Male circumcision is a controversial subject in surgical practice. There are, however, clear surgical indications of this procedure. The American Academy of Pediatrics (AAP) recommends newborn male circumcision for its preventive and public health benefits that has been shown to outweigh the risks of newborn male circumcision. Many surgical techniques have been reported. The present review discusses some of these techniques with their merits and drawbacks. This is an attempt to inform the reader on surgical aspects of male circumcision aiding in making appropriate choice of a technique to offer patients. Pubmed search was done with the keywords: Circumcision, technique, complications, and history. Relevant articles on techniques of circumcision were selected for the review. Various methods of circumcision including several devices are in use for male circumcision. These methods can be grouped into three: Shield and clamp, dorsal slit, and excision. The device methods appear favored in the pediatric circumcision while the risk of complications increases with increasing age of the patient at surgery.
Keywords: Complication, dorsal slit, device, excision, male circumcision, public health benefit, technique
Circumcision is the surgical removal of the prepuce (foreskin) either in whole or in part. Religion, cultural, medical, and recently public health reasons[1,2] are known to be the major indications of the procedure. Usually, it is done in neonatal period but can be performed at any age. To maximize its health benefits,[1,2] to reduce procedural risks and cost,[2,3,4,5,6] however, it is advocated to be offered in neonatal period. Surgical approaches to circumcision are extremely varied.
About 25-33% of the total world male population is circumcised.[8,9,10,11] In the US, an average of a million newborn males are circumcised yearly. Circumcision rate in US is as high as 70%, while in Britain it is 6%. In Nigeria, circumcision rate is estimated to be 87%.
Circumcision is arguably the oldest surgical procedure in history. Religious circumcision is practiced by the Jews; religious and cultural circumcision is also practiced by Muslims, Black Africans, Australian aborigines, and other ethnic groups in different parts of the world. In Western societies, circumcision is mostly performed for medical reasons, the most common of which is phimosis.[7,12,13] Other medical indications are paraphimosis, balanitis (inflammation of the prepuce), posthitis (inflammation of the glans), localized condylomata acuminata, and localized carcinoma.[13,14,15]
Currently, the public health benefits of male circumcision are topic of interest particularly as regards human immunodeficiency virus (HIV) prevention.[1,2] It is shown to reduce the risk of transmission of HIV infection in heterosexuals.[16,17] Its benefits in reducing the risk of urinary tract infections in boys and reduction in transmission of other sexually transmitted infections are well documented.[1,2,3,4,5,6]
Contraindications of this procedure include congenital abnormalities of the phallus such as hypospadias, epispadias, megalourethra, webbed penis, and any other condition in which prior circumcision renders treatment more difficult. Others are prematurity, bleeding problems, myelomeningocele, and anorectal anomaly.[12,14]
Developmentally, during the third month of intrauterine life (65 mm fetus), a fold of skin develops at the base of the glans penis. This fold of skin grows distally from the glans penis and eventually becomes the prepuce. The dorsal aspect of the fold grows more rapidly than the ventral aspect, initially only the dorsum of the glans penis is covered by this fold. As the glanular urethra fuses in the midline, it carries the ventral prepuce along with it. This ventral fusion of the prepuce is marked by the frenulum. Preputial formation is usually complete by the fifth month of intrauterine life (100 mm fetus). The inner surface of the prepuce and epithelium of the glans, are both stratified squamous epithelium in type, and both fuses together. Later, presumably under the influence of androgens, the squamous cells begin to keratinize and arrange themselves in whorls. The whorled cells then disintegrate so that clefts appear between the prepuce and the glans. These clefts eventually propagate and separate the inner preputial epithelium and the epithelium of the glans from each other. This process of separation is usually incomplete at birth and continues through childhood and sometimes to adult life.[14,18]
The principles of circumcision are asepsis, adequate excision of outer and inner preputial skin layers, hemostasis, protection of the glans and urethra, and cosmesis. The goal of the procedure is to expose the glans sufficient to prevent phimosis or paraphimosis. Circumcision methods can be classified into one of three types or combinations thereof: dorsal slit, shield and clamp, and excision.[12,14] Many of the methods in use today fall in to one of these major classes. Shield and clamp adopts the use of device to effect circumcision obviating the use of knife in majority of cases. The device method is the commonly used method of circumcision in recent practice.
The procedure is done under local anesthesia. There are many ways of achieving this: penile ring block, penile dorsal nerve block, and local anesthetic spray jet injector have all been described.[19,20,21] While the spray injector procedure requires an appliance that is uncommon and expensive (e.g., No-Needle MadaJet®), penile dorsal nerve block and the ring penile block can be easily learned and carried out by all.[19,20]
Penile dorsal nerve block is a safe and appropriate anesthesia technique for circumcision procedure. The aim of the block is to deliver adequate local anesthetic agent at a dose of 1 ml + 0.1 ml/kg body weight around the main trunk of the dorsal nerve of the penis and its ventral branch. This is easily accessible just below the symphysis pubis deep to the fascia and on either side of the penile suspensory ligament. Care is taken to avoid the midline where dorsal vessels that may be cause of hematoma and poor nerve block passes.