|Year : 2022 | Volume
| Issue : 4 | Page : 312-314
Iatrogenic partial glanular amputation: A rare complication of circumcision
Aditya Prakash Sharma1, Thummala Yashaswi1, Jerry R John2, Shrawan Kumar Singh1
1 Department of Urology, PGIMER, Chandigarh, India
2 Department of Plastic Surgery, PGIMER, Chandigarh, India
|Date of Submission||21-May-2022|
|Date of Decision||21-Jul-2022|
|Date of Acceptance||26-Aug-2022|
|Date of Web Publication||1-Oct-2022|
Department of Urology, PGIMER, Chandigarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Circumcision is a customary ritual across many cultures. However, the safety of such procedures remains a concern. A boy underwent circumcision in 2014 by a religious worker at the age of 7 years. Post circumcision, the patient had gradual narrowing of the penis, between the glans and the shaft, with an iatrogenic partial glanular amputation and presented to us at the age of 14 years. The patient underwent end-to-end urethroplasty and glansplasty. Postoperatively, the patient did well and the wound remained healthy. Circumcision has complications even in expert hands. Religious circumcision can result in dreadful complications in children and adolescents.
|How to cite this article:|
Sharma AP, Yashaswi T, John JR, Singh SK. Iatrogenic partial glanular amputation: A rare complication of circumcision. Indian J Urol 2022;38:312-4
| Introduction|| |
Religious circumcision remains a customary ritual across cultures. However, the safety of such procedures remains of concern, as in many parts of the world it is performed by unskilled or semiskilled healthcare workers or religious workers. Post circumcision, complications range from 1% to 15%, and this incidence increases with the increasing age of the child. In many communities, circumcision is still performed by unskilled persons rather than the medical practitioners, giving rise to various complications.
| Case Report|| |
A 7-year-old boy underwent circumcision in 2014 by a “religious worker” who apparently performs all the circumcisions in the locality. Following the procedure, the patient had gradual narrowing of the penis between the glans and shaft [Figure 1]a, resulting in a near-total amputation of the glans. He presented to us 7 years after the procedure, at the age of 14. On examination, the glans was pale, but sensations were intact and it was attached to the penile shaft by a band of tissue. Both the proximal and the distal opening of the urethra were seen at the site of the narrowing [Figure 1]b. Both the openings were calibrated with a 12 Fr Foley catheter, which passed across with ease. The patient underwent end-to-end urethroplasty and glansplasty. The proximal and the distal urethral margins were mobilized, and end-to-end urethroplasty was performed with vicryl 4-0 over a 12 Fr urethral catheter [Figure 2]a. The tunica albuginea and skin were closed thereafter, with multiple Z-plasties placed on the skin to prevent a circumferential contracture [Figure 2]b. Postoperatively, the patient did well and the wound remained healthy [Figure 2]c. The patient had nocturnal erections in the glans at 2 months of follow-up.
|Figure 1: (a) Near-total amputation of the penis between the glans and shaft. (b) Both the proximal and the distal opening of the urethra seen at the narrowing site|
Click here to view
|Figure 2: (a) End-to-end urethroplasty using interrupted 4-0 PDS sutures. (b) Glansplasty and preputioplasty using Z-plasty incisions. (c) Postsurgery (urethroplasty and glansplasty) photograph showing normal looking penis|
Click here to view
| Discussion|| |
Ischemia of the glans penis is a rare condition and the common underlying etiologies are circumcision, trauma, penile strangulation, and application of vasoconstrictive agents. The incidence of glans injury during circumcision is approximately 0.7 per lakh circumcisions performed. Ischemia of the glans penis after circumcision can result from dorsal penile nerve block, inappropriate use of surgical devices, and inadequate surgical technique. Therapeutic options for acute ischemia include hyperbaric therapy, pentoxifylline, enoxaparin, iloprost, antiplatelet, corticosteroids, and surgical management. Almost all the cases of glanular ischemia and circumcision-induced glanular injury reported in the literature belong to the acute setting. Chronic ischemia leading to transection of the glans with urethral injury has not been reported till now.
