Circumcision standards: can we improve further?

Lv et al.1 present a newly designed disposable circumcision device. The device cuts the foreskin and closes the skin edges with staples simultaneously. Their results suggest a fast operating time, low complication rate, and high patient satisfaction. This device is easy to operate and can be used with local anesthesia alone. In an age when several African countries consider mass circumcision to reduce HIV transmission rates,2,3 physicians have been looking for a simple and safe circumcision method that can easily be taught to others. Provided the results can be replicated by others, this device appears to be an ideal tool for adult mass circumcisions. It has the distinct advantage over the Shang Ring and other penile clamps of immediately removing the skin and the device rather than leaving the ring and await subsequent skin necrosis and healing. In this study, the Shang Ring resulted in higher postoperative pain scores. The cost and general availability for the device have not been discussed and may potentially be a limiting factor for some health services. The device is also not suitable for patients with foreskin adhesions or a buried penis, who will continue to need surgical skills and a manual circumcision. Secondly, there is a novel approach to the circumcision anesthetic using 5% lidocaine cream alone rather than a penile block with 10 ml 2% lidocaine injection. Patients given 5% lidocaine cream alone had less intraoperative pain than those receiving an injection. However, other variables such as shorter surgical times with the device and technique and volume of the lignocaine injection may have influenced intraoperative pain levels. In my own practice, I use a mixture of 10 ml 1% lidocaine, 10 ml 0.5% bupivacaine, and 10 ml normal saline. A volume of 20 ml is injected as penile block and ring block, leaving 10 ml in the rare case of residual discomfort. Using this technique my patients are usually completely pain free during surgery. However, the idea of anesthesia with cream alone will certainly appeal more to patients than an injection. A further prospective study comparing anesthesia with lidocaine cream versus injection to clarify the suitability and benefit of surface analgesia alone for standard circumcision is required. Thirdly, the concept of measuring healing time is introduced, which raises the interesting question of objectively defining when a wound is healed and whether this can be assessed on a daily basis. Skin edge healing was quicker when a healthy skin edge was left using a ring-shaped blade compared to skin edges with thermal injury from electrocautery incision or healing following pressure necrosis.* Intuitively this makes sense. In the United Kingdom, the National Institute for Health and Clinical Excellence also advises against skin incisions with electrocautery on grounds of increased infection rates.4 Despite these limitations, the new device is an exciting development and high patient satisfaction combined with low complication rates commend its further use, ideally with additional prospective data collection to confirm its benefits further.