- Email: [email protected]
Scrotal injuries during neonatal circumcision
Accepted Manuscript Scrotal Injuries during Neonatal Circumcision Yuval Bar-Yosef, Snir Dekalo, Noam Bar-Yaakov, Joseph Binyamini, Mario Sofer, Jacob Ben-Chaim PII:
S1477-5131(18)30424-8
DOI:
10.1016/j.jpurol.2018.10.009
Reference:
JPUROL 2990
To appear in:
Journal of Pediatric Urology
Received Date: 31 July 2018 Revised Date:
4 October 2018
Accepted Date: 12 October 2018
Please cite this article as: Bar-Yosef Y, Dekalo S, Bar-Yaakov N, Binyamini J, Sofer M, Ben-Chaim J, Scrotal Injuries during Neonatal Circumcision, Journal of Pediatric Urology (2018), doi: https:// doi.org/10.1016/j.jpurol.2018.10.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Scrotal Injuries during Neonatal Circumcision
RI PT
Yuval Bar-Yosef, Snir Dekalo, Noam Bar-Yaakov, Joseph Binyamini, Mario Sofer, and Jacob Ben-Chaim
M AN U
of Medicine, Tel-Aviv University Tel-Aviv, Israel
SC
Pediatric Urology, Dana-Dwek Children’s Hospital, Tel-Aviv Medical Center, Sackler Faculty
Corresponding author:
Yuval Bar-Yosef, MD, FEAPU Pediatric Urology
Dana-Dwek Children’s Hospital
TE D
Tel-Aviv Medical Center 6 Weizman Street
Tel-Aviv 6423906, Israel
EP
E-mail: [email protected]
AC C
Running head: Scrotal injuries during neonatal circumcision Competing interests: none.
ACCEPTED MANUSCRIPT
SUMMARY OBJECTIVE: To report very rarely encountered scrotal injuries during neonatal circumcision. Hospitals and physicians in the authors’ country are mandated to report
RI PT
circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency room or the admitting department. This is believed to be the first case series describing scrotal injuries during ritual circumcision.
SC
PATIENTS AND METHODS: Reports of all circumcision complications between
2007-2014 were evaluated. Retrieved data on cases of scrotal injuries included patient's
M AN U
age, time between injury and hospital admission, nature of the injury, and administered treatment.
RESULTS: Twelve of a total of 489 reports of circumcision injuries involved the scrotum (2.5%). All circumcisions were performed during the neonatal period, and the
TE D
infants were admitted on the day of injury. The only related genital injury was significant shortage of penile skin reported in 6 patients. Scrotal exploration and skin closure in the operating room was undertaken in 6 cases, 5 under general anesthesia. Suture closure in
EP
the emergency department was performed in 3 patients, and the scrotal skin was left to heal with secondary intention in 3 other patients. Scrotal content injury that extended to
AC C
the tunica vaginalis of the testis was noted in one exploration. DISCUSSION: The injuries sustained by the 12 study infants were mostly superficial and are not expected to cause long-term damage, although half of the patients required treatment under general anesthesia in the operating room or under sedation in the emergency department. While all reported patients emerged unscathed from the anesthetic procedures, the possible immediate complications of anesthesia as well as its
1
ACCEPTED MANUSCRIPT
long-term effects are not to be taken lightly, especially when treating a newborn. Further education of medical providers as well as performers of ritual circumcisions may help lower the risk of this rare injury as well as other more severe complications.
RI PT
CONCLUSION: Scrotal injury during neonatal circumcision is rare. While half of the 12 reported patients required exploration in the operating room, the injuries were mostly
superficial and did not involve scrotal content, although they often involved extensive
SC
resection of penile skin.
