Circumcision (the removal of the foreskin of the penis) is commonly done on newborn infants as a routine medical or religious practice. Circumcision is also performed on adults and differs dramatically from infant circumcision in terms of surgical accuracy and skill required to achieve optimal patient results. Surgeons who specialize in cosmetic circumcision usually use a scalpel rather than scissors or a clamp, and use absorbable sutures of the highest quality (suitable for facial plastic surgery).
ICI Injections For More Precise Removal of Foreskin
The study aims to evaluate the outcomes of adult circumcision with the use of intracavernosal injection (ICI) of prostaglandin to induce an erection at time of operation. Methods: Twenty patients undergoing circumcision received ICI with prostaglandin prior to surgery. Demographics of all patients along with outcomes and complications at 2-week and 3-month follow-up were recorded. Results: No complications were evident at 2-week and 3-month followup. All 20 patients were satisfied with cosmetic result. Conclusions: Circumcisions performed with ICI is a novel technique that allows accurate removal of foreskin and can be safely applied to current surgical technique for improved cosmetic results.
Circumcision is one of the oldest and most common surgical procedures performed on men  . Nearly 30% of men worldwide, including 77% of American-born men, are circumcised with the vast majority undergoing circumcision early in life [2, 3]. Indications for adult circumcision have evolved over the years with an increasing number of adult male patients seen in our practice requesting circumcision for cosmetic purposes. Interestingly, almost 12% of adult males receive circumcisions due to the request of their female partner .
Since circumcisions are generally performed with the penis in the flaccid state, removing the ideal and precise amount of foreskin can often be difficult with less than optimal cosmetic results. Removing too much foreskin may lead to penile chordee, penoscrotal webbing with scrotal hair on the penile shaft, and burying of the proximal aspect of the penis within the supra-pubic fat .
Similarly, insufficient or asymmetric removal of foreskin in patients with straight or curved erections can result in a poor cosmetic outcome for the patient with a possible need for surgical revision  . We aimed to analyze the outcomes of circumcision with the use of intracavernosal injection (ICI) of prostaglandin. We hypothesize that using prostaglandin to induce an erection during circumcision will help in removing the appropriate amount of foreskin and offer a superior cosmetic result.
Fig. 1. ICI of alprostadil prior to surgery.
Fig. 2. Careful assessment of foreskin prior to removal.
Fig. 3. Traditional sleeve circumcision performed on erect penis.
Fig. 4. Final outcome of circumcision with ICI.
Fig. 5. Frenular tethering is better evaluated during penile erection.
Fig. 6. The precise location and width of phimotic foreskin can bemeasured prior to circumcision.
From 2010 through 2014, the charts of 20 patients who underwent elective circumcision with ICI were reviewed. The median age of the patients was 32 (range 20–55) years. Median body mass index was 24 (range 20–42).
All patients received an ICI of 10 or 20 μg of alprostadil immediately prior to the induction of anesthesia using a 31-gauge 8-mm needle until a full erection was induced ( fig. 1 ). The amount of preputial tissue that had to be removed was then carefully measured ( fig. 2 ) and excised ( fig. 3 ). The foreskin was then re-approximated circumferentially in the standard subcoronal fashion with interrupted sutures ( fig. 4 ).
Following surgery, all patients were examined in the recovery room prior to discharge and called by telephone several hours later to confirm resolution of erection. Patients were then seen at 2 weeks and 3 months for postoperative evaluation and assessed for overall satisfaction and any complications.
The indication for circumcision was cosmesis in 16 of 20 patients (80%), lichen sclerosus with phimosis in 2 of 20 patients (10%), short frenulum in 1 of 20 patients (5%) and circumcision revision in 1 of 20 patients (5%). Ten of the 20 patients (50%) required an additional 10 μg injection of alprostadil to achieve a sufficient erection for procedure. No patients developed any complications – including postoperative priapism. All patients were satisfied with the cosmetic outcome at time of the follow-up.
Circumcisions have been performed for over thousands of years but have never been reported in the literature using ICI of prostaglandin. ICI has traditionally been used in the management of erectile dysfunction but also has been described in the correction of penoscrotal webbing [7, 8] . We believe that a pharmacologically induced erection at the time of surgery is the best way to plan the removal of the most precise amount of foreskin during circumcision.
With the penis in the erect state, the surgeon is better able to measure the elasticity of the foreskin and detect any natural or acquired curvatures of the penis. This visual feedback at the time of operation not only provides more control in removing the precise amount of foreskin but also offers greater flexibility with surgical planning. For example, frenular tethering is better appreciated in the erect state, and frenuloplasty may be performed more precisely in select cases ( fig. 5 ). In cases of phimosis, the exact width of the phimotic band is more easily measured prior to its removal ( fig. 6 ). These features of circumcision are often overlooked during routine circumcisions with the penis in a flaccid state and can result in suboptimal cosmetic outcomes.
With an increasing number of patients in our practice now seeking circumcision for cosmetic purposes, we believe that ICI prior to circumcision offers the best aesthetic result. All 20 patients in our study were satisfied with the results and no complications were reported at 2-week and 3-month follow-up. Additional testing with a larger number of patients and longer follow-up with objective measures will better elucidate the overall outcome of using ICI for circumcision. However, we do not anticipate that the use of ICI for circumcision poses any significant added risk for complications.
The biggest risk of using ICI is postoperative priapism. No cases of priapism were reported in all 20 patients reviewed in this study. We believe this risk can be minimized by appropriately screening patients prior to surgery. Patients with history of priapism, sickle cell disease or trait, multiple myeloma and leukemia should not receive ICI given their inherent risk of prolonged erection  . Additionally, the risk of priapism is minimized by appropriately dosing alprostadil. All patients in our study were initially injected 10 μg of alprostadil. An additional 10 μg was only injected in patients who did not respond to the initial dose. In spite of these measures, we recognize that priapism is a valid concern when using ICI. Accordingly, all postoperative patients are evaluated in the recovery room and called by telephone several hours later to confirm proper penile detumescence following surgery.
We found the use of ICI during circumcision to be safe with no complications reported. Most urologists are likely familiar with ICI and could easily incorporate it to their current surgical technique for circumcision. The same principles of the traditional sleeve circumcision can be safely applied to the erect penis with the use of prostaglandin injection without a significant learning curve or additional operating time. Additionally, newer modifications for circumcision (i.e. Quill TM knotless tissue closure device) can still be offered to patients for additional cosmesis  . Performing the circumcision with the penis in an erect state simply allows the surgeon to better predict cosmetic result and this offers a unique advantage from the traditional technique.
None of the contributing authors have any conflict of interest, including specific financial interests or relationships and affiliations relevant to the subject matter or materials discussed in this manuscript.
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