Introduction

Circumcision is the most common operation performed on males worldwide; for cultural, religious and medical reasons (1-4). Complications of the procedure vary from minor to tragic, these being: haemorrhage, infection, wound dehiscence, removal of incorrect amount of foreskin, glandular and penile injuries, glans and penile ampu-tations, prepucioglandular fusion, glandular necrosis, splitting(opening) of the distal urethra, meatal steno-sis, urethral fistula, lymphoedema, and painful scar-ring(1-8). Serious complications of circumcision are rare (4, 6, 7).

 

This study evaluates urethral injuries of circumcision and assesses the outcomes of surgery.

 

Patients and methods

This retropective study on urethral injuries due to cir-cumcision, covered 8 years at the Coast Province General Hospital (2004-2008) and Moi District Hospital, Voi (2009-2011) both in the Coast Province of Kenya. Operation and case notes of patients treated for circum cision urethral injuries by the authors were reviewed, in-cluding a small number from the private practice of the first author.

 

Abstraction of patient demographics, presentation, diag-nosis, surgical procedures and outcome was undertaken. Diagnosis was by clinical examination. No radiological investigations were performed. Magnifying loupes were used in all the reconstructions. Urethrocutaneous fistulas were closed with 6/0 poly-glactin either interrupted through and through or con-tinuous subcuticular. All the repairs were covered with pedicled dartos layer; the superficial fascia of the penis which was mobilised from either the ventral or dorsal side of the penis.It was ensured, the suture lines did not oppose (Figure 1).

 

Subcoronal hypospadiac meatal stenosis with chronic urine retention occurred in an 11 year old boy following circumcision. Meatoplasty, tubularised incised plate hy-pospadias repair and dorsal penile dartos coverage were done.

 

Urethral stricture at the level of the corona in a 2.5 year old boy necessitated suprapubic cystostomy for urinary

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retention. Repair was by an augmented anastomotic ure-throplasty with a full thickness skin graft from the groin, done 4 months after the circumcision (Figure 2). A urethral stent was used in all repairs.

 

Results

 

Fifteen patients with urethral injuries due to circumci-sion were studied (Table 1).

 

Age range was 1.5 - 24 years, median 6 years and mean of 8 years.

 

All the 13 patients with urethrocutaneous fistula had good results with no complication such as recurrence of the fistula.The patient with meatal stenosis had mild tor-sion of the penis after reconstruction.One patient, 2.5 years, with urethral stricture had a good result of nor-mal, asymptomatic voiding following urethroplasty.

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Discussion

In our study urethral injuries due to circumcision were rare considering the universal practice of male circum-cision in the region for cultural and religious reasons. Similar observations have been made by other authors who report rare occurrence of serious adverse events of circumcision (1, 2, 4, 5, 7). Urethrocutaneous fistulas were the commonest urethral injuries in our series. Previous authors (2, 6, 7) reported these as the commonest severe circumcision injuries. The fistulas were all coronal or subcoronal in location, in concurrence with other reports that give these sites as the commonest (2, 5, 9). All our reconstructions were stented and covered with dartos fascia in tandem with the account of Mkony (9). The principle of coverage of a urethral repair with well

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Click to view table 1

 

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vascularised tissue is also used in urethral fistulas result-ing from hypospadias repair as dartos or other fascia coverage is associated with lower rates of urethral fistula recurrence (10, 11). The observation in our series of no recurrence or occurrence of fistula after reconstruction, is mainly attributable to coverage with the dartos layer (9-11). In contrast, simple fistula closure was associated with a higher recurrence rate as in the series by Latifoglu et al.(2).

 

In conclusion, the use of dartos fascia to cover recon-structions of urethral injuries due to circumcision was associated with excellent results with no recurrence or occurrence of urethral fistula.

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Acknowledgement

I sincerely thank Jason Mwawana for the computer work and drawings and the Provincial Director of Medical Ser-vices, Coast Province, Kenya for authority to publish this article.

 

References

 

1. Ceylan K, Barhan K, Yilnaz Y et al. Severe complications of circumcision; an analysis of 48 cases. Journ of Paed Urol 2007; 3:32-35.

2. Latifoglu O, Yavuzer R, Unal S et al. Complications of cir-cumcision. Eur Journ. of Plast Surg 1999;22:85-88.

3. Johnson PRV. Childhood circumcision. Surg Int 2008; 26:314-316.

4. Weiss HA, Larke N, Halperin D et al. Complications of cir-cumcision in male neonates, infants and children: a system-atic review. BMC Urol 2010; 10:2.

5. Baskin LS, Canning DA, Snyder III HM, et al. Surgical repair of urethral circumcision injuries. Journ. of Urol. 1997; 158: 2269-2271.

6. Oriaifo IO, Osifo OD, Circumcision mishap in Nigeria chil-dren. Annals Afri. Med. 2009; 8: 266-70.

7. Sowande OA, Adejuyigble O. Circumcision mishap: a con-tinuing challenge in the developing countries. East, Centr. Afr. Journ. Surg. 2009; 14: 109-113.

8. Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of male circumcision in Ibadan, Nigeria. BMC Urol 2006; 6:21

9. Mkony C A, Aboud M. Post-circumcision urethrocutaneous fistula: the Key to Successful Reconstruction. East, Centr. Afr. Journ. Surg. 2006; 11(1):118 – 120.

10. Muruganandham K, Ansari MS, Dubey D, et al. Urethrocu-taneous fistula after hypospadias repair: outcome of three types of closure techniques. Paediatr. Surg. Int. 2010; 26: 305-308.

11. Holland AJA, Abubacker M, Smith GHH et al. Management of urethrocutaneous fistula following hypospadias repair. Paediatr. Surg. Int. 2008; 24: 1047 – 1051