AC C
EP
TE D
M AN U
Key Words: Circumcision, Scrotum, Injury
Figure legend: Scrotal skin injury and penile skin deficiency following neonatal circumcision, left to heal by secondary intention. 2
ACCEPTED MANUSCRIPT
Introduction The more commonly reported genital injuries during neonatal circumcision include bleeding and shortage of skin. Bleeding is usually mild, and it frequently resolves with
RI PT
conservative treatment. Massive bleeding is occasionally encountered, and it requires surgical intervention.1,2 Glans amputation3 and urethral injury are rarer and more
complicated injuries,4,5 while scrotal injuries are very rare. The hospitals and physicians
SC
in the authors’ country are mandated to report circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency department
injuries during ritual circumcision.
PATIENTS AND METHODS
M AN U
or the admitting department. This is believed to be the first case series describing scrotal
TE D
The circumcision complications database of the Ministry of Health was reviewed for reported cases of circumcision injuries involving scrotal skin or content. The study was approved by the local IRB committee. Reports of all circumcision complications between
EP
2007-2014 were evaluated. The data retrieved on cases of scrotal injuries included patient's age at the time of the procedure, time elapsed between injury and presentation
AC C
for medical care, nature and extent of the injury, and the administered treatment.
RESULTS
Twelve out of a total of 489 (2.5%) reports of circumcision injuries involved the scrotum. All circumcisions were performed during the neonatal period by non-physicians, and all the infants were admitted for treatment on the day of injury. The only related genital
3
ACCEPTED MANUSCRIPT
injury was significant shortage of penile skin, and it was reported in 6 patients. Scrotal exploration and skin closure in the operating room was undertaken in 6 cases, 5 under general anesthesia and the 6th under sedation. Suture closure in the emergency department
RI PT
was performed in 3 patients, and the scrotal skin was left to heal with secondary intention in 3 other patients. Scrotal content injury was noted in one exploration where the injury extended to the tunica vaginalis of the testis with no damage to the testis or testicular
SC
vasculature.
M AN U
DISCUSSION
Circumcision remains a very common procedure, with varying rates reported worldwide. A recent report from the Centers for Disease Control and Prevention estimated a prevalence rate of 80.5% for circumcision in the United States.6 While circumcision may
TE D
have health benefits, they should be weighed against possible complications. The 2012 policy statement of the American Academy of Pediatrics states that the health benefits of neonatal circumcision outweigh the possible risks of the procedure. The policy lists
EP
reduction of urinary tract infection during the first year of life as well as reduction of the risk of heterosexual acquisition of HIV and transmission of other sexually transmitted
AC C
infections among the benefits.7
Several anatomic genital characteristics or pathologies, including scrotal or penile
features, may raise the risk for scrotal injuries. Scrotal pathologies, such as hydroceles, may make newborns prone to circumcision-related scrotal injuries, but none were reported for any of the patients reported herein. Penile malformations, such as a buried penis or penoscrotal webbing, may also be a risk factor for scrotal injury. A multi-
4
ACCEPTED MANUSCRIPT
institutional consensus on objective criteria for use in determining patient suitability for neonatal clamp circumcision was recently published.8 Several anatomic characteristics were included in its checklist, including penile length, lack of curvature or torsion,
RI PT
evident coronal ridge, appearance of the prepuce and the median raphe, as well as the appearance of penoscrotal and penopubic junctions. Out of 193 candidates for
circumcision, 23% were found unsuitable for a neonatal clamp procedure. Penoscrotal
SC
webbing accounted for 19 of the cases deemed unsuitable, representing 30% of the 64 unsuitable patients and 9.8% of the entire cohort. Those authors, however, did not
M AN U
precisely define what they meant by “penoscrotal webbing”. Other reports in the literature include the results of corrective procedures, but little or no information on the prevalence of penoscrotal webbing. 9-12 This relatively common anatomic finding may cause scrotal skin injury during ritual circumcision, but it would not be evident directly
TE D
after the performance of a circumcision and therefore not included in the admission reports available for the current review, thus precluding the possibility of determining its contribution to injury in the herein reported cases.
