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ORIGINAL ARTICLE Table of Contents   
Year : 2014  |  Volume : 11  |  Issue : 2  |  Page : 179-183
Ten years experience with a novel modification of plastibell circumcision


Department of Surgery, Pediatric Surgery Unit, Al-Azhar University Hospitals, Cairo, Egypt

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Date of Web Publication20-May-2014
 

   Abstract 

Background: Plastibell device is a satisfactory method of circumcision in infants. However the most common post-operative complication was bleeding (especially from the frenulum site). As a result, we introduce a novel modification of the device to prevent this complication. Patients and Methods: A prospective comparative study of Plastibell circumcision in infants up to the age of 12 months was conducted, using conventional Plastibell device and modified Plastibell device circumcision. In The first group (1000 infants), circumcision was performed with conventional Plastibell device while in the second group (4500 infants), circumcision was done with modified Plastibell device. Results: The mean age was 8 weeks. The mean operating time were 8.5 min and 5.9 min for conventional Plastibell ring and modified Plastibell device circumcision respectively. The most common postoperative complication in first groups was bleeding. Conclusion: This modified Plastibell device, prevents the most series complication of bleeding. It is fast and ensures excellent cosmoses compared with the standard Plastibell template circumcision. Also it is easy to perform and allows the paediatric surgeon to achieve consistently excellent cosmetic results. Moreover, the shorter operating time makes circumcision by the modified Plastibell device a more practical method. The technique will be described in detail.

Keywords: Circumcision, Plastibell, Children

How to cite this article:
Hammed A, Helal AA, Badway R, Goda SH, Yehya A, Razik MA, Elshamy A, Elsamahy O. Ten years experience with a novel modification of plastibell circumcision. Afr J Paediatr Surg 2014;11:179-83

How to cite this URL:
Hammed A, Helal AA, Badway R, Goda SH, Yehya A, Razik MA, Elshamy A, Elsamahy O. Ten years experience with a novel modification of plastibell circumcision. Afr J Paediatr Surg [serial online] 2014 [cited 2019 Jun 17];11:179-83. Available from: http://www.afrjpaedsurg.org/text.asp?2014/11/2/179/132832

   Introduction Top


Circumcision is a cultural and religious practice, as well as a surgical procedure with defined risks and benefits. [1] Circumcision involves removing the fold of skin that normally covers the glans penis. Although no consensus exists among scholars regarding the origins of circumcision, some have suggested that this procedure likely originated in Egypt some 15,000 years ago and that its practice later spread throughout the world during prehistoric human migrations. Egyptian mummies and wall carvings discovered in the 19th century offer some of the earliest records of circumcision dating this procedure to at least 6000 years BC . [2]

Across the 32-year period from 1979 through 2010, the national rate of newborn circumcision in the States declined 10% overall, from 64.5% to 58.3%. During this time, the overall percentage of newborns circumcised during their birth hospitalization was highest in 1981 at 64.9%, and lowest in 2007 at 55.4%. [3]

The three most common devices used to date are the Gomco clamp (67%), the Plastibell device (19%) and the Mogen clamp (10%). [4] The Plastibell Circumcision device, invented by Hollister in 1950 is a clear plastic ring with handle designed for male circumcision. The ring has a deep groove running circumferentially. Despite its simplicity, the use of correctly sized bells, meticulous aseptic techniques, securely tied ligatures and close postoperative follow-up are essential to minimize the development of postoperative complications. [5]

We noticed that there are two sources of bleeding after Plastibell circumcision, first due to too much dorsal slit of the prepuce unsecured by ligature and the second and most common one is bleeding due to forcible placement of Plastibell device against the triangular frenulum fold. Torn frenulum with raw surface area at the ventrum of glans penis is uncontrollable point of bleeding. To solve this problem we made a novel modification of Plastibell template with removal of a segment at the lower edge of the Plastibell ring, so it could be easily settle down circumferentially at coronal sulcus and fitted well over the frenular fold [Figure 1].
Figure 1: The ventrally removed segment of Plastibell ring to fit around the frenular fold

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   Patients and Methods Top


From January 2002 to December 2012, 5500 infants were circumcised at the King Saud hospital, Saudi Arabia, and Al-azhar university hospitals, Cario, Egypt. Infants were classified into two groups, in the first group (1000 infants), circumcision was done with conventional Plastibell device, while in the second group (4500 infants), circumcision was done with the modified Plastibell device.


