'Superglue' for Circumcision Cost Effective and Cosmetically Appealing

From Reuters Health Information
Karla Gale, MS

September 3, 2010 — A sutureless and scalpel-free circumcision technique saves time and money, and the outcomes look good too, investigators report.

Dr. Andrew J. Kirsch and associates at Emory University School of Medicine, Atlanta, have done circumcisions using electrocautery and 2-octyl cyanoacrylate (2-OCA) instead of scalpels and sutures for the last four years.

In an August 24th online paper in the Journal of Urology, they report on 1008 boys ages 6 months to 12 years (mean 1.8 years) who had either primary circumcision or circumcision revision between 2006 and 2009.

The authors did all the procedures with electrocautery. They used 2-OCA in 493 primary procedures and 248 revisions, and 6-0 sutures in 152 primary circumcisions and 115 revisions.

The trial was not randomized, the authors note; the main reason for suture use was a resident's request for suturing experience.

The most complex condition treated was phimosis; there were no cases of chordee, penile torsion, hypospadias or phalloplasty. They did not use Gomco clamps.

After removing the foreskin, the surgeons would pinch the shaft skin at the base of the penis, push it distally toward the preputial collar, then apply a thin layer of 2-OCA dorsal and intermittently in circumferential fashion. After 30 seconds' drying time, they applied 2-OCA continuously around the apposed skin edges. They spread antibiotic ointment over the entire penis, scrotum and mons pubis (partly to keep the 2-OCA from sticking) and told parents to do the same when changing diapers or at least twice a day.

Three patients treated with 2-OCA and two treated with sutures reentered the hospital with bleeding, but none needed blood transfusion. Within a year and a half, one patient in the suture group underwent a revision because the parents didn't like the way the first procedure looked, and one patient in the 2-OCA group was treated for adhesions. There were no cases of dehiscence due to erection.

Operative times averaged 8 minutes using 2-OCA and 27 minutes using sutures (p < 0.001).

The authors note that at their institution, the anesthesia fee is about $189 per 15-minute block, and the operating room fee for circumcision is $571 for each 15 minutes. When factoring in the cost of 2-OCA and sutures, the 2-OCA technique cost $744 less than the suture technique.

"Patient satisfaction was equally high in all groups," the authors report, "but surgeon satisfaction was higher in the 2-OCA groups due to absent suture tracks and suture sinuses."

They emphasize the importance when using 2-OCA of determining how much preputial skin to excise to achieve the ideal skin fit, characterized by tension-free approximation of the shaft skin with the preputial collar even before applying 2-OCA.

In an editorial comment, Dr. Mark R. Zaontz, from Temple University School of Medicine, Philadelphia, says that his practice has also adopted the sutureless, scalpel-free technique, even though "running suture... is as rapid in my hands as applying the glue."

However, his group places holding sutures at the 6 and 12 o'clock positions to better line up wound edges. He cautions that this technique may not be as appropriate for older boys. Also, he is concerned about glue getting between the skin edges and the risk of epidermoid cyst formation.

In response, Dr. Kirsch and his group agree that this technique is probably best reserved for prepubescent boys "given the decreased vascularity and force of erection."

J Urol. 2010;184:1758-1762.