EP
Previous reports of severe circumcision-related injuries have speculated on possible mechanisms of these injuries. Insufficient lysis of adhesions is one of those
AC C
mechanisms that has been implicated.3 Persistent adhesions may also very well lead to scrotal injuries, since tension applied to the preputial skin may lead to inclusion of scrotal skin when penile skin is not adequately released and mobilized. Inappropriate instruments or technique are other possible reasons for these rare injuries. We have no information regarding the instruments used in the cases we describe. However, all were performed by non-physicians. Ritual circumcision in our country is commonly
5
ACCEPTED MANUSCRIPT
performed with the traditional Jewish device known as Mogen (Hebrew for shield), a slotted shield designed to protect the penis. Alternatively, the Mogen clamp (also known as the Bronstein clamp after its inventor) is utilized, which has the same
RI PT
design as the traditional Mogen with the addition of a hinge and cam which create a crushing hemostatic effect. Other devices such as Gomco clamp or Plastibell are not utilized.
SC
The reported rate of scrotal injuries during neonatal ritual circumcision in the
current study is approximately 2.5%. As is the case with any study which is based on
M AN U
reports and databases, it is limited by a reporting bias. Not all complications are reported for various reasons. It is possible that physicians tend to report unique and rare injuries, such as scrotal injuries, whereas common injuries remain unreported. As such, scrotal injuries would be over-represented in the current series, and the actual rate of scrotal
TE D
injuries out of the total circumcision complications would be lower than reported. Moreover, failure to report even a small number of scrotal injuries may significantly alter the results and lower the reported rate of these rare injuries.
EP
The injuries sustained by the 12 study infants were mostly superficial and are not expected to cause long-term damage related to their scrotal injury. The deficiency of skin,
AC C
noted in many of the patients, could however lead to skin tethering, penile curvature, pain with erections or cosmetic concerns later in life. Half of the patients required treatment under general anesthesia in the operating room or under sedation in the emergency department. While all reported patients emerged unscathed from the anesthetic procedures, the possible immediate complications of anesthesia as well as its long-term effects are not to be taken lightly, especially when treating a newborn. Further education
6
ACCEPTED MANUSCRIPT
of medical providers as well as performers of ritual circumcisions may help lower the risk of this rare injury as well as other more severe complications.
RI PT
Conclusions
Scrotal injury during circumcision is rare. While one-half of the reported patients
required exploration in the operating room, the injuries were mostly superficial and did
SC
not involve scrotal content, although they often involved extensive shortage of penile
Conflict of Interest/Funding: None References 1.
M AN U
skin.
Edler G, Axelsson I, Barker GM, Lie S, Naumburg E. Serious complications in male
TE D
infant circumcisions in Scandinavia indicate that this always be performed as a hospitalbased procedure. Acta Paediatr. 2016;105(7):842-850. doi:10.1111/apa.13402. 2.
Bocquet N, Chappuy H, Lortat-Jacob S, Chéron G. Bleeding complications after ritual
EP
circumcision: about six children. Eur J Pediatr. 2010;169(3):359-362. doi:10.1007/s00431-009-1021-1. Pippi Salle JL, Jesus LE, Lorenzo AJ, et al. Glans amputation during routine neonatal
AC C
3.
circumcision: mechanism of injury and strategy for prevention. J Pediatr Urol. 2013;9(6 Pt A):763-768. doi:10.1016/j.jpurol.2012.09.012. 4.
Ceylan K, Burhan K, Yilmaz Y, Can S, Kuş A, Mustafa G. Severe complications of circumcision: an analysis of 48 cases. J Pediatr Urol. 2007;3(1):32-35. doi:10.1016/j.jpurol.2006.02.009.
7
ACCEPTED MANUSCRIPT
5.
