The protocol was carried out in accordance with the principles of the Helsinki Declaration and all the methods described here have been approved by the ethics committee of Daping Hospital and written consent was obtained from the patients.
1. Instruments for operation
<ol>
	<li>Conduct all the procedures under an operating microscope with 5-10x magnification to achieve precise anastomoses and anatomic reconstruction.</li>
</ol>
2. Inclusion and ...

<ol>
	<li>Pippi Salle, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glans+amputation+during+routine+neonatal+circumcision:+mechanism+of+injury+and+strategy+for+prevention.">Glans amputation during routine neonatal circumcision: mechanism of injury and strategy for prevention.</a> Journal of Pediatric Urology. 9, 763-768 (2013).</li><li>Rizvi, S. A., Naqvi, S. A., Hussain, M., Hasan, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Religious+circumcision:+a+Muslim+view.">Religious circumcision: a Muslim view.</a> BJU International. 83, 13-16 (1999).</li><li>Weiss, H. A., Larke, N., Halperin, D., Schenker, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+of+circumcision+in+male+neonates,+infants+and+children:+a+systematic+review.">Complications of circumcision in male neonates, infants and children: a systematic review.</a> BMC Urology. 10, 2 (2010).</li><li>Harrison, N. W., Eshleman, J. L., Ngugi, P. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ethical+issues+in+the+developing+world.">Ethical issues in the developing world.</a> BJU International. 76, 93-96 (1995).</li><li>Ceylan, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Severe+complications+of+circumcision:+an+analysis+of+48+cases.">Severe complications of circumcision: an analysis of 48 cases.</a> Journal of Pediatric Urology. 3 (1), 32-35 (2007).</li><li>Okeke, L. I., Asinobi, A. A., Ikuerowo, O. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epidemiology+of+complications+of+male+circumcision+in+Ibadan,+Nigeria.">Epidemiology of complications of male circumcision in Ibadan, Nigeria.</a> BMC Urology. 6, 21 (2006).</li><li>Shabanzadeh, D. M., Clausen, S., Maigaard, K., Fode, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Male+circumcision+complications+-+A+systematic+review,+meta-analysis+and+meta-regression.">Male circumcision complications - A systematic review, meta-analysis and meta-regression.</a> Urology. 152, 25-34 (2021).</li><li>Aboutaleb, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reconstruction+of+an+amputated+glans+penis+with+a+buccal+mucosal+graft:+case+report+of+a+novel+technique.">Reconstruction of an amputated glans penis with a buccal mucosal graft: case report of a novel technique.</a> Korean Journal of Urology. 55 (12), 841-843 (2014).</li><li>Co&#349;kunfirat, O. K., Sayilkan, S., Velidedeoglu, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glans+and+penile+skin+amputation+as+a+complication+of+circumcision.">Glans and penile skin amputation as a complication of circumcision.</a> Annals of Plastic Surgery. 43 (4), 457 (1999).</li><li>El-Bahnasawy, M. S., El-Sherbiny, M. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Paediatric+penile+trauma.">Paediatric penile trauma.</a> BJU International. 90 (1), 92-96 (2002).</li><li>Petrella, F., Amar, S., El-Sherbiny, M., Capolicchio, J. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Total+glans+amputation+after+neonatal+circumcision.">Total glans amputation after neonatal circumcision.</a> Urology Case Reports. 37, 101624 (2021).</li><li>Raisin, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glans+injury+during+ritual+circumcision.">Glans injury during ritual circumcision.</a> Journal of Pediatric Urology. 16 (4), 471 (2020).</li><li>Nasr, R., Traboulsi, S. L., Abou Ghaida, R. R., Bakhach, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Iatrogenic+penile+glans+amputation:+major+novel+reconstructive+procedure.">Iatrogenic penile glans amputation: major novel reconstructive procedure.</a> Case Reports in Urology. 2013, 741980 (2013).</li><li>Yosra, K., Wiem, H., Mourad, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Saving+an+amputated+glans:+Role+of+winter+shunt.">Saving an amputated glans: Role of winter shunt.</a> Journal of Pediatric Urology. 16 (2), 238-240 (2020).</li><li>Manentsa, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+of+high+volume+circumcision:+glans+amputation+in+adolescents;+a+case+report.">Complications of high volume circumcision: glans amputation in adolescents; a case report.</a> BMC Urology. 19 (1), 65 (2019).</li><li>Wang, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microscopic+Replantation+of+Complete+Penile+Amputation+With+Video+Demonstration.">Microscopic Replantation of Complete Penile Amputation With Video Demonstration.</a> Urology. , (2022).</li></ol>

