 2 Shows the hemostatic effect of Gomco clamp in the sutureless technique.

There was no significant difference in patients’ age and
weight between both groups (Table 1). The procedure was
significantly longer in group 2 (p < 0.001).
Results
wound gapping was slightly higher in group 1 (RR: 7.49; 95%
confidence interval: 0.96e58.67). The risk of sinus forma-
tion increased in group 2 compared to group 1 (RR: 14.95,
95% confidence interval: 2.01e111.37). No patient had
foreskin adhesions, redundant foreskin, or buried penis.
Postoperative complications are presented in Table 2.

Thirteen patients (out of 27 patients) had cyst/sinus repair.

There was no difference in bleeding between both groups
(Risk ration (RR): 1.87; 95% confidence interval: Discussion
0.35e9.97). No patient had wound infections nor urine
retention. Circumcision can be performed with several techniques,
All patients were followed for six months. Risk of cyst and the superiority of one approach over the other is still
formation was significantly reduced in group 1 (RR: 0.144; debated. Many surgeons use interrupted sutures to oppose
95% confidence interval: 0.03e0.62) (Fig. 3). The risk of the skin edges, and in some reports, tissue glue was used
for skin edges re-approximation with acceptable cosmetic
results [11,12]. We compared the sutureless and inter-
Table 1 Baseline patients’ data. Continuous variables are rupted sutures technique for neonatal circumcision, and
presented as mean and standard deviation (Group 1 the rate of sinus and cyst formation was higher in patients
included patients with sutureless technique and group 2 who had sutures.
included patients who had interrupted sutures Circumcision has potential complications, including
circumcision). bleeding, infection, wound dehiscence, meatal stenosis, a
cosmetic failure because of abnormal scarring, penile
Group 1; Group 2; P-Value injury, such as glandular necrosis and glans and penis
sutureless interrupted amputation, and urethral injury, such as urethra-cutaneous
(n Z 94) sutures fistula [13,14].
(n Z 88) In general, the reported complications are less frequent
Age (days) 11.22  7.22 12.43  7.84 0.35 among neonates and infants than among older boys, and
Weight (kg) 2.84  0.365 2.87  0.34 0.40 most prospective studies in this age group did not report
Procedure 6.54  1.42 12.24  2.17 <0.001 serious complications, with only minor and treatable
duration adverse events [7]. This low incidence of complications
(minutes) among neonates could be attributed to the minimal activity
in the newborn, which promotes wound healing.

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Sutureless versus interrupted sutures circumcision
Figure 3 Shows the suture technique with cyst and sinus formation.
The expected complication rate ranges from 0.19% to
3.1%, with higher complication rates occurring beyond the
neonatal period [15]. Late complications do occur and
fortunately are usually minor. Most late complications
involve adhesions, skin bridges, incomplete circumcision
with the uncircumcised appearance, and meatal stenosis
[16,17]. Major complications are extremely infrequent.
Bleeding is the most common complication of circumci-
sion [18]. Bleeding can occur at different points during
circumcision and typically happens from the vessels of the
dorsal dartos fascia at the preputial excision line or from
the frenulum. Bleeding can be managed with direct pres-
sure or with the application of silver nitrate to the bleeding
point. Re-exploration is rarely required in case of hema-
toma formation, and in patients with persistent bleeding,
coagulation screening is recommended. In our study, we did
not find a significant difference in bleeding between both
groups.
In Saudi Arabia and most Muslim countries, circumcision
was performed without sutures to approximate the skin
edges and using primitive instruments. Most of the old and
middle-aged men who were circumcised with the tradi-
tional method had excellent cosmetic results. In the early
experience of suture circumcision in our country, larger-
sized sutures (2/0) had delayed absorption with an
increased incidence of skin sinuses and cyst formation at
the site of circumcision. Therefore, there is a strong belief
in our community that the sutureless technique is far better
than the interrupted suture technique, and the parents
typically request circumcision without suture. This was the
rationale for performing the present study to compare the
outcomes between sutureless and suture techniques.
In neonates, the skin is thin, and the movement of the
newborn is minimal, in addition to this, the crushing effect
of the Gomco clamp decreases the incidence of major
bleeding in this group of patients. On the other hand, the
healing rate in neonates is fast, and the formation of a skin
tunnel or sinuses is common. With the use of rapidly
absorbed suture, the formation of skin sinuses decreases;
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493.e5
however, the risk is still present, and in this study, the rate
was high despite the use of very thin sutures.
The use of dressing did not affect the complication rates
of other penile surgery, and it is unlikely to affect the
complications after circumcision [19]. We believe that
dressing carries an essential role in stabilizing the wound in
the first 24e48 h, which gives time for clot formation and
starts the healing process.
In our study, the mean time taken for sutureless
circumcision was about 7 min, and for the suture circum-
cision, it took around 11 min. Elmore and colleagues re-
ported that their standard suturing time was approximately
10 min [11]. Therefore, the sutureless technique has a
time-saving advantage. Reducing the procedure time might
reduce the circumcision cost, in addition to saving the cost
of sutures.
World Health Organization has introduced male medical
circumcision as a human immunodeficiency virus (HIV)
preventive method [20]. Recent data stating that circum-
cision confers significant protection against the spread of
HIV has raised considerable interest in the procedure [21].
Study limitations
There are several limitations of the study, including lack of
blinding; however, parents and the process of data collec-
tion and analysis were blinded. Another limitation is the
randomization method since we used simple randomiza-
tion; the number of patients in each group was not equal.
The study included patients aged less than four weeks;
therefore, the generalization of the results to all ages is not
feasible.
Conclusion
Male circumcision is a common and safe technique with
minor and treatable complications. Risks of bleeding and
sinus track formation are low with the sutureless
493.e6 O.A. Bawazir, A.M. Banaja

