Circumcision

Definition
• Removal of some or all of the foreskin (prepuce)
from the male reproductive organ
Anatomy
History
• One of the oldest surgery performed
 more than 6000 years old
• Related to religious sacrifice, sign of
adulthood, method to discourage
masturbation, aid to hygiene, etc
• Elective circumcision is still
controversial until now
INDICATION vs
CONTRAINDICATION
Indication
• Phimosis
• Paraphimosis
• Recurrent UTI or balanitis
Contraindication
• Circumcision should not be performed in
neonates with other penile conditions that
require surgical correction
• Hypospadia
• Penile curvature (chordee)
• Dorsal hood deformity
• Buried penis
• Webbed penis
Buried Penis Webbed Penis
Benefits of Elective Circumcision
• Prevention of penile cancer
• Prevention of UTI, and balanitis
• Reduced risk of STD (e.g. HIV)

“Although health benefits are not great

enough to recommend routine circumcision
for all male newborns, the benefits of
circumcision are sufficient to justify access
to this procedure for families choosing it… “
-- AAP Task Force on Circumcision, 2012
IATROGENIC TRAUMA
DUE TO CIRCUMCISION
Epidemiology
• The incidence of complications after
circumcision varies considerably (0.2–31%)
depending on the study type, technique,
geographic area, age, indications, and era.

• Complications occur less frequently among

neonates and infants than in older boys and
adult
Iatrogenic Trauma Complications
• Early complications
• Postoperative bleeding is the most common early complication. The rate
ranges from 0.1% to 5%
• Infection is also common (0.2–4%)
• Urinary retention due to tight circular bandaging
• Glans necrosis

• Late complications
• Meatitis is the most common late complication and occurs in 8–31% of
circumcised young boys
• Excessive or inadequate foreskin
• Skin bridges between the glans penis and the penile shaft
• Inclusion cysts
• Penile torsion or curvature
• Urethrocutaneous fistula
• Phimosis
• Penile adhesions
CIRCUMCISION TECHNIQUE
 Technique and Devices
Technique Devices
• Dorsumcision • Mogen clamp
• Excision (Sleeve resection) • Gomco Clamp
• Forceps guided (Guillotine) • Plastic bell
• SmartKlamp
 Dorcumcision Tehnique
1. Informed Consent
2. Genital Preparation ( Shave pubic hair, drape using
10% Povidone Iodine, sterile doek)
3. Anesthesia (Topical anesthetic, dorsal penile nerve
block, ring block, general / regional anesthesia)
4. Surgery
 Dorsumcision Steps
1. The glans and foreskin are separated to fully expose the coronal
groove (in young children)
2. Remove smegma (white pasty substance made up of dead cells
which previously held the foreskin and glans together)
3. Place straight clamp on the position of 11 and 1 o’clock of the penis
4. Perform the dorsal slit at the position of 12 o’clock of the penis
5. Cut the skin and mucous along the coronal groove
6. Hemostasis
7. Dressing the wound.
SmartKlamp
Complication
• Bleeding
• Infection
• Penile skin complication
• Glanular adhesions and skin bridges
• Meatal stenosis
Asymmetrical redundant penile Penile skin bridge Urethral and glanular resection
Meatal Stenosis
 References
1. MA (Hon WSMM, FACS AJWMP, MBA LRKM, PhD AWPM, MD CAP. Campbell-Walsh
Urology 11th Edition Review. 2 edition. Philadelphia, PA: Elsevier; 2015. 624 p.
2. Techniques of Male Circumcision [Internet]. [cited 2019 Nov 16]. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3888996/
3. Circumcision Policy Statement | American Academy of Pediatrics [Internet]. [cited
2019 Nov 16]. Available from: https://
pediatrics.aappublications.org/content/130/3/585
4. Summerton DJ, Kitrey ND, Lumen N, et al. EAU Guidelines on Iatrogenic Trauma.
European Urology .2012. vol. 62: 628-639