RE-AUDIT OF EARLY COMPLICATION ESPECIALLY IMPACTION OF DISPOSABLE DEVICE: IMPROVING OUTCOMES OF CIRCUMCISIONS WITH PLASTIBELL AND CIRCUMPLAST RINGS IN CHILDREN IN A COMMUNITY CLINIC

AIM: To evaluate the early postoperative complications particularly impaction of disposable devices ( Plastibell and Circumplast ) in children’s circumcision procedures under local anaesthesia between different age groups, size and types of rings, and different doctors in a community clinic.
MATERIAL AND METHODS
In our re-audit, the outcome of circumcisions (n=1449) was studied over a 1 year period (May 2016 to April 2017) performed under local anaesthesia, by trained doctors in a community clinic doing Circumplast Circumcisions (CC) (n=470) and Plastibell circumcisions (PC) (n=979). Data was collected prospectively and early postoperative complications especially ring impaction were compared between age of the child, size and types of device, and doctors who have performed the circumcision. Follow-up was arranged if required.
RESULTS
The mean age was 6.5±0.4 months (median 1.6). Overall complication rate was 6.7% (97/1449). There is no significant difference in overall complications rate in CC (7% n=33/470) versus PC (6.5% n=64/979) (p>0.5). Although ring impaction is significantly lower in Circumplast circumcision  (0.4% n=2/470) versus Plastibell circumcision (3.4% n=33/979) (p<0.05) but it has significantly improved from the previous audit (CC 3.2% n=7/208 versus PC 8.7% n=102/1179 – ESPU 2016). There is significantly lower incidence in ring impaction with Plastibell size 1.4 as compared to 1.3, 1.5 and 1.7. There is no impaction in 1.1 and 1.2 sizes. Ring impaction was significantly lower in infants versus over 1 year child (1.5% vs 10% n= 19/1280 vs 17/169, p<0.5) respectively. There is no significant difference in complications (8.5%, 7.1%, 6.5%, 5.8% and 5%) among the five doctors’ cases (p>0.5). Mean follow-up for 354 (24%) children were 14 days (median 6).
CONCLUSIONS
This concludes that no significant difference noted in overall early complications of circumcisions between age of the child, size and types of device used, and among different doctors. However, ring impaction was significantly lower in infants, Plastibell size 1.4 and Circumplast.

Accepted as a poster and presentation in ESPU 2018. This abstract is published at https://congress2018.espu.org/

All children operated at Thornhill clinic, Luton, Leyton Clinic, London and Croydon Clinic, London

ADEQUATE PERI-OPERATIVE MANAGEMENT DECREASES COSMETIC COMPLICATIONS AFTER CIRCUMCISION WITH DISPOSABLE RINGS (CIRCUMPLAST AND PLASTIBELL) IN CHILDREN

Source: ESPU 2017, Thornhill and London Circumcision Clinic, England UK

"We reviewed our experience in treating children with cosmetic complications following non-therapeutic male circumcision (NMC) with Plastibell and Circumplast devices at a community clinic. This study highlights the factors leading to these complications and clinical management to improve the cosmetic appearance.

A retrospective review of 3360 children who underwent Circumplast (CC) and Plastibell circumcision (PC) under local anaesthesia at a community clinic from May 2014 to October 2016. Parents were given detailed information and consented preoperatively to children with potential risks. This was provided verbally and in written format.

All complications were reviewed by a paediatric surgeon. All preputial adhesions were separated under anaesthetic cream. The buried penis was treated conservatively. Incomplete circumcisions were corrected by excision of excess skin.  Acquired phimosis was treated by steroid, simple double incision of the scar and surgical reconstruction. Complications were further looked for CC and PC. Follow-up visits were arranged in all cases.

There is no significant difference in the complications between Circumplast Circumcision  (2.2 % n=22/1002) and Plastibell circumcision  (2.3% n= 55/2357). Preputial adhesions were higher in Plastibell Circumcision  (1.5%) than Circumplast Circumcision  (0.8%) but not statistically significant. 