Raisin et al. described their experience of managing glans ischemia associated with urethral injury. They managed these injuries with end-to-end anastomosis for the urethral injury along with anastomosis of the amputated glans either simultaneously or in a staged manner. In their study, the time of presentation was 7–9 days after the circumcision. Similar findings were published by Pepe et al. In our case, the surgical repair was performed by de-epithelialization of the glans and shaft and an end-to-end urethroplasty was performed along with the anastomosis of the glans to the penile shaft. The corpora were tucked into the mid-glans using tunical sutures to provide for adequate erection of the glans. Use of grafts has also been reported for glans repair. Aboutaleb reported the use of buccal mucosa to reconstruct the glans.
Although glans injury is more common in the hands of untrained practitioners, these injuries have also been reported after standard circumcision performed by trained surgeons where it is mainly reported with the use of the Mogen clamp. Glans injury typically occurs in cases with ventral adhesions, and it is recommended that practitioners using the Mogen clamp should adequately release the ventral adhesions to prevent glans injury. Visual control of the glans position during the circumcision also helps in preventing this complication. The likelihood of injury is also higher if the circumcision is performed in newborns in the presence of swelling, without general anesthesia. Release of preputial adhesions after thorough physical examination is the key to preventing this complication.
When the procedure is performed by trained doctors, the incidence of complications is primarily related to the expertise of the operator. Lucas et al. reported 36 cases of glans injury. They reported three techniques in their program of circumcision in Africa: forceps-guided, dorsal slit, and sleeve resection. They reported that most children who underwent a forceps-guided circumcision or a dorsal slit technique had lacerations, which are easier to repair and have better outcomes than amputations. Urethral injury can result in an iatrogenic hypospadias, which is mainly subcoronal, or in meatal narrowing. Baskin et al. described two types of urethral injuries that can occur; namely subcoronal urethrocutaneous fistula and scarred abnormal urethra from partial glans amputation. They successfully repaired the subcoronally located urethrocutaneous fistula by glans splitting and neourethra formation using a vascularized pedicle. Abnormal urethra after partial glans amputation is more difficult to repair, but a satisfactory cosmetic and functional outcome, as in our case, can be achieved by first aligning the urethra and then performing the glansplasty.
Common complications after glans replantation include meatal stenosis, hypospadias, fistula, and glans necrosis. Repercussions range from functional (erectile dysfunction) to cosmetic (near total amputation of the glans) to psychological.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship: Nil.
Conflicts of interest: There are no conflicts of interest.
| References|| |
Lucas TJ, Toledo C, Davis SM, Watts DH, Cavanaugh JS, Kiggundu V, et al.
Case series of glans injuries during voluntary medical male circumcision for HIV prevention - Eastern and Southern Africa, 2015-2018. BMC Urol 2020;20:45.
Raisin G, Kocherov S, Jaber J, Shenfeld O, Hardak B, Chertin B. Glans injury during ritual circumcision. J Pediatr Urol 2020;16:471.e1-5.
Pepe P, Pietropaolo F, Candiano G, Pennisi M. Ischemia of the glans penis following circumcision: Case report and revision of the literature. Arch Ital Urol Androl 2015;87:93-4.
Pippi Salle JL, Jesus LE, Lorenzo AJ, Romão RL, Figueroa VH, Bägli DJ, et al.
Glans amputation during routine neonatal circumcision: Mechanism of injury and strategy for prevention. J Pediatr Urol 2013;9:763-8.
Aboutaleb H. Reconstruction of an amputated glans penis with a buccal mucosal graft: Case report of a novel technique. Korean J Urol 2014;55:841-3.
Rudin YE, Runenko VI, Marukhinenko DV, Aliev KD, Rudin AY. Penile glans amputation during circumcision: Causes, treatments and preventive measures. Urologiia 2021;4:79-86.
Baskin LS, Canning DA, Snyder HM 3rd
, Duckett JW Jr. Surgical repair of urethral circumcision injuries. J Urol 1997;158:2269-71.
[Figure 1], [Figure 2]