   Technique Top


Before circumcision, the surgeon who will perform the procedure will review the informed consent which obtained from the parents. With a discussion of the benefits, risks, and ensures that the parents understand what will happen during the procedure. Lignocaine 1% was given as a penile/ring block. At first the foreskin was separated from the glans penis by blunt forceps, any cohesion between the foreskin and glans penis were separated and all visible smegma was removed with saline moist gauze. Mark was drowned 2 to 3 mm proximal to the shadow of coronal sulcus. Then a dorsal slit was made until the corona become visible. An appropriate size of Plastibell was then placed on the glans and the foreskin brought over it. Determining the appropriate size of the device used was very important. Too small size can cause tissue strangulation, and too wide one may result in too much foreskin being removed and penile denudation. The Plastibell size is selected by observational estimate of the glans penis girth, commonly the Plastibell comes in seven sizes. Selection of the proper size gets better with practice and experience.

The appropriate one is chosen and applied to the head. The ring is placed under vision with the removed segment placed ventrally, to fit around the frenular fold (our modification) [Figure 2] which was facilitated by another mark on the handle. The cotton thread supplied with the Plastibell, was then secured. Then the foreskin was trimmed and the handle of the ring snapped [Figure 3]. The entire procedure takes 5-15 minutes, depending on the experience and skills of the surgeon. No dressing was applied. The child was discharged on the same day or the following day with instructions to the parent about the need for a regular 2-3 times sits bath in warm water, with follow up at outpatient clinic at weekly interval till the wound become cleanly healed, or the bell separated and any associated inflammation subsided. Normally, after the procedure, the cut edge will appear red at first. Then, a soft yellow scab will develop, and it will go away in a few days. During this process, the parents should watch for worsening redness, swelling or bleeding.
Figure 2: A segment of the Plastibell ring was removed (a) and applied (b)

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Figure 3: The foreskin was trimmed and the handle of the ring snapped

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Usually no further care is needed. The ring usually falls off in 7 to 10 days leaving a circumferential wound that will heal over the following week. It is a quick procedure once mastered, taking a few minutes to perform, and hopefully causing minimal discomfort for the baby. No dressing is required, allowing easy monitoring for infection, bleeding. Healing occurs when the edges of the prepuce are secured in the ring, making skin bridges (where the outer foreskin's of the corona heals to the inner one). Rarely, the tip of the glans may protrude through the ring and become swollen, trapping the ring in place.


   Results Top


Between January 2002 and December 2012, 5,500 infants had circumcisions (mean age 8 weeks) performed at King Saud Hospital, Saudi Arabia and Al-Azhar university hospitals, with Plastibell ring. In the first 1000 infants, the classic Plastibell device was applied, while in the remaining infants our modified Plastibell ring was used, to minimize intra-operative and post-procedure complications [Figure 4].
Figure 4: Complications of Plastibell circumcision: (a) Bleeding. (b) Ring retraction and glandular edema. (c) Release of the ring

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With the original Plastibell device (first group), used in 1000 cases of neonatal circumcision, the incidence of complications was 6.3%, with the most frequent being haemorrhage. Among 4500 infants (second group) operated upon with our modified Plastibell ring, the complication rate dropped to 2.7%. Major complications such as glandular necrosis, glans and penis amputations, urethral fistula were never seen in our study. Among the first group, bleeding during and after the procedure was the most common complication and was noted in 25 infants (2.5%). Fifteen of these required stitching under local anaesthesia (mostly the cause of bleeding is due to torn frenulum), while in other 10 infants the bleeding stopped with local compression occasionally with overnight observation in the Paediatric surgery ward (almost always caused by too much dorsal slit incision of foreskin which was unsecured with the tie). Also, seven children who were originally assigned to the Plastibell circumcision were converted to conventional dissection method intraoperatively. These seven cases were counted as intra-operative complication of Plastibell device circumcision. In four children, the bell slipped off after the redundant foreskin was trimmed. In another three children, a haematoma developed after the redundant foreskin was trimmed, so the bell was removed, haematoma evacuated with suturing of the foreskin wound. In both cases, it was likely that the ligature was not tied securely enough.

In the second group, bleeding noted in 15 cases, 11 cases required interference (7 cases due to torn frenulum caused by malposition of Plastibell ring and 4 cases of slipped off Plastibell ring). The next most common post-procedure problem encountered was incomplete or delayed separation, which occurred in 10 patients (1 %) in the first group and in 35 (0.7%) in the second group [Table 1].
Table 1: Short and long-term complication rates after circumcision in 5500 infant

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Retained Plastibell devices were encountered in 8 (0.8 %) infants in the first group and in 25 (0.5%) patients in the second group, the separated ring can cause constriction of the glans penis and rarely the separated ring tracked back onto the shaft of the penis and had to be removed using a ring-cutter. No anaesthesia was required for this, as the procedure was quick, simple and atraumatic [Figure 4]b, c. There were five infants in the first group and 19 patients in the second group who were given antibiotics because of suspected wound infection; however, none had any positive bacterial culture.