Baskin LS, Canning DA, Snyder HM, Duckett JW. Surgical repair of urethral circumcision injuries. J Urol. 1997;158(6):2269-2271. http://www.ncbi.nlm.nih.gov/pubmed/9366374. Accessed September 19, 2017. Introcaso CE, Xu F, Kilmarx PH, Zaidi A, Markowitz LE. Prevalence of circumcision
RI PT
6.
among men and boys aged 14 to 59 years in the United States, National Health and
doi:10.1097/01.OLQ.0000430797.56499.0d. 7.
SC
Nutrition Examination Surveys 2005-2010. Sex Transm Dis. 2013;40(7):521-525.
American Academy of Pediatrics Task Force on Circumcision. Circumcision policy
8.
M AN U
statement. Pediatrics. 2012;130(3):585-586. doi:10.1542/peds.2012-1989. Concodora CW, Maizels M, Dean GE, et al. Checklist assessment tool to evaluate suitability and success of neonatal clamp circumcision: A prospective study. J Pediatr Urol. 2016;12(4):235.e1-5. doi:10.1016/j.jpurol.2016.05.028.
Herndon CDA, Casale AJ, Cain MP, Rink RC. Long-term outcome of the surgical
TE D
9.
treatment of concealed penis. J Urol. 2003;170(4 Pt 2):1695-7; discussion 1697. doi:10.1097/01.ju.0000083911.59937.c6.
Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the
EP
10.
buried penis: description of a classification system and a technique to correct the
AC C
disorder. J Urol. 1986;136(1 Pt 2):268-271. http://www.ncbi.nlm.nih.gov/pubmed/2873259. Accessed September 19, 2017. 11.
Redman JF. A technique for the correction of penoscrotal fusion. J Urol. 1985;133(3):432-433. http://www.ncbi.nlm.nih.gov/pubmed/3973991. Accessed September 19, 2017.
12.
Bonitz RP, Hanna MK. Correction of congenital penoscrotal webbing in children: a
8
ACCEPTED MANUSCRIPT
retrospective review of three surgical techniques. J Pediatr Urol. 2016;12(3):161.e1-5.
AC C
EP
TE D
M AN U
SC
RI PT
doi:10.1016/j.jpurol.2016.02.003.
9
S1477-5131(18)30424-8
DOI:
10.1016/j.jpurol.2018.10.009
Reference:
JPUROL 2990
To appear in:
Journal of Pediatric Urology
Received Date: 31 July 2018 Revised Date:
4 October 2018
Accepted Date: 12 October 2018
Please cite this article as: Bar-Yosef Y, Dekalo S, Bar-Yaakov N, Binyamini J, Sofer M, Ben-Chaim J, Scrotal Injuries during Neonatal Circumcision, Journal of Pediatric Urology (2018), doi: https:// doi.org/10.1016/j.jpurol.2018.10.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Scrotal Injuries during Neonatal Circumcision
RI PT
Yuval Bar-Yosef, Snir Dekalo, Noam Bar-Yaakov, Joseph Binyamini, Mario Sofer, and Jacob Ben-Chaim
M AN U
of Medicine, Tel-Aviv University Tel-Aviv, Israel
SC
Pediatric Urology, Dana-Dwek Children’s Hospital, Tel-Aviv Medical Center, Sackler Faculty
Corresponding author:
Yuval Bar-Yosef, MD, FEAPU Pediatric Urology
Dana-Dwek Children’s Hospital
TE D
Tel-Aviv Medical Center 6 Weizman Street
Tel-Aviv 6423906, Israel
EP
E-mail: [email protected]
AC C
Running head: Scrotal injuries during neonatal circumcision Competing interests: none.
ACCEPTED MANUSCRIPT
SUMMARY OBJECTIVE: To report very rarely encountered scrotal injuries during neonatal circumcision. Hospitals and physicians in the authors’ country are mandated to report
RI PT
circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency room or the admitting department. This is believed to be the first case series describing scrotal injuries during ritual circumcision.
