Amputation of distal penile glans during neonatal ritual circumcision - a rare complication

Case Report

Case report

An 8-day-old male newborn presented 1 h after accidental amputation of the distal glans penis during ritual circumcision. The excised tissue, comprising the distal glans, meatus and distal urethra, was wrapped in sterile saline-soaked gauze.

Intra-operative examination showed a viable penis, with no shaft skin loss, and a clean wound resulting from excision of the foreskin and distal part of the glans. A gentle and minimal debridement of the corpus spongiosum was performed and the urethra and the corpus spongiosum were re-anastomosed with 7/0 and 6/0 dexon sutures, respectively, over a 6F silicone Foley catheter (Figs 1 and 2).

The skin of the penile shaft was closed using a pursestring suture over the reattached part of the glans and around the catheter (Fig. 3). The pursestring was released after 48 h and the shaft skin was allowed to retract proximal to the corona.

Tetracycline ointment was applied on the glans three times a day. The urethral catheter was removed after 2 weeks, with a good take of the graft. After 2 months, there was no meatal stenosis and voiding was normal.

Comment

Circumcision is the most common operation in male newborns in Israel. In the ritual setting its risks remain controversial. Although a minor procedure, the incidence of complications ranges from 1.5 to 5%¹.

Glanular amputation is a rare complication of neonatal circumcision and should be treated according to the principles of grafting². Intra-operative debridement allows neo-vascularization and immobilization of the graft with dressings or with the shaft-skin purse-string is important in allowing imbibition and inosculation. Antibiotics are appropriate to prevent infection. The purse-string of the penile shaft skin was used because no shaft-skin is lost. The most common complication of the procedure, meatal stenosis, was avoided successfully in this case.

Authors

E. Neulander, MD, Chief Resident.
S. Walfisch, MD, Senior Surgeon.
J. Kaneti, MD, Professor of Urology, Head of Urology Department.
Correspondence: Dr E. Neulander, Department of Urology,  Soroka Medical Centre,  Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Editorial

The authors report what they describe as a rare complication following a neonatal ritual circumcision of amputation of the distal glans penis. It is said that about 65% of male newborns in the United States are circumcised. All Jews are circumcised neonatally and the majority of Muslims circumcised when they are older. Fistula formation, lymphoedema and iatrogenic hypospadias have all been reported. Most amputations are almost certainly not reported. I have seen half a penis amputated in a 4-year-old boy during a ritual Muslim circumcision. The penis was left by the General Practitioner surgeon in the waste-paper basket of his surgery but successfully re-anastomosed to the corpora with some skin loss when it was eventually retrieved. Circumcision is not an operation to be undertaken lightly and if it is to be performed in Great Britain it is probably best performed in a hospital environment, in an older child as a general anaesthetic day-case. The costs to the Health Service of carrying out these religious circumcisions are probably less than treating the complications that occur from untrained circumcisionists carrying out the operations under local anaesthesia in private practice.

Note:

One may obtain a Portable Document Format (PDF) file with the full text and figures from  http://www.blackwell-synergy.com/doi/abs/10.1046/j.1464-410X.1996.06934.x

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