The Open Urology & Nephrology Journal




ISSN: 1874-303X ― Volume 12, 2019
CASE REPORT

Successful Reconstruction of the Penile Skin Loss Using a Scrotal Flap as a Result of Complete Resection Following a Traditional Circumcision: A Case Report



Axel M. Nwaha1, Theodore B. Sala1, Landry W. Tchuenkam2, *, Gael Dongmo2, Georges Kabko2, Angwafo Fru3
1 Urology Unit, Department of Surgery, Douala Laquintinie Hospital, Douala, Cameroon
2 Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
3 Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon

Abstract

Background:

Circumcision is the oldest and most common surgical procedure in the world. One out of three adult males is subjected to this procedure at some point in their lives. Circumcision is done for different reasons, most often to meet religious and/or cultural obligations. Though rare, there exist medical indications for this procedure. As in all surgical procedures, there are early or late complications or morbidities associated with circumcision ranging from mild to severe. The factors that influence the rate of occurrence of complications include: the surgical technique applied, the degree of asepsis during the procedure, and the expertise of the practitioner carrying out the procedure.

Case Presentation:

This is the case of a 20-year-old black male. He presented in the emergency department of the Douala Laquintinie Hospital (DLH) two hours after circumcision with persistent bleeding from the penile wound. This was performed by a traditional healer using the technique of guillotine. Examination of the external genitalia revealed a wound on the penis with loss of skin over the whole penile shaft. Under spinal anesthesia, a reconstruction intervention which involved a single step scrotal skin flap advancement over the penile shaft was done. We noted satisfactory healing process with a pleasing aesthetic appearance of the penis. He confirmed satisfactory penile erection and sexual activity two months after hospital discharge.

Conclusion:

Circumcision is a simple surgical procedure that can result to life threatening complications or high morbidity more often when performed by an unskilled practitioner. Education of the population on the safer sites of circumcision can help in the prevention and early management of complications.

Keywords: Skin loss, Circumcision, Scrotal flap, Threatening complications, Morbidity, Practitioner.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
First Page: 9
Last Page: 13
Publisher Id: TOUNJ-12-9
DOI: 10.2174/1874303X01912010009

Article History:

Received Date: 22/02/2019
Revision Received Date: 10/05/2019
Acceptance Date: 16/05/2019
Electronic publication date: 30/06/2019
Collection year: 2019

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© 2019 Axel et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon; Tel: +237691528498; E-mail: landrytchuenkus@gmail.com




1. BACKGROUND

Circumcision is a process that involves the surgical removal of the foreskin [1WHO. Manual for male circumcision under local anaesthesia and HIV prevention services for adolescent boys and men [Internet] WHO [2018May17]; Available from: http://www.who.int/hiv/pub/maleci rcumcision/male-circumcision-guide-2018/en/]. Worldwide, the overall prevalence of circumcision is estimated at 36.7% [2Morris BJ, Wamai RG, Henebeng EB, et al. Estimation of country-specific and global prevalence of male circumcision. Popul Health Metr 2016; 14: 4.
[http://dx.doi.org/10.1186/s12963-016-0073-5] [PMID: 26933388]
]. In Cameroon, up to 94% [3Kenu E, Sint TT, Kamenga C, Ekpini R. Early infant male circumcision in cameroon and aenegal: Demand, aervice provision, and cultural context. Glob Health Sci Pract 2016; 4(Suppl. 1): S18-28.
[http://dx.doi.org/10.9745/GHSP-D-15-00185] [PMID: 27413080]
] of the male population is circumcised. Most often, this is done under religious and/or cultural obligations. During adolescence, circumcision is considered in some cultures as a rite of transition into adulthood [4Wilcken A, Keil T, Dick B. Traditional male circumcision in eastern and southern Africa: A systematic review of prevalence and complications. Bull World Health Organ 2010; 88(12): 907-14.
[http://dx.doi.org/10.2471/BLT.09.072975] [PMID: 21124715]
, 5Douglas M, Maluleke TX, Manyaapelo T, Pinkney-Atkinson V. Opinions and perceptions regarding traditional male circumcision with related deaths and complications. Am J Men Health 2018; 12(2): 453-62.
[http://dx.doi.org/10.1177/1557988317736991] [PMID: 29072123]
]. The benefits of circumcision in medical science is highly debatable in several countries [1WHO. Manual for male circumcision under local anaesthesia and