Introduction
Circumcision is the surgical procedure in which removal of the foreskin covering the glans penis. It is the one of the oldest surgical procedure practiced worldwide.1 The term circumcision is derived from Latin word circumcidere, meaning "to cut around".2 Reasons behind the circumcision are cultural, religious, medical or cosmetic. There are various technics commonly used to do circumcision. These entire technic have the main goal is to do circumcision with minimal bleeding and complications.3 The most common neonatal circumcision complication is bleeding, infection and irrational removal of foreskin.4 Amputation of glans is the most devastating complication in neonatal circumcision. We are reporting here a case penile amputation during circumcision, a drastic complication.
Case Report
A 45 days old male child born with full term normal vaginal institutional delivery was admitted at our institution with complaint of continuous bleeding after ritual circumcision. On clinical examination left radial pulse rate was 107 per minute, hypovolemic, feeble. Respiratory rate was 39 per minute. He was clinically pallor. On local examination the glanspenis was complete separated from penile shaft. A bit of skin was holding the distal amputated glans and penile shaft otherwise circumferentially skin was incised. Baby was optimized first. Blood sample was sent for cross match, baseline investigations. Blood transfusion was done. Risk and prognosis was explained to parents and written consent was taken for surgical repair. Baby was taken for surgery after optimization. He was operated under general anaesthesia with endotracheal intubation. After painting and draping local region was cleaned again with povidine solution. A 6 french silicon foley’s catheter was introduced through glans meatus and then introduced in penile shaft urethra. Foleys catheter balloon was inflated with 2 ml normal saline. With this catheter stent glans was super imposed over amputated end of penile shaft in anatomical position and simple repair was done circumferentially with vicryl suture in interrupted pattern. Over this skin was repaired. Dorsal slitting of prepuce was done to observe the viability of glans during dressing and their after. Shukla dressing was done to prevent excessive movement of repaired tissue and catheter. First dressing was done after five days. The glans was viable and stitch line of skin was intact. Second dressing was done after five days of first dressing. Glans was intact and slight gaping was present at left lateral stitch line, otherwise normal. Skin was healed with secondary intention. There was no pus discharge or urine leak from wound site. After three days dressing was removed and Foleys catheter kept intact. The wound kept open. He was discharged on oral medication with Foleys catheter insitu. Foleys catheter was removed after six weeks of repair. After removal urine stream was straight and coming out from urethral meatus. There was no urethrocutaneous fistula. Six month follow up was uneventful.
Discussion
Circumcision in neonates or children is commonly done for either ritual or cultural reason or medical reason.5, 6 It is commonly done in Muslims, Jews, Southeast Asia and Africa and in United States.6, 7 In Jews community circumcision of male infant performed on live day eight. The Torah holy book of Jews state that it was the covenant between Abraham and God. This covenant confirmed by male infant circumcision. Muslims do circumcision for determination of relationship with God and purification.6
Circumcision used to perform from ancient time. Various complications were reported with time. The Complications after neonatal circumcision were observed by Sebastian O. Ekenze et al. in their study and reported in 2013. They found glanular adhesion, meatal stenosis, urethrocutaneous fistula, trapped penis, implantation dermoid, and glans amputation after circumcision.8 Penile amputation is really a traumatic to children and their parents. To decrease these complications with time various methods and apparatus were introduced in medical science. The techniques used for circumcision are Shield and clamp, Plastibell, Gomco, Zhenxi Rings, Tara Klamp, Smart Klamp, Shang Ring, PrePex, and Laser circumcision.9
Penile replantation was first reported by Ehrich WS (1929) in self-inflicted penile amputation by a man with radial saw.10 But successful replantation was reported in 1977. The replantation was done by micro neurovascular repair. First they repair urethra with stenting 8 french catheter.11 We also repair first urethra over 6 french silicon catheter stent. After it corpora spongiosum is repaired and then after corpora cavernosa were repaired in anatomical position. Covering skin was approximated after refreshing the margin. Micro vascular anastomosis was not possible, due to some circumstances. Similar replantation was done by Bouassida Khaireddine et al. (2012) in two cases and found good results.12
Conclusion
Circumcision is a procedure which performed commonly worldwide. Reasons behind circumcision are different, but it should be performed by experienced medical practitioner. And non-medical person doing ritual or cultural circumcision should be trained by medical professional to avoid complications.
