Circumcision
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Circiumcision for prevention of AIDS How to perform circumcision what''s new in Circiumcision method Complication
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Circumcision
- 1. Circumcision in male infants and children
- 2. • U.S. Centers for Disease Control and Prevention’s Summary of Its Draft Male Circumcision Recommendations, 2017 50% HIV infection risk by a male during penile-vaginal sex (heterosexual sex)
- 3. • 2012 Circumcision Policy Statement by the American Academy of Pediatrics Task Force on Circumcision Estimated 14/1000 Uncircumcised Estimated 2/1000 circumcised The risk of urinary tract infection in the first year of life in male infants
- 4. Infection risk of Herpes simplex virus type-2 (HSV–2) Types of human papilloma virus (HPV) which can cause Penile and other anogenital cancers 30%
- 5. • Protective effect of childhood/adolescent circumcision on invasive penile cancer (OR = 0.33; 95% CI 0.13-0.83; 3 studies) • increased risk of cancer is related to phimosis, which can be the result of poor penile hygiene • Circumcision in adulthood was associated with an increased risk of invasive penile cancer (OR = 2.71; 95% CI 0.93-7.94; 3studies) Larke NL, et al. Male circumcision and penile cancer: a systematic review and meta-analysis. Cancer Causes Control. 2011
- 6. • Circumcised men were less likely than uncircumcised men to have HPV infection (OR 0.37, 95% CI 0.16-0.85 after adjustment of confounders) • Male circumcision was associated with a trend for reduced risk of cervical HPV and cervical cancer (OR 0.75, 95% CI 0.49-1.14) in the female partner Davis MA, et al. Male circumcision decreases high-risk human papillomavirus viral load in female partners: a randomized trial in Rakai, Uganda. Int J Cancer. 2013 CastellsaguéX, et al . Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med. 2002
- 8. Surgical procedures For adults and adolescents • Forceps-guided method • Sleeve method • Dorsal slit method For infants and children • Dorsal slit method • Plastibell method • Mogen clamp method • Gomco clamp method
- 9. The Anatomy and Technique of Penile Block http://emedicine.medscape.com/article/81077-overview http://www.circumcisioninformation.com/brown1.htm
- 11. 4 5 6
- 12. Dorsal slit method of circumcision 1 2 3
- 15. 4 5 6
- 16. 7 8
- 17. Dorsal slit method 1 2 3
- 18. 4 5
- 19. Plastibell method 1 2 3
- 20. 4 5
- 21. Mogen clamp method 1 2 3 4
- 22. Gomco clamp
- 23. 3 4 1 2
- 24. How to use it to do circumcision http://prepex.com/device-overview/clinical-procedure/
- 25. • What’s new technology for circumcision? •Scalpel •Electrosurgical Unit •Laser
- 29. • 75 boys, aged 6–9 (median 7) years • circumcision between May 2013 and August 2014. • Iodine disinfection under general anesthesia, the adhesions on the coronal sulcus are separated • The preputial skin is pulled up, a straight hemostat is applied loosely to the preputium
- 30. • The incision is made distal to the hemostat using a CO2 laser, applying 350 millijoules energy at 40 pulses/second in continuous mode. • No bleeding requiring bipolar use was detected after the excision. • Cyanoacrylate applied after approximating the mucosa and remaining skin on the penis. • A chlorhexidine wound covering and Coban bandage for wound care
- 31. Guillotine method • The foreskin is released • Mosquito forceps are applied to the tip of the foreskin ventrally and dorsally and the foreskin protracted. • A straight forcep is applied along the lower foreskin above the glans. • The foreskin is excised by cutting above the forceps using a large scalpel blade. • The inner mucosa is trimmed with scissors, leaving an adequate mucosal cuff.
- 34. Complication • Medical complications • Bleeding • Infection • Surgical complication
- 35. Bleeding • injury to the frenular artery or dermal cut edges • Coagulopathy • firm manual pressure for 10 to 20 minutes • compression dressing • circumferential bandage: risk of penile ischemia or urinary retention
- 36. Infection • Wound infection: infrequently • local topical triple antibiotic ointment • Urine tract infection? • A reduced risk of UTI is a benefit of circumcision!
