What is the recommended procedure for circumcision?

Recommended Procedure for Circumcision

For standard circumcision procedures, the recommended approach includes proper patient preparation, sterile technique, adequate pain management, and meticulous surgical technique to minimize complications while ensuring optimal outcomes. 1

Patient Selection and Preparation

• Perform thorough physical examination to assess penile anatomy, including documentation of size, location, morphology, and relationship to other structures 1
• Evaluate for contraindications such as bleeding disorders, penile abnormalities, or unstable medical conditions 2
• Ensure patient is stable and healthy before performing elective circumcision 2
• Obtain informed consent after discussing benefits, risks, and alternatives with parents/patient 2

Procedural Steps

Anesthesia

• Provide adequate pain management using one or more of the following:
  • Dorsal penile nerve block (preferred for low birth weight infants) 2
  • Topical anesthetic creams (caution in low birth weight infants due to higher risk of skin irritation) 2
  • Adjunctive non-pharmacologic techniques (positioning, sucrose pacifiers) should not be used alone 2

Surgical Technique

1. Preparation and Draping:

   • Clean the genital area with antiseptic solution 3
   • Drape the area with sterile towels to create a sterile field 3

2. Circumcision Procedure:

   • For standard circumcision: perform wide local excision including circumcision with careful attention to hemostasis 1
   • When using thermal cautery devices:
     • Adjust temperature according to skin thickness
     • Turn the cautery in a serial manner using both sides of the blade
     • Perform cutting in two steps for better control
     • Avoid this technique for buried penis 4

3. Hemostasis:

   • Achieve meticulous hemostasis using diathermy/electrocautery or sutures 1, 4
   • Consider use of prepackaged surgical instruments for efficiency and standardization 1

4. Wound Management:

   • Apply appropriate dressing to protect the wound 3
   • Provide clear instructions for post-operative care 2

Special Considerations

• For penile cancer cases, circumcision may be followed by additional treatments based on tumor characteristics:

  • For T1-2, N0 tumors <4cm: Consider brachytherapy or EBRT following circumcision 1
  • For larger tumors or more advanced disease: More extensive surgical approaches may be required 1

• For HIV prevention in high-prevalence settings:

  • Follow WHO and UNAIDS recommendations for voluntary medical male circumcision 1
  • Consider task-shifting approaches and use of specialized devices to increase efficiency 1

Post-Procedure Care

• Provide detailed instructions on wound care for both circumcised and uncircumcised penises 2
• Schedule appropriate follow-up to monitor for complications 1
• Instruct parents/patients on signs of complications requiring medical attention (excessive bleeding, infection, urinary retention) 3, 5

Potential Complications and Management

• Minor complications (bleeding, hematoma, infection) can usually be managed conservatively 5
• Major complications requiring surgical intervention include:
  • Excess skin excision: may require repair with full-thickness skin grafts 3
  • Skin necrosis: requires debridement and either primary repair or grafting 3
  • Trapped penis: requires surgical correction 4
  • Meatal stenosis: may require meatotomy 4

Pitfalls to Avoid

• Performing circumcision by untrained individuals significantly increases complication rates 3, 4
• Multiple simultaneous circumcisions ("circumcision feasts") increase risk of complications and disease transmission 3
• Inadequate pain management leads to unnecessary suffering and potential complications 2
• Improper patient selection (unstable medical condition, anatomical abnormalities) increases risks 2, 5

Circumcision should be performed by trained and competent practitioners using sterile techniques and effective pain management to minimize complications and ensure optimal outcomes 2, 5.