For religious or therapeutic purposes, about one-quarter of men around the world have had circumcision1. The incidence of complications is far from negligible, approximately 1% to 20%3,4,5,6,7. Circumcision-related glans amputation is extremely rare and there are no exact statistics depicting its incidence. Owing to its rarity, previous...

Around 25% of men worldwide are circumcised1,2. Circumcision in China is mostly performed in childhood. Over the past decades, the improvements in surgical techniques and equipment have made circumcision less complicated, faster, and with fewer post-circumcision complications. However, the popularity of these devices has also brought new challenges.
The incidence of post-circumcision complications is around 1%-20%, mostly mild3,4,5,6,7. In a recent meta-analysis, which included 351 studies with 4,042,988 participants, the overall complication risk was 3.84% (95% confidence interval 3.35-4.37)7. Circumcision-related glans amputation is a quite rare yet devastating injury during the surgery. Such complication is conventionally treated by simple hemostasis to achieve self-healing, early gross replantation, or delayed plastic surgery8,9. However, these can result in permanent damage to penile appearance and function, along with psychologic problems, if not handled properly8,9. The prevention and treatment of glans amputation have recently developed into a challenging problem for circumcision due to the increasing public health awareness and use of various suture devices in China. There are currently no existing protocols or guidelines for the treatment of such injury, which may be due to its rarity. As a result, there is no unified understanding of the injury mechanism of glans amputations, and there is a lack of early treatment management or prevention strategies.
In this study, we reported a case series of amputated penile glans caused by dispoable stapler during&#160;circumcision, which were successfully treated by microsurgery. The&#160;technical details of microsurgery were presented by video, and their possible injury mechanisms and prevention strategies were also discussed. This protocol is applicable for early microscopic replantation of all patients with penile glans amputation caused by accidental injury.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Catheter&#160;</td>
			<td>Guangzhou Weili Co., Ltd</td>
			<td>12 Fr</td>
			<td></td>
		</tr>
		<tr>
			<td>Cefuroxime sodium</td>
			<td>Yiyi Saite, Co., Ltd</td>
			<td>0.75 g</td>
			<td></td>
		</tr>
		<tr>
			<td>Cis-atrecu besylate</td>
			<td>Jiangsu Dongying CO.,&#160; Ltd</td>
			<td>10 mg</td>
			<td></td>
		</tr>
		<tr>
			<td>Operating microscope system</td>
			<td>Carl Zeiss Co., Ltd</td>
			<td>OPMI VARIO 700&#160;</td>
			<td></td>
		</tr>
		<tr>
			<td>Pentylpheptyl ether hydrochloride</td>
			<td>Chengdu Lisi Co., Ltd</td>
			<td>1.0 mg</td>
			<td></td>
		</tr>
		<tr>
			<td>Prolene</td>
			<td>Ethicon, LLC</td>
			<td>W2777/2780</td>
			<td></td>
		</tr>
		<tr>
			<td>Sufentanni citrate</td>
			<td>Renfu Phermaceutical</td>
			<td>50 &#181;g</td>
			<td></td>
		</tr>
		<tr>
			<td>Vicryl</td>
			<td>Ethicon, LLC</td>
			<td>W9981</td>
			<td></td>
		</tr>
	</tbody>
</table>

microscopic replantation of penile glans amputation due to circumcision

Circumcision using a disposable stapler is becoming quite popular in China. However, improper surgical procedures also bring the risk of penile glans amputation, which is a very rare iatrogenic genital injury. Such complication is conventionally treated by simple hemostasis to achieve self-healing, early gross replantation, or delayed plastic surgery. However, these may lead to obvious unfavorable outcomes such as amputated glans loss, necrosis, malformation healing, or urethral orifice stenosis. In the present study, we adopted microscopic replantation as an emergency approach to achieve the precise anastomoses and anatomic reconstruction of penile glans. The goal of this protocol is to present a detailed emergency management strategy with meticulous surgical skills for the penile glans amputation. The postoperative results showed that the original shape of the glans was perfectly restored with satisfactory cosmetic appearance. The micturition function was completely restored to normal without any obvious complications. There was also no significant reduction in the sensation of amputated glans area. Hence, early meticulous microscopic replantation as soon as possible is an ideal emergency management strategy for the penile glans amputation due to circumcision.