SC
PATIENTS AND METHODS: Reports of all circumcision complications between
2007-2014 were evaluated. Retrieved data on cases of scrotal injuries included patient's
M AN U
age, time between injury and hospital admission, nature of the injury, and administered treatment.
RESULTS: Twelve of a total of 489 reports of circumcision injuries involved the scrotum (2.5%). All circumcisions were performed during the neonatal period, and the
TE D
infants were admitted on the day of injury. The only related genital injury was significant shortage of penile skin reported in 6 patients. Scrotal exploration and skin closure in the operating room was undertaken in 6 cases, 5 under general anesthesia. Suture closure in
EP
the emergency department was performed in 3 patients, and the scrotal skin was left to heal with secondary intention in 3 other patients. Scrotal content injury that extended to
AC C
the tunica vaginalis of the testis was noted in one exploration. DISCUSSION: The injuries sustained by the 12 study infants were mostly superficial and are not expected to cause long-term damage, although half of the patients required treatment under general anesthesia in the operating room or under sedation in the emergency department. While all reported patients emerged unscathed from the anesthetic procedures, the possible immediate complications of anesthesia as well as its
1
ACCEPTED MANUSCRIPT
long-term effects are not to be taken lightly, especially when treating a newborn. Further education of medical providers as well as performers of ritual circumcisions may help lower the risk of this rare injury as well as other more severe complications.
RI PT
CONCLUSION: Scrotal injury during neonatal circumcision is rare. While half of the 12 reported patients required exploration in the operating room, the injuries were mostly
superficial and did not involve scrotal content, although they often involved extensive
SC
resection of penile skin.
AC C
EP
TE D
M AN U
Key Words: Circumcision, Scrotum, Injury
Figure legend: Scrotal skin injury and penile skin deficiency following neonatal circumcision, left to heal by secondary intention. 2
ACCEPTED MANUSCRIPT
Introduction The more commonly reported genital injuries during neonatal circumcision include bleeding and shortage of skin. Bleeding is usually mild, and it frequently resolves with
RI PT
conservative treatment. Massive bleeding is occasionally encountered, and it requires surgical intervention.1,2 Glans amputation3 and urethral injury are rarer and more
complicated injuries,4,5 while scrotal injuries are very rare. The hospitals and physicians
SC
in the authors’ country are mandated to report circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency department
injuries during ritual circumcision.
PATIENTS AND METHODS
M AN U
or the admitting department. This is believed to be the first case series describing scrotal
TE D
The circumcision complications database of the Ministry of Health was reviewed for reported cases of circumcision injuries involving scrotal skin or content. The study was approved by the local IRB committee. Reports of all circumcision complications between
EP
2007-2014 were evaluated. The data retrieved on cases of scrotal injuries included patient's age at the time of the procedure, time elapsed between injury and presentation
AC C
for medical care, nature and extent of the injury, and the administered treatment.
RESULTS
Twelve out of a total of 489 (2.5%) reports of circumcision injuries involved the scrotum. All circumcisions were performed during the neonatal period by non-physicians, and all the infants were admitted for treatment on the day of injury. The only related genital
3
ACCEPTED MANUSCRIPT
injury was significant shortage of penile skin, and it was reported in 6 patients. Scrotal exploration and skin closure in the operating room was undertaken in 6 cases, 5 under general anesthesia and the 6th under sedation. Suture closure in the emergency department
RI PT
was performed in 3 patients, and the scrotal skin was left to heal with secondary intention in 3 other patients. Scrotal content injury was noted in one exploration where the injury extended to the tunica vaginalis of the testis with no damage to the testis or testicular
SC
vasculature.