There have been 2 cases of retention of urine in the first group only secondary to glandular prolapse. In the first group, three infants (0.3%) required revision of circumcision and two boys developed a meatal stricture that required meatal dilatation within 6 months of the initial procedure. Among 4500 infants in the second group 13 (0.28%) required re-circumcision and 3 cases (0.07%) required meatal dilatation for meatal stricture within 6 months of the initial procedure. Preputio-glandular fusions are usually the result of preputial skin incompletely peeled off the glans, incomplete excision and insufficient post-circumcision care. In these patients, the place where the preputium adhered to the glans was dissected and the resulting wound on the glans was sutured with 5/0 chromic catgut, then, the excess preputial tissue was excised. Other long-term complications included concealed penis and unsatisfactory cosmoses [Table 1].

Three parents in the first group and three parents in the second group remained dissatisfied and complained about the irregular skin margin (Unsatisfactory cosmoses). The most common complications of dorsal penile nerve blocks and ring blocks are bruising, bleeding, and inadequate analgesia. All 178 patients who suffered complications were followed up for a minimum of 3 months after the procedure. In both groups, circumcisions carried out by consultant pediatric surgeons had slightly lower haemorrhage rates (0.3%) than those performed by specialist paediatric surgeon (0.5%) or resident (0.8%) surgeons. The operation duration was ranged from 5 to 16 and 4 to 8 min, and the mean were 8.5 and 5.9 min for conventional Plastibell ring and modified Plastibell circumcision respectively.


   Discussion Top


It has been estimated that 25% of the men around the globe are circumcised . Considering this fact, it is clear that circumcision is the most commonly performed surgical operation. [4] Most circumcisions are performed for religious not medical reasons. [6] Circumcision has a low but defined risk of surgical complications, varying from 1% to 15%. [4],[7] Bleeding after Plastibell circumcision, is the most common problem identified, usually related to two causes: one because of tearing of frenulum during traction or ring insertion and the other, because the dorsal slit of the foreskin is made too long and part of it not secured with the tie around the bell properly. The first problem was well recognized and was reduced with removing a segment from the lower edge of the Plastibell ring immediately under one of the two pillares of the handle, this defect is identified with a mark on the handle to direct the defect downward to fit around the frenulum [Figure 2]b.

The major advantages of our modification are reduction of bleeding, especially due to torn frenulum and prevention of urine retention. Although the modified Plastibell group had a diverse type of complications, there was marked reduction of bleeding, it occurred in 15 cases (0.3%) of infants underwent circumcision with modified Plastibell in comparison with the classic Plastibell group where it occurred in 25 cases (2.5%).

Retained Plastibell devices or proximal migration of Plastibell ring was the next common problem. Slippage of the detached Plastibell down the shaft can be troublesome, and again is usually the result of incorrect selection of the ring size or excessive traction on the foreskin. It should be noted that the ring separates faster in younger children due to thin prepuce and easier sloughing which is an advantage in this age group. The infection rate was 0.5% in conventional Plastibell group, while it was 0.42% in the modified group. This is significantly lower than those reported by Mak et al. [8] since the criteria of infection were only clinical in our study as well as other studies, it may be underestimated. Some mild degree of erythema and edema of the penile skin without pus was frequently seen associated with the use of Plastibell.

These cases of mild erythema and swelling were likely to be the result of foreign body reaction (cotton thread), as the swelling and redness subsided rapidly (within 1-2 days) after separation of the bell. Although application of local antibiotics as prophylactic agents needs to be confirmed, [9] we used topical fucidin antibiotic cream as a lubricant and prophylactic agent. This may explain the lower rate of infection compared to other mentioned studies. Two case of Concealed penis in classic Plastibell group and two cases in modified Plastibell group were likely to be due to the inappropriately sized Plastibells. There are several reports in the medical literature of urinary retention after circumcision with the Plastibell device. [10],[11] In our study Urinary retention seen in two cases in the first group only, as the foreskin is pulled too tight, then there were be considerable tension pulling the ring against the tip of glans penis, thus compressing or kinking the urethra and making urination difficult or impossible [Figure 3]a. Our modification is completely abolish this complication as there was no tension applied over the frenulum, so no cases of urine retention reported in the second group .

