Complications of Disposable Circumcision Suture Device Necessitating Surgical Intervention: A Case Series
Yi-Hsuan Chen, Chih-Chiao Lee, Li-Chen Chen, Wei-Kung Tsai
Department of Urology, Mackay Memorial Hospital
Circumcision is an ancient surgery with ongoing development. Nevertheless, there are still complications despite the much experience gained from the past thousands of years. Hemorrhage, infection, wound dehiscence, excessive foreskin removal, urethrocutaneous fistula and glans injury are all documented in previous literatures. Disposable circumcision suture device (DCSD) is an emerging method firstly reported in 2014. Compared to conventional circumcision by excision, advantages of DCSD include shorter operation and recovery time, less intraoperative and postoperative pain, better patient satisfaction, and lower complication rate. However, three patients with postoperative complications after circumcision with DCSD which necessitated second operation were encountered in our medical center. To our best knowledge, severe complications of DCSD mandating surgical intervention were not reported before. The prevention and the management of complications of DCSD are also discussed.
A 37-year-old male patient with poorly controlled diabetes and persistent balanoposthitis underwent circumcision with DCSD smoothly after a week of topical treatment. However, he returned to emergency department at the night of operative day due to progressing tenderness and swelling of penis with bleeding. Emergent exploration was performed, and an active bleeder was noted with hematoma accumulation.
A phimotic 39-year-old male underwent DCSD circumcision without intraoperative events. The staples failed to fall off 2 weeks after surgery and manual removal was performed at clinic. A laceration wound in ventral penile shaft was noted and thus oral and topical antibiotics were prescribed. His symptoms progressed and computed tomography taken on postoperative day (POD) 24 reported fluid accumulation around the penile shaft about 4.2*1.3 cm. He was then admitted for further management of penile abscess and incisional drainage was performed.
A 55-year-old male complained of phimosis with recurrent balanitis was circumcised with DCSD. Staple removal was performed on POD 24 but persistent distal prepuce edema with discomfort were complained. Physical examinations reveal scar formation causing paraphimotic symptoms. He later went on local excision of penile scar and frenuloplasty.
In spite of the advantages reported in previous literatures, the mechanism and design of DCSD can lead to potential severe complications requiring further intervention. Intraoperative and postoperative bleeding are likely the most problematic complication. Inadequate hemostasis during operation can be caused by frenulum or superficial dorsal vein, partial disruption of vessels by staples, retracted vessel ends, and no electrocoagulation hemostasis. A two-layer pressure wrapping technique was proposed for prevention of postoperative bleeding.Another frequently encountered issue is delayed fall-off of staples. It was reported that residual staple removal is required in up to 80% of patient. Devices with elastic bands which promoting staple falling were launched in market. Back to the basics, patient selection is always important. An adequate size of device, avoiding thick foreskin or frenulum breve are all essential to prevent complications.