M AN U
DISCUSSION
Circumcision remains a very common procedure, with varying rates reported worldwide. A recent report from the Centers for Disease Control and Prevention estimated a prevalence rate of 80.5% for circumcision in the United States.6 While circumcision may
TE D
have health benefits, they should be weighed against possible complications. The 2012 policy statement of the American Academy of Pediatrics states that the health benefits of neonatal circumcision outweigh the possible risks of the procedure. The policy lists
EP
reduction of urinary tract infection during the first year of life as well as reduction of the risk of heterosexual acquisition of HIV and transmission of other sexually transmitted
AC C
infections among the benefits.7
Several anatomic genital characteristics or pathologies, including scrotal or penile
features, may raise the risk for scrotal injuries. Scrotal pathologies, such as hydroceles, may make newborns prone to circumcision-related scrotal injuries, but none were reported for any of the patients reported herein. Penile malformations, such as a buried penis or penoscrotal webbing, may also be a risk factor for scrotal injury. A multi-
4
ACCEPTED MANUSCRIPT
institutional consensus on objective criteria for use in determining patient suitability for neonatal clamp circumcision was recently published.8 Several anatomic characteristics were included in its checklist, including penile length, lack of curvature or torsion,
RI PT
evident coronal ridge, appearance of the prepuce and the median raphe, as well as the appearance of penoscrotal and penopubic junctions. Out of 193 candidates for
circumcision, 23% were found unsuitable for a neonatal clamp procedure. Penoscrotal
SC
webbing accounted for 19 of the cases deemed unsuitable, representing 30% of the 64 unsuitable patients and 9.8% of the entire cohort. Those authors, however, did not
M AN U
precisely define what they meant by “penoscrotal webbing”. Other reports in the literature include the results of corrective procedures, but little or no information on the prevalence of penoscrotal webbing. 9-12 This relatively common anatomic finding may cause scrotal skin injury during ritual circumcision, but it would not be evident directly
TE D
after the performance of a circumcision and therefore not included in the admission reports available for the current review, thus precluding the possibility of determining its contribution to injury in the herein reported cases.
EP
Previous reports of severe circumcision-related injuries have speculated on possible mechanisms of these injuries. Insufficient lysis of adhesions is one of those
AC C
mechanisms that has been implicated.3 Persistent adhesions may also very well lead to scrotal injuries, since tension applied to the preputial skin may lead to inclusion of scrotal skin when penile skin is not adequately released and mobilized. Inappropriate instruments or technique are other possible reasons for these rare injuries. We have no information regarding the instruments used in the cases we describe. However, all were performed by non-physicians. Ritual circumcision in our country is commonly
5
ACCEPTED MANUSCRIPT
performed with the traditional Jewish device known as Mogen (Hebrew for shield), a slotted shield designed to protect the penis. Alternatively, the Mogen clamp (also known as the Bronstein clamp after its inventor) is utilized, which has the same
RI PT
design as the traditional Mogen with the addition of a hinge and cam which create a crushing hemostatic effect. Other devices such as Gomco clamp or Plastibell are not utilized.
SC
The reported rate of scrotal injuries during neonatal ritual circumcision in the
current study is approximately 2.5%. As is the case with any study which is based on
M AN U
reports and databases, it is limited by a reporting bias. Not all complications are reported for various reasons. It is possible that physicians tend to report unique and rare injuries, such as scrotal injuries, whereas common injuries remain unreported. As such, scrotal injuries would be over-represented in the current series, and the actual rate of scrotal
TE D
injuries out of the total circumcision complications would be lower than reported. Moreover, failure to report even a small number of scrotal injuries may significantly alter the results and lower the reported rate of these rare injuries.
EP
The injuries sustained by the 12 study infants were mostly superficial and are not expected to cause long-term damage related to their scrotal injury. The deficiency of skin,
AC C
noted in many of the patients, could however lead to skin tethering, penile curvature, pain with erections or cosmetic concerns later in life. Half of the patients required treatment under general anesthesia in the operating room or under sedation in the emergency department. While all reported patients emerged unscathed from the anesthetic procedures, the possible immediate complications of anesthesia as well as its long-term effects are not to be taken lightly, especially when treating a newborn. Further education
6
ACCEPTED MANUSCRIPT
of medical providers as well as performers of ritual circumcisions may help lower the risk of this rare injury as well as other more severe complications.