[3] Elder JS. Circumcisiondare you with us or against us? J Urol

Table 2 Postoperative outcomes. Categorical variables 2006;176:1911.
are presented as number and percent (Group 1 included [4] Maeda J, , Thomson Reuters, Chari R, Rand), Elixhauser A,
patients with sutureless technique and group 2 included AHRQ). Circumcisions in U.S. Community hospitals, 2009.
patients who had interrupted sutures circumcision). HCUP statistical brief #126. Rockville, MD: Agency for
Healthcare Research and Quality; February 2012. Available at:
Group 1; Group 2; interrupted P-Value
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb126.pdf.
sutureless sutures (n Z 88)
[5] Wiswell TE, Hachey WE. Urinary tract infection and the un-
(n Z 94) circumcised state: an update. Clin Pediatr 1993;32:130e4.
Composite 2 (2.13%) 27 (30.68%) <0.001 [6] Circumcision policy statement. American Academy of pedi-
siunus/cyst atrics. Task force on circumcision. Pediatrics 1999;103:
Bleeding 4 (4.26%) 2 (2.27%) 0.68 686e93.
[7] Weiss HA, Larke N, Halperin D, Schenker I. Complications of
Wound 8 (8.5%) 1 (1.14%) 0.02
circumcision in male neonates, infants and children: a sys-
gaping
temic review. BMC Urol 2010;10:2.
Skin tunnel/ 0 14 (15.91%) <0.001 [8] Kaplan GW. Complication of circumcision. Urol Clin 1983;10:
sinus 543e9.
Cyst 2 (2.13%) 13 (14.77%) 0.002 [9] Horowitz M, Gershbein AB. Gomco circumcision: when it is
formation safe? J Pediatr Surg 2001;36:1047e9.
Re-suturing 1 (1.06%) 1 (1.14%) ˃0.99 [10] AAP Task Force on Circumcision. Technical report: male
Silver nitrite 3 (3.19%) 1 (1.14%) 0.62 circumcision. Pediatrics 2012;130:e756e85.
dressing [11] Elmore JM, Smith EA, Kirsch AJ. Sutureless circumcision using
2-octyl cyanoacrylate (Dermabond): appraisal after 18-month
experience. Urology 2007;70:803e6.
[12] Zafar F, Thompson JN, Pati J, Kiely EA, Abel PD. Sutureless
circumcision. Br J Surg 1993;80:859.
technique. The sutureless method is recommended after
[13] Ceylan K, Burhan K, Yilmaz Y, Can S, Kus A, Mustafa G. Severe
Gamco circumcision as the standard technique for male
complications of circumcision: an analysis of 48 cases. J
circumcision in the newborn. Pediatr Urol 2007;3:32e5.
[14] Johnson PV. Childhood circumcision. Surgery 2008;26:314e6.
 Ethics Approval and Consent to Participate: All proced- [15] Bawazir OA. A controlled trial of Gomco versus Plastibell for
ures performed in studies involving human participants neonatal circumcisions in Saudi Arabia. Int J Pediatr Adoles-
were in accordance with the ethical standards of the cent Med 2019. https:
institutional and/or national research committee, and //doi.org/10.1016/j.ijpam.2019.03.002.
with the 1964 Helsinki declaration and its later amend- [16] Palmer J. Abnormalities of the external genitalia in boys. In:
Wein, editor. Campbell-walsh urology. 10th ed. Elsevier
ments or comparable ethical standards. Approval of
Saunders; 2012. p. 3537e56.
research protocol was given by the Institutional Review
[17] Krill AJ, Palmer LS, Palmer JS. Complications of circumcision.
Board (IRB). Verbal and written consent was obtained Sci World J 2011;11:2458e68.
from the parents of all patients included in the study. [18] Niku SD, Stock JA, Kaplan GW. Neonatal circumcision. Urol
Clin 1995;22:57e65.
[19] Van Savage JG, Palanca LG, Slaughenhoupt BL. A prospective
Conflicts of interest randomized trial of dressings versus no dressings for hypo-
spadias repair. J Urol 2000;164(3 Pt 2):981e3.
Authors have no conflict of interests and the work was [20] Male circumcision for HIV prevention: research implications
not supported or funded by any drug company and the for policy and programming WHO/UNAIDS technical consulta-
authors declare that they have no competing interests. tion 6-8 March 2007 conclusions and recommendations (Ex-
cerpts). Reproduct Health Matter 2007;15(29):11e4. Available
at: http://data.unaids.org/pub/Report/2007/mc_
References recommendations_en.pdf.
[21] Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN,
[1] Burgu B, Aydogdu O, Tangal S, Soygur T. Circumcision: pros et al. Male circumcision for HIV prevention in young
and cons. Indian J Urol 2010;26:12e5. men in Kisumu, Kenya: a randomized controlled trial. Lancet
[2] Schoen EJ. The status of circumcision of newborns. N Engl J 2007;369:643e56. https://doi.org/10.1016/S0140-6736(07)
Med 1990;322:1308e12. 60312-2.

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