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Plastibell Circumcision with a Frenulum-Sparing Technique

Plastibell circumcision with frenulum-sparing technique

Ismael Zamilpa MD and Madison Haraway

Introduction: The penile frenulum connects the prepuce to the glans on the underside of the penis. Although the frenulum plays a role in sexual arousal, it can cause painful erections when its length is too short. Conventional neonatal circumcision techniques involve removing the entire foreskin covering the glans, often with division of the frenulum (1). Recently, tissue-sparing approaches have become a matter of interest to reduce the risk of complications, such as bleeding, altered glans sensitivity, and meatal stenosis.

Methods: We describe a frenulum-sparing technique in combination with the Plastibell method. Lysis of preputial adhesions near the frenulum is performed carefully. Selection of an appropriately sized bell is paramount as oversize or undersize can cause bell migration and tissue necrosis (2). The bell should fit snugly over two-thirds of the glans of the penis and fall off spontaneously within 3-7 days.

Results: The patient is a 2-month-old male who presented to Arkansas Children’s Urology with phimosis, which is preputial tightness that prevents foreskin retraction over the glans. He was born at 37 weeks gestation and was not circumcised at birth due to concern for heart murmur. After obtaining cardiac clearance and parental consent, Plastibell circumcision was performed with good preservation of the frenulum, and the patient tolerated the procedure well.

Discussion/conclusions: There is current controversy over the ideal extent of preputial preservation during circumcision. Several publications have highlighted the frenulum’s function in penile erection, owing to its innervation by fine-touch sensory receptors, such as Meissner’s corpuscles (1).

By leaving the frenulum intact, we aim to reduce the risk of complications, particularly meatal stenosis, which is the narrowing of the urethra in circumcised children (3). These children commonly present with symptoms of high-velocity stream (usually upwards), dysuria, and urinary frequency after toilet training.

In conclusion, this tissue-sparing approach potentially reduces complications, improves cosmesis, and retains sensitivity.

References:

Shenoy SP, Marla PK, Sharma P, Bhat N, Rao, AR. Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique. Journal of clinical and diagnostic research. 2015; (9)12: PC01-3. doi:10.7860/JCDR/2015/14972.6860.

Nagdeve NG, Naik H, Bhingare PD,Morey SM. Parental evaluation of postoperative outcome of circumcision with Plastibell or conventional dissection by dorsal slit technique: A randomized controlled trial. Journal of Pediatric Urology. 2013; 9(5): 675-682. doi:10.1016/j.jpurol.2012.08.001.

Abid AF, Hussein NS. Meatal stenosis posttraditional neonatal circumcision-cross-sectional study. Urology annals. 2021; 13(1): 62-66. doi:10.4103/UA.UA_30_20.

A frenulum-sparing technique in combination with the Plastibell method of neonatal circumcision.
The indications for circumcision were phimosis and parental decision.
Contraindications to newborn circumcision include conditions of abnormal penile anatomy, such as chordee, concealed penis, epispadias, hypospadias, penile torsion, and penoscrotral webbing. Medical contraindications include admission to NICU, blood dyscrasias (e.g., hemophilia), and current illness.
The patient was placed in a supine position, and the penis was prepped and draped in sterile fashion. The procedure was performed under local anesthesia. The patient was given a dose of acetaminophen and a penile ring block using 1% lidocaine without adrenaline. The baby was given sugar water to help relieve discomfort.
Patient was born at 37 weeks gestation. He was not circumcised as a newborn due to concern for heart murmur. After being evaluated and cleared by cardiology, the parents wanted to move forward with circumcision. On physical exam, the patient had a normal-appearing, uncircumcised penis, and his testicles were descended bilaterally. The primary diagnosis was phimosis.
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A frenulum-sparing approach has the potential advantages of reducing the risk of complications, improving cosmetic outcomes, and preserving glans sensitivity. The Plastibell method has short duration and can be performed with less assistance. Since the Plastibell is a foreign body, it has the disadvantages of becoming dislodged or infecting the site.
Glans injury, bleeding, and insufficient or excessive skin removal can occur with the Plastibell technique. Oversize of the bell can lead to proximal migration, while undersize of the bell can cause tissue necrosis. Late complications include penile injury/amputation, infection, necrosis of glans, adhesions, phimosis, and meatal stenosis and scarring.
Neither myself, Madison Haraway, nor Ismael Zamilpa MD have relevant financial or non-financial interests that relate to the procedure described this video to disclose.
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1. Shenoy SP, Marla PK, Sharma P, Bhat N, Rao, AR. Frenulum Sparing Circumcision: Step-By-Step Approach of a Novel Technique. Journal of clinical and diagnostic research. 2015; (9)12: PC01-3. doi:10.7860/JCDR/2015/14972.6860. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717729/ 2. Nagdeve NG, Naik H, Bhingare PD, Morey SM. Parental evaluation of postoperative outcome of circumcision with Plastibell or conventional dissection by dorsal slit technique: A randomized controlled trial. Journal of Pediatric Urology. 2013; 9(5): 675-682. doi:10.1016/j.jpurol.2012.08.001. https://www.sciencedirect.com/science/article/pii/S1477513112002100 3. Abid AF, Hussein NS. Meatal stenosis posttraditional neonatal circumcision-cross-sectional study. Urology annals. 2021; 13(1): 62-66. doi:10.4103/UA.UA_30_20. https://journals.lww.com/urol/Fulltext/2021/13010/Meatal_stenosis_posttraditional_neonatal.12.aspx

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