We had 16 cases (0.29%) of redundant mucosa in both groups that may be due to the inappropriately sized bell. The choice of a correctly sized bell is important. If the bell is too small, it causes compression and edema of the glans penis leading to micturition difficulty and or retained Plastibell devices. Too much skin will probably be left behind leading to recurrent phimosis and high revision rate. [12]

According to the American Academy of Paediatrics, circumcision, especially when performed before the age of 1 year, reduces the risk of urinary tract infection (UTI) and future risk of penile cancer development. [13] Wiswell and John, [14] reported that the risk of UTI was 11 times more in uncircumcised children, and thus all infants should be routinely circumcised. As reported in other studies, [15] an obvious advantage of using the Plastibell was the short surgery time. Average procedure duration with the modified Plastibell group was 5.9 minutes, compared with 8.5 minutes with the classic Plastibell group. Parents have generally been very satisfied and the complication rate was acceptable, with most problems occurring early in the series, could be ameliorated, suggesting an improvement with our modification and experience.


   Conclusion Top


Our modification was simple, but helpful in reduction one of the most common and serious complications of circumcision. Based on our results, the overall complications rate of the modified Plastibell method is less than that of classic Plastibell ring. The advantages of this novel modification are avoidance of bleeding due to torn frenulum, and kinking of uretheral meatal opening against inner aspect of the Plastibell ring, due to traction of frenulum (if not torn) that induce urine retention, and better cosmetic appearance as the conical summit of glans penis with centralized uretheral meatus will protrude easily through the Plastibell with preservation of frenular fold. Finally the technique is fast and ensures excellent cosmoses compared with the standard Plastibell device circumcision. It is easy to perform and allows the paediatric surgeon to achieve consistently excellent cosmetic results.

 
   References Top

1.Palit V, Menebhi DK, Taylor I, Young M, Elmasry Y, Shah T. A unique service in UK delivering Plastibell circumcision: Review of 9-year results. Pediatr Surg Int 2007;23:45-8.  Back to cited text no. 1
    
2.Alanis MC, Lucidi RS. Neonatal circumcision: A review of the world's oldest and most controversial operation. Obstet Gynecol Surv 2004;59:379-95.  Back to cited text no. 2
    
3.Centers for Disease Control and Prevention. Trends in in-hospital newborn male circumcision-United States, 1999-2010. MMWR 2011;60:1167-8.  Back to cited text no. 3
    
4.Ceylan K, Burhan K, Yilmaz Y, Can S, Kuş A, Mustafa G. Severe complications of circumcision: An analysis of 48 cases. J Pediatr Urol 2007;3:32-5.  Back to cited text no. 4
    
5.Mousavi SA, Salehifar E. Circumcision complications associated with the Plastibell device and conventional dissection surgery: A trial of 586 infants of ages up to 12 months. Adv Urol 2008;1-5.  Back to cited text no. 5
    
6.Harrison NW, Eshleman JL, Ngugi PM. Ethical issues in the developing world. Br J Urol 1995;76 Suppl 2:93-6.  Back to cited text no. 6
    
7.Rizvi SA, Naqvi SA, Hussain M, Hasan AS. Religious circumcision: A Muslim view. BJU Int 1999;83 (Suppl 1):13-6.  Back to cited text no. 7
    
8.Mak YL, Cho SC, Fai MW. Childhood circumcision: Conventional dissection or Plastibell device - A prospective randomized trial. Hong Kong Pract 1995;17:101-5.   Back to cited text no. 8
    
9. Quayle SS, Coplen DE, Austin PF. The effect of health care coverage on circumcision rates among newborns. J Urol 2003;170:1533-6.  Back to cited text no. 9
    
10.Mihssin N, Moorthy K, Houghton PW. Retention of urine: An unusual complication of the Plastibell device. BJU Int 1999;84:745.  Back to cited text no. 10
    
11.Lerman SE, Liao JC. Neonatal circumcision. Pediatr Clin North Am 2001;48:1539-57.  Back to cited text no. 11
    
12.Kwak C, Oh SJ, Lee A, Choi H. Effect of circumcision on urinary tract infection after successful antireflux surgery. BJU Int 2004;94:627-9.  Back to cited text no. 12
    
13.Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision. Pediatrics 1999;103:686-93.  Back to cited text no. 13
[PUBMED]    
14.Wiswell TE. John K. Lattimer Lecture. Prepuce presence portends prevalence of potentially perilous periurethral pathogens. J Urol 1992;148:739-42.  Back to cited text no. 14
    
15.Fraser IA, Allen MJ, Bagshaw PF, Johnstone M. A randomized trial to assess childhood circumcision with the Plastibell device compared to a conventional dissection technique. Br J Surg 1981;68:593-5.  Back to cited text no. 15
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Correspondence Address:
Dr. Ashraf Hammed
Department of Surgery, Pediatric Surgery Unit, Al-Azhar University Hospitals, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.132832

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