Partial Amputation of Glans Penis During Mogen Clamp Circumcision

Although no numerical data are available, the most common techniques for performing newborn circumcision in the United States involve the use of the Plastibell, the Gomco clamp, and the Mogen clamp, likely in that order. The Mogen clamp (see Fig 1 and 2) is the least familiar to most pediatricians. It has a number of advantages when compared with the other techniques:

1. the one size of the Mogen fits all;
2. it is the most rapid;
3. the Mogen instrument allows full visualization of exactly how much prepuce to remove.

In Mogen circumcision, however, the glans is not visualized before removal of the prepuce. The Plastibell and Gomco differ from the Mogen in that the glans is visualized before removal of the foreskin, and each of these devices utilizes a bell made of either plastic or metal that is placed over the glans and serves to protect it and the urethra/urethral meatus during the procedure. Although literature distributed with the Mogen clamp claims no injury to glans possible, this is a case report of the amputation of the distal 2 mm of the glans penis during a routine circumcision by a pediatrician who had extensive experience performing this procedure. Despite anecdotal reports of similar occurrences, no similar reports appear in the literature.

CASE REPORT

This 3450-g term infant underwent circumcision with a Mogen clamp on his first day of life at his parent's request. His genital anatomy was notable only in that he had a relatively small penis, a scrotum that inserted about halfway up the penile shaft, and a considerable but not abnormal amount of redundancy of his foreskin. The procedure was performed by a pediatrician with 21 years in practice who had performed over 2000 previous circumcisions, over 250 using the Mogen clamp. These had been accompushed without serious or unusual complications. Following a dorsal penile nerve block, the Mogen clamp was applied in the usual manner. When the clamp was removed it was obvious that the distal 2 mm (or tip) of the penis, including the urethral opening, had been amputated. This was immediately retrieved along with the foreskin remnant and placed in a medicine cup containing 10 mL of saline, which was then placed on ice. Pressure was applied to the tip of the penis to prevent bleeding. A urologist was notified, the child was taken to the operating room, and with the assistance of a plastic surgeon, the severed tip was reattached, including end-to-end anastomosis of the urethra using a microsurgical technique, which was performed within an hour of the amputation. The re-anastomosis was totally successful (see photograph (Fig 3) taken 2 weeks postsurgery). Follow-up at 2 years of age by a pediatric urologist revealed a minimal cosmetic defect with entirely normal function and the prognosis for normal growth andfunction in the future.

DISCUSSION

Although there are references in the literature to possible injury to the glans as a complication of circumcision, there are no specific reports of an injury of this nature from a Mogen clamp.³ The company producing this clamp refused to accept a report of this occurrence or reveal whether they had knowledge of similar occurrences. The insert accompanying the new clamp states no injury to glans possible, because of beveled underedge and narrow aperture. The clamp used was less than 2 years old and not different in aperture from new clamps arriving from the manufacturer.

Although circumcision with a Mogen clamp has been reported as easy, quick, and safe, and is being taught in a number of centers, it may be that some children, particularly those with smaller organs or those with redundant foreskin, should not be considered as candidates for the use of this device. Although this may be an isolated event, as there is a reluctance to report adverse occurrences, the true risks of this device are not known.

This author invites physicians with knowledge of similar occurrences to contact me. Your confidentiality will be honored.

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