Paediatric urologist

The Use of Tissue Glue for Circumcision in Children: Systematic Review and Meta-analysis 2018

 OBJECTIVE

To evaluate the efficacy of tissue glue in pediatric (children) circumcision.

 MATERIALS AND METHODS

A systematic review and meta-analysis of the English literature (1997-2017) was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement on children who underwent circumcision with tissue glue. Meta-analysis was conducted using RevMan 5.3, Comprehensive Meta-Analysis 2, and MedCalc 18. P values <.05 were considered significant.

 RESULTS

The search returned 15 studies for a total of 4567 circumcisions, of which 3045 (66%) were performed with tissue glue. The systematic review indicated that overall complication rates were 4.3% (tissue glue) and 5.9% (sutures). The use of tissue glue was associated with reduced postoperative pain, better cosmetic results, and reduced cost. Meta-analysis showed that there was no difference between the incidence of total postoperative complications (relative risk [RR] 0.86 [95% confidence interval {CI}: 0.62-1.19], P = .36) and wound infection and dehiscence between the 2 groups (RR 0.95 [95% CI: 0.59-1.56], P = .85). Postoperative bleeding and hematoma formation were reduced with the use of tissue glue (RR 0.55 [95% CI: 0.32-0.95], P = .03). Tissue glue also significantly shorten the operative time (mean difference −0.22 [95% CI: −0.39 to −0.05], P = .01).

 CONCLUSION

The incidence of postoperative bleeding and hematoma formation in pediatric circumcision is reduced with the use of tissue glue. Tissue glue has reduced operative time; furthermore, it might be associated with reduced postoperative pain, less overall cost, and superior cosmetic results.

Ref: UROLOGY 115: 21–28, 2018. © 2018 Elsevier Inc.

CQC published the case study- London Circumcision Clinic fulfils 95% standards

Case study – good practice for Newborn or Baby circumcision

This case study is taken from a GP practice that has conducted traditional circumcision for 28 years. ( published CQC website)

In this practice, parents receive written information and advice in advance of the procedure. This includes a consent form and information about aftercare. The practice requires both parents to give consent to the procedure.

Parents are advised not to feed the infant for two hours before the procedure. This ensures that the baby feeds immediately afterwards to provide comfort.

The doctor assesses the level and type of local anaesthesia appropriate for each infant, taking account of their age and weight and the requirements of the procedure. Pain relief is proportionate and appropriate for the individual needs of the infant.

If the doctor concludes that the procedure cannot be safely conducted in his GP practice, he advises parents of this and suggests alternative options (for example, referral to hospital care).

During the procedure, the infant is held comfortably still. Another person is always present to assist and respond to the infant’s needs if they are in any distress.

The family is advised to remain at the practice for at least an hour after the procedure and once the doctors is certain that the baby is not bleeding.

The doctor is available for aftercare and the arrangements for follow up are clear.

Written instructions for parents include a request to text or ring the doctor after their first check. The parents are advised to contact the doctor at any time by text or phone if they have any concerns. If this happens, the doctor will visit the baby at home or see him at the surgery, as is most appropriate.

The doctor encourages good practice among other providers by offering training in the procedure.

Ref: 

Advice for inspectors

Circumcision of male children

January 2016 Care Quality Commission

Cosmetic appearance of penis in children before or after circumcision

Before the circumcision in infants and children, every child anatomy is different, and their shape or size of penis and foreskin are also different. Penis is sometimes  rotated, bended  or buried in pubic areas. When  parents arrange a circumcision,  they may have in mind that the child will look like the father or head of the penis may not be completely exposed as religious or cultural requirements, but this is definitely not the case in some children. Children develops differently as well. Degree of buried penis can change as child grows older.

Hypospadias describes an anatomical variant where the wee hole (external mental opening) did not complete its development and did not close fully to the tip of the penis leaving an opening along the underside of the penis. Opening could be present away from tip of the penis to scrotum or perineum. This also requires hypospadias repair under general anaesthesia and the foreskin may be helpful for this purpose, so circumcision must not be done until the hypospadias repair is done. In most of the cases, you can recognise as foreskin is hooded. In some cases, hypospadias may be present on intact foreskin and described as megameastus or glandular hypospadias.  This can only recognised after retracting the foreskin and circumcision should be postponed until hypospadias repair is done. 

Some babies, infants and children have long and skinny penis and others short and fat penis. Some have showed bending to the left or to the right before or after circumcision. Some children penis is buried into the abdominal fat. Some are more bent than others, even more to 90 degrees. This markedly bent penis is described as a penile chordee and requires paediatric urology to straighten, and the foreskin is useful for this procedure in these cases, so should not have circumcision until the corrective operation of penile chordee is done under general anaesthesia in the hospital.

Buried penis is very common now a days. In most of the cases, it is mild form which may not require any further corrective surgery and it is possible to do circumcision. Many boys have loose attachment of the skin to the shaft of the penis. In these children, there may be a high insertion of the scrotal skin along the underside of the shaft of the penis, or there may be a pad of “puppy fat” in front of the pubic bone pushing the skin forward and away from the penis which is anchored at its internal base to the pubic bone. The penis appears to disappear behind the skin, and this is sometimes referred to as the “Disappearing Penis Syndrome”. It is also referred to as a “buried penis”,  "hidden penis" or "inconspicuous penis"

It is primarily an issue of loose attachment of the skin and it is usual for the penis to “reappear” by the time the child is about 1-6 years of age, with the reduction in this pubic fat and the growth of the child. However, some few older children or adults retain this appearance at rest; yet, it looks and performs perfectly adequately in sexual situations.

This anatomical variant, however, causes the parents concern after a circumcision, because as the skin moves forward over the head of the penis, it appears that not enough skin has been removed. This is not the case. The paediatric urologist ( Mr A R Khan) has to estimate the length of skin to leave in order that when the child is grown, there will be enough skin to cover the erect penis and not leave too much area that will be covered by scar tissue. It is only in the infant years, then, that the child may appear to have been inadequately circumcised.

It is very important in such boys, that the parents retract the cut foreskin regularly to prevent the cut edge healing and attaching to the head of the penis after 3 days of separation of the ring circumcision and creating a cosmetic result that is not desired. Therefore, if you notice that the skin of the penis is falling forward covering the head of the penis at any time after the operation, even up to a few years later, ( such that it looks like not enough skin was removed), then please have the child reviewed at our clinic by Dr. Khan. He will explain to you how to manage the skin so as not to form permanent attachments to the head of the penis, and he may have to separate the skin from head (glans) of penis for you at times or referral to the GP for further managamnet at tertiary centre in UK..


 The content on the our website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice from Dr. Khan regarding any medical questions or conditions developed after circumcision.

Five stars reviews and feedbacks- Dr. Khan

Father says “Great Service, Highly recommend”
— ET- 2 months old baby father (text to Dr Khan)

Dr. Khan has received 200 feedbacks and reviews from parents and patients who have been given five star professional service by paediatric Surgeon / Urologist.   

They  have treatments like adult circumcision, infants and children circumcision and other procedures under care of Mr. (Dr.) A R Khan 

These reviews have been variefied by I Want Great Care

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