- 37. SURGICAL COMPLICATIONS • Urethral complications • Urethrocutaneous fistulas, Meatal stenosis • Glans injury • Excessive skin removal • Too little skin removed • Epidermal inclusion cyst • Scarring complications • Minor adhesions, Skin bridges, Cicatrix
- 38. Urethral injury • if too much upward traction is placed on the foreskin prior to clamp application, as it can cause entrapment of the glans in the clamp, possibly from incomplete separation of the glans from the inner prepuce. • the coronal sulcus should be clearly delineated prior to commencement of the circumcision
- 39. Urethrocutaneous fistulas • Fistula correction requires a second operation that is performed six months after the initial procedure
- 40. • Meatotomy • Sutures to reapproximate the cut edges scarring on the ventral aspect of the meatus
- 41. Glans injury • The glans is inadequately protected at the time the foreskin is excised, or if the glans is caught in the clamp apparatus when the foreskin is excised • Penile amputation • successful reattachment is possible if performed within eight hours of injury • Necrosis of the glans secondary to ischemia • Electrocautery
- 42. Excessive skin removal • wet to dry or antibiotic ointment dressings results in adequate healing by secondary intention • primary re-approximation or skin grafting
- 43. Too little skin removed • May circumcision revision
- 44. Epidermal inclusion cyst • occurs when an island of skin is left to heal underneath the skin of the penile shaft. • formal excision of the entire cyst
- 45. Minor adhesions • Topical steroid cream • Gentle retraction to lyse the adhesion
- 46. Skin bridges • possible lysis of adhesions via scalpel after the application of a topical anesthetic
- 47. Cicatrix • Hypertrophic scar or keloid formation • Treatment • Topical betamethasone • Revision involves excision of the scar, often with skin flap coverage to substitute for a paucity of penile shaft skin
- 48. Reference • Manual for male circumcision under local anesthesia • Uptodate: circumcision
Editor's Notes
- Conclusions of the 2012 Circumcision Policy Statement by the American Academy of Pediatrics Task Force on Circumcision3 Systematic evaluation of English-language peer-reviewed literature from 1995 through 2010 indicates that preventive health benefits of elective circumcision of male newborns outweigh the risks of the procedure. Benefits include significant reductions in the risk of urinary tract infection in the first year of life and, subsequently, in the risk of heterosexual acquisition of HIV and the transmission of other sexually transmitted infections. By using these rates and the increased risks suggested from the literature, it is estimated that 7 to 14 of 1000 uncircumcised male infants will develop a UTI during the first year of life, compared with 1 to 2 infants among 1000 circumcised male infants.
- Good evidence of the protective effect of male circumcision is available from two of the large randomized controlled trials in Africa. In the South African study, the incidence of HSV-2 was 34% lower in circumcised men.73 In the Uganda study, the risk of HSV-2 infection (adjusted for other factors) was 28% lower in circumcised men.71 The prevalence of infection was lower for the 2 viral types with the highest risk of causing cancer, however, at 4.7% for HPV type 16 and 1.9% for HPV type 18.95 There is good evidence that male circumcision is protective against all types of HPV infection (nononcogenic and oncogenic). Two prevalence studies with good evidence found a 30% to 40% reduction in risk of infection among circumcised men.96,97 The evidence does not demonstrate any relationship between circumcision and gonorrheal infection.85,86,92–94
- 6
- Mark the intended outer line of the incision, as described above (Fig. 5.33), with a V shape, pointed towards the frenulum, on the underside (ventral aspect) of the penis (Fig. 5.34). The apex of the V should correspond with the midline raphe
- It may be necessary in older boys to trim the mucosal layer of the foreskin to 2–3 mm from the corona. If this layer is left too long, the suture line can slip back over the glans, constricting it and making it appear as if the foreskin has not been removed (“concealed glans”). Control any significant bleeding by clipping the blood vessel with an artery forceps and then tying. Bipolar diathermy may be used, if available. Minor bleeding can be controlled with simple pressure for five minutes.
- Check that there is no bleeding. If all is well, the child can be sent home and looked after in the normal way, including normal washing and use of nappies. The rim of tissue distal to the ligature will become necrotic and the Plastibell will drop off after 5–8 days. Alternatively the infant can be checked after 36–48 hours and the ligature cut.
- (UltraPulse 5000C, Coherent Medical Group, Santa Clara, USA) (Leukosan Adhesive, BSN Medical, Hamburg, Germany)
- Guillotine method: the foreskin is released. Mosquito forceps are applied to the tip of the foreskin ventrally and dorsally and the foreskin protracted. A straight forcep is applied along the lower foreskin above the glans. Care must be taken to ensure that the glans is not caught within the forceps. The foreskin is excised by cutting above the forceps using a large scalpel blade. The inner mucosa is trimmed with scissors, leaving an adequate mucosal cuff.
- Ref: Uptodate: circumcision