title: Glans amputation during routine neonatal circumcision: mechanism of injury and strategy for prevention.
abstract: OBJECTIVE
  Glans injury during circumcision is an uncommon yet potentially devastating complication. Its mechanism remains poorly understood. Herein we critically evaluate a case series and, based on common characteristics, hypothesize the mechanism of injury as well as means to prevent it.
  
  
  METHODS
  Retrospective review of circumcision-related glans amputation cases referred for evaluation and management, focusing on detection of common history and presentation patterns in order to evaluate possible underlying mechanisms.
  
  
  RESULTS
  A neonatal elective circumcision was conducted using a Mogen clamp and an oblique injury to the ventro-lateral aspect of the glans was noted in 6 cases referred over a 5-year period, suggesting a similar trauma pattern. The urethra was consistently involved. The amputated segments were reattached as free composite grafts in 2/6 cases. Three patients underwent delayed glansplasty months after the trauma in an attempt to restore natural symmetry and cosmesis. In one case a buccal mucosa graft was employed to rebuild the ventral coronal sulcus.
  
  
  CONCLUSIONS
  Trauma pattern suggests that the ventral glans is at high risk for injury by traction on incompletely released ventral preputial adhesions with subsequent glans entrapment. Practitioners performing neonatal circumcisions, particularly with a Mogen clamp, should exercise adequate release of ventral adhesions to prevent this complication.
authors.affiliation: Division of Urology, The Hospital for Sick Children and University of Toronto, 555 University Ave. Rm M299, Toronto, ON M5G 1X8, Canada. Electronic address: pippi.salle@sickkids.ca.
authors.forename: Joao L
authors.initials: JL
authors.lastname: Pippi Salle
authors.forename: Lisieux E
authors.initials: LE
authors.lastname: Jesus
authors.forename: Armando J
authors.initials: AJ
authors.lastname: Lorenzo
authors.forename: Rodrigo L P
authors.initials: RL
authors.lastname: Romão
authors.forename: Victor H
authors.initials: VH
authors.lastname: Figueroa
authors.forename: Darius J
authors.initials: DJ
authors.lastname: Bägli
authors.forename: Edward
authors.initials: E
authors.lastname: Reda
authors.forename: Martin A
authors.initials: MA
authors.lastname: Koyle
authors.forename: Walid A
authors.initials: WA
authors.lastname: Farhat
mesh_terms: D002944:Circumcision, Male / Q000009:adverse effects*; D052816:Foreskin / Q000601:surgery; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D009061:Mouth Mucosa / Q000637:transplantation; D010413:Penis / Q000293:injuries* / Q000601:surgery*; D011183:Postoperative Complications / Q000517:prevention & control* / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods; D012092:Replantation / Q000379:methods*; D012189:Retrospective Studies; D014521:Urethra / Q000293:injuries / Q000601:surgery
keywords: Amputation; Circumcision; Complication; Glans; Mogen clamp; Penile reconstruction