RI PT
Conclusions
Scrotal injury during circumcision is rare. While one-half of the reported patients
required exploration in the operating room, the injuries were mostly superficial and did
SC
not involve scrotal content, although they often involved extensive shortage of penile
Conflict of Interest/Funding: None References 1.
M AN U
skin.
Edler G, Axelsson I, Barker GM, Lie S, Naumburg E. Serious complications in male
TE D
infant circumcisions in Scandinavia indicate that this always be performed as a hospitalbased procedure. Acta Paediatr. 2016;105(7):842-850. doi:10.1111/apa.13402. 2.
Bocquet N, Chappuy H, Lortat-Jacob S, Chéron G. Bleeding complications after ritual
EP
circumcision: about six children. Eur J Pediatr. 2010;169(3):359-362. doi:10.1007/s00431-009-1021-1. Pippi Salle JL, Jesus LE, Lorenzo AJ, et al. Glans amputation during routine neonatal
AC C
3.
circumcision: mechanism of injury and strategy for prevention. J Pediatr Urol. 2013;9(6 Pt A):763-768. doi:10.1016/j.jpurol.2012.09.012. 4.
Ceylan K, Burhan K, Yilmaz Y, Can S, Kuş A, Mustafa G. Severe complications of circumcision: an analysis of 48 cases. J Pediatr Urol. 2007;3(1):32-35. doi:10.1016/j.jpurol.2006.02.009.
7
ACCEPTED MANUSCRIPT
5.
Baskin LS, Canning DA, Snyder HM, Duckett JW. Surgical repair of urethral circumcision injuries. J Urol. 1997;158(6):2269-2271. http://www.ncbi.nlm.nih.gov/pubmed/9366374. Accessed September 19, 2017. Introcaso CE, Xu F, Kilmarx PH, Zaidi A, Markowitz LE. Prevalence of circumcision
RI PT
6.
among men and boys aged 14 to 59 years in the United States, National Health and
doi:10.1097/01.OLQ.0000430797.56499.0d. 7.
SC
Nutrition Examination Surveys 2005-2010. Sex Transm Dis. 2013;40(7):521-525.
American Academy of Pediatrics Task Force on Circumcision. Circumcision policy
8.
M AN U
statement. Pediatrics. 2012;130(3):585-586. doi:10.1542/peds.2012-1989. Concodora CW, Maizels M, Dean GE, et al. Checklist assessment tool to evaluate suitability and success of neonatal clamp circumcision: A prospective study. J Pediatr Urol. 2016;12(4):235.e1-5. doi:10.1016/j.jpurol.2016.05.028.
Herndon CDA, Casale AJ, Cain MP, Rink RC. Long-term outcome of the surgical
TE D
9.
treatment of concealed penis. J Urol. 2003;170(4 Pt 2):1695-7; discussion 1697. doi:10.1097/01.ju.0000083911.59937.c6.
Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF. Surgical correction of the
EP
10.
buried penis: description of a classification system and a technique to correct the
AC C
disorder. J Urol. 1986;136(1 Pt 2):268-271. http://www.ncbi.nlm.nih.gov/pubmed/2873259. Accessed September 19, 2017. 11.
Redman JF. A technique for the correction of penoscrotal fusion. J Urol. 1985;133(3):432-433. http://www.ncbi.nlm.nih.gov/pubmed/3973991. Accessed September 19, 2017.
12.
Bonitz RP, Hanna MK. Correction of congenital penoscrotal webbing in children: a
8
ACCEPTED MANUSCRIPT
retrospective review of three surgical techniques. J Pediatr Urol. 2016;12(3):161.e1-5.
AC C
EP
TE D
M AN U
SC
RI PT
doi:10.1016/j.jpurol.2016.02.003.
9