Circumcision
Male circumcision appears to be one of the oldest surgical procedures, practiced since ancient times for medical or non-medical reasons (religious in Jewish, Muslim, and traditional African cultures, social, cultural, and personal reasons). To date, it is estimated that the prevalence of circumcised men ranges between 12.5% and 33% of the global male population.
Circumcision rates vary according to race, ethnicity, culture, social and economic conditions, and religion. It is important to note that voluntary medical male circumcision (VMMC) is a key preventive intervention against HIV promoted by the World Health Organization (WHO).
The most common indications for circumcision in adults are phimosis, ritual circumcision, phimosis associated with balanitis or balanoposthitis. Dyspareunia can also be a frequent indication for circumcision.
Circumcision is considered a simple surgical procedure; however, an overall complication risk of 3.8% has been reported. The main and most frequently encountered complications of male circumcision are minor and include wound infections, bleeding, and incomplete or excessive removal of the foreskin. Meatitis and urethral meatal stenosis are more serious and occur more rarely, believed to be due to injury to the frenular vessels or in cases of lichen sclerosus. High-grade but rare complications (0.2-0.6%) reported in the literature include urethral fistulas, necrotizing fasciitis, lymphedema, partial penile amputation, and penile necrosis. Mortality is extremely rare: 1 in 500,000 surgical procedures.
Although many reviews have been conducted, no significant differences have been found in terms of success and complications among the various techniques and devices used for circumcision. Circumcision devices may be slightly preferred over standard surgical procedures because they reduce operative time and postoperative pain within the first 24 hours. However, the preferred technique should take into account some contextual factors such as the patient’s age, cost, patient preferences and values, and access to skilled healthcare workers and facilities in certain settings.
Circumcision Techniques
In men and older boys, the best technique appears to be the “Sleeve Circumcision” (Figure 1). In clinical practice, the incision line should be extended straight across the base of the frenulum, through the dartos fascia to the superficial layer of Buck’s fascia. After reducing the foreskin, a second incision is marked, following the outline of the coronal margin and the V-shape of the frenulum on the ventral side. The frenulum usually retracts into a V-shape. Frenuloplasty without circumcision is not considered a standard treatment, but it can be used in young patients who wish to avoid or postpone total circumcision.
Figure 1. Sleeve Circumcision
The evidence regarding the effect of circumcision on sexual function, pleasure, and glans sensitivity is limited and not well understood. The corneal epithelium covering the circumcised glans may lead to some reduction in penile sensitivity, although there is no evidence that this phenomenon alters the time needed to reach orgasm or sexual satisfaction. Circumcision seems to have no overall negative effects on penile sensitivity, sexual arousal, sexual sensation, erectile function, premature ejaculation, ejaculatory latency, orgasmic difficulties, sexual satisfaction, pleasure, or pain during penetration. In some studies, it has shown benefits on sexual function, sensation, satisfaction, and pleasure for males circumcised in infancy or adulthood.
Prepuce-Preserving Techniques
The term preputioplasty refers to various surgical techniques aimed at resolving phimosis without resorting to radical or partial circumcision. Prepuce-preserving techniques have been developed to improve the aesthetic outcomes of radical circumcision by increasing the preservation of the penile foreskin. Six different prepuce-preserving techniques have been reported for the treatment of phimosis: triple incision plasty, the “Heineke–Mikulicz” technique, ventral V-plasty, Y-V plasty, trident preputial plasty, and Z-plasty. However, only the Heineke–Mikulicz and Y-V plasty techniques have been described in adults.
Prepuce-Preserving Plasty and Simple Running Suture (Figure 2)
The first incision is made on the external lamina of the prepuce, and the second on the internal lamina in the opposite oblique direction. This allows for the complete removal of the phimotic ring and increases the circumference of the two laminae, which are then realigned and sutured with simple running sutures. The results were evaluated through comparative photos and confirmed by assessing the presence or absence of recurrence, scar evaluation, and the VAS scale for patient satisfaction. No pathological scarring was observed during follow-up, and there were no recurrences of phimosis. Finally, all patients resumed normal sexual activity.
Y-V Preputioplasty (Figure 2)
The Y-V plasty procedure to relieve phimosis was first described by Ebbehøj’s group in 1984. This procedure is limited to men who can partially retract the foreskin. In this technique, the constricting phimotic ring is incised with a single dorsal cut that goes through the full thickness of the skin. The incision is then extended distally in two directions to form a “Y” shape. The resulting triangular flap is advanced proximally over the defect and sutured with 4/0 vicryl thread. In one study, the results of this technique showed that 12 patients (40%) were very satisfied, 10 (33%) were satisfied, while 4 (13%) were indifferent, and 4 (13%) were dissatisfied. Only two patients later underwent a traditional circumcision.
Figure 2. V-Y Plasty.
Heineke-Mikulicz Preputioplasty (Figure 3)
Heineke-Mikulicz preputioplasty (HMP) is a conservative surgical treatment for phimosis in the adult population that preserves the foreskin. The technique involves a 2-3 cm vertical incision over the phimotic ring on the dorsal surface, extending just above Buck’s fascia. If phimosis persists after the dorsal release, an additional incision is made on the ventral surface. The incision is then closed horizontally in two layers.
A study that applied this technique on seven patients reported the following data: two patients required both dorsal and ventral incisions, no intraoperative complications were noted, and one patient experienced bothersome phimosis due to scar formation, which was successfully treated with a traditional circumcision.
Figure 3. Heineke-Mikulicz technique
In conclusion, circumcision and preputioplasty techniques represent important surgical choices that require careful and personalized evaluation for each patient. Whether the procedure is aimed at preserving the foreskin or at total removal, it carries not only physical but also emotional and psychological implications. It is essential that patients are fully informed about the available options, the benefits, and the potential risks, so they can make informed decisions in collaboration with their physician. The patient’s well-being must remain at the forefront of every decision, with the goal of improving quality of life and ensuring satisfactory outcomes from both a medical and personal perspective.
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