Three 7-8 years old children, whose distal penile glans were completely (2 cases) or incompletely (1 case) amputated during circumcision using a disposable stapler, were admitted to the hospital within 2-3 h after injury from June 2019 to July 2021. Physical examination confirmed that about 1/3 of the distal end of the penile glans with 3-4 mm of distal urethra was completely or incompletely amputated. In one severe case, the inner plate of prepuce and frenulum on the ventral side of the glans were also seriously damaged...

Watch this Scientific Journal Video about Microscopic Replantation of Penile Glans Amputation Due to Circumcision at JoVE.com

Microscopic Replantation of Penile Glans Amputation Due to Circumcision

The present protocol describes the emergency management of microscopic replantation of penile glans amputation due to circumcision.

Circumcision using a disposable stapler is becoming quite popular in China. However, improper surgical procedures also bring the risk of penile glans ...

Microscopic replantation of penile glans amputation due to circumcision. Glans amputation during circumcision is an extremely rare, but devastating complication. Such complication is conventionally treated by simple hemostasis to achieve self-healing, early gross replantation or delayed plastic surgery which leads to obvious complications such as amputated glans loss, necrosis, malformation healing or urethral orifice stenosis.It is thus clear that this damage often results in permanent damage to penile appearance and function, along with psychological problems if not handled properly. We developed a new emergency strategy using microscopic technique to achieve an early precise anatomic replantation and reconstruction. The patients were injured during the operation of circumcision using disposable stapler.The distal penile glans was completely or incompletely amputated. There are three main steps in total. Step one, repair the amputated penile glans and frenulum.Apply 8-0 nonabsorbable thread to suture the inner cavernous incision of the glans. Meanwhile, use 6-0 absorbable thread to suture the tears on the surface of the glans. Step two, end-to-end urethral anastomosis.Align the amputated glans and frenulum with the stump of glans. Insert an 8Fr, Foley catheter via the urethral orifice for the drainage of urine. Perform end-to-end urethral anastomosis using 6-0 absorbable thread by intermittent suture method with precise positioning.Usually, suture one stitch at 12:00 and six o'clock of the urethra at first, and then on the base of two positioning points, suture about four stitches tightly on the left and right sides respectively in a counterclockwise or clockwise direction. Step three, anastomosis of amputated glans surface and reconstruction of the frenulum. Suture the edge of amputated glans to the edge of the penile stump using 6-0 absorbable thread.Suture a few fixed points at six, 12, nine, and three o'clock at first, and then suture the space between the fixed points with a space of one millimeter for each to achieve a precise anastomosis. Trim the excess inter plate of prepuce on the ventral side of the penile glans. Reconstruct the frenulum by intermittent suture to achieve a satisfactory shape.The penile glans of the three patients are repaired satisfactorily and normal appearances are achieved after surgery. Postoperative observation at different time. One day after operation, the glans area is dark red and congested.One week after operation, the surface of the replanted glans and frenulum turn blackish, which might be epidermal scabby tissue. One month after operation, the morphology of the glans basically returns back to normal, with little blackish scabs. Two months after operation, the morphology of the glans returns back to normal.Two years after the operation, the morphology of the glans and urination are completely normal. Representative outcomes. Three children aged seven to eight years, penile glans were completely or incompletely amputated during the operation of circumcision using a disposable stapler, were admitted to our hospital from June 2019 to July 2021.The cold and warm ischemia time was from zero to five and half an hour. The operative time was about two hours. The follow-up results showed that the penile glans of all the children healed very well.The original shape of the glans was perfectly restored and get satisfactory cosmetic appearance without any obvious complications. Conclusions, early meticulous microscopic replantation as soon as possible is an ideal early emergency treatment method for the penile glans amputation, which can achieve a perfect cosmetic appearance without any obvious complications or functional deficiency.

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