Children with cosmetic complications following NMC by disposable rings (Circumplast and Plastibell) can be prevented by meticulous perioperative management. Parental education and surgical expertise is required to minimise these complications"

ESPU 2017

Circumcisions with Circumplast has reached to 1000 in number at Thornhill and London (Leyton and Croydon) clinic in October 2016

Circumcisions with Circumplast has reached to 1000 in number at Thornhill and London (Leyton, Oliver Road, and Croydon) clinic in October 2016.

Non-therapeutic male circumcision by the Circumplast device can be safely performed in a community clinic. This novel device decreases the risks of complication especially in children under 3 months of age.

Doctor is using the Circumplast device for children circumcision at Uddevalla, Sweden

Doctor from Sweden was trained at London for the Circumplast circumcision and has started to use Circumplast circumcision device for the  children at his centre. 

He was very impressed with the results of the Circumplast circumcision and design of Circumplast device. 

Outcome of Circumplast and Plastibell at Thornhill Circumcision Centre

This cohort study will evaluate the early postoperative complications in Circumplast and Plastibell techniques, in a community clinic- Thornhill Circumcision Centre, for non-therapeutic male circumcision.

We reviewed the outcome of non-therapeutic male circumcision in children (n=1387) over a 1 year period (May 2014 to April 2015) in a community clinic - Thornhill clinic , performed under local anaesthesia, by trained doctors with the backup of a trained paediatric surgeon (figure 1-4). The technique was selected by doctors’ preference. Data was collected prospectively and early postoperative complications were compared between Circumplast and Plastibell circumcisions. Follow-up consultations were arranged if required.

The mean age was 18 ± 1.9 months (median 5.1) in Circumplast circumcision (CC) and 9.4 ± 0.6 months (median 1.5) in Plastibell circumcision (PC). Incidence of complications is significantly lower in CC (6.3% n=13/208) versus PC (13% n=154/1179) (p<0.05) (complications graph). Postoperative use of antibiotics was higher in CC versus PC (6.7% vs 3.8% n=14 vs 45) but not statistically significant (P>0.05). Mean follow-up consultations were 19 days (range 1 to 373) in CC and 20 days (range 1 to 305) in PC.

Outcome

Non-therapeutic male circumcision by the Circumplast device has a significantly lower risk of early postoperative complications in a community clinic, especially migration/impaction of the ring when compared to the standard Plastibell device.

Circumplast device size

Circumplast device are available in four different sizes (9.5, 11, 12, and 13) which is equivalent to Plastibell sizes 1.2, 1.3, 1.4 and 1.5. Boxes and individual items are colour coded with green (size 9.5), red (size 11), orange (size 12) and dark blue (size 13). 

CIRCUMCISION WITH A NOVEL DISPOSABLE RING

CIRCUMPLAST®. DOES THIS NEW DESIGN PREVENT RING MIGRATION AND GLANS PENIS INCARCERATION?

Circumplast® was used to perform non-therapeutic circumcisions on 112 male children between April 2013 and March 2014. The procedures were performed at a community clinic under local anaesthesia by the trained paediatric surgeon

Average age of patients was 2.9 years (range, 7 days to 11 years) and median age was 5 months. Patients (n=111) had spontaneous ring separation. Delayed separation of the ring in a 9 year old patient required ring removal as the ring had not come off on day 15 post-operatively due to inadequate size of ring when compared to glans penis. Using the Plastibell® method on 1883 patients over a one year period resulted in delayed/partial ring separation or proximal migration in 2.1% (n=40) of patients. Due to Circumplast’s® cylindrical design, there is no risk associated with the glans moving distally as there are no obstructions. In contrast, the Plastibell™ ring is conical with a narrowed distal end and the glans is held against the distal opening which causes the glans to protrude through this opening. Circumplast allows for multiple locations to secure the ligature and easy access to the glans and frenulum postoperatively.

The Circumplast® device with a cylindrical design virtually eliminates the risk of migration/impaction of the ring to the shaft of the penis in our experience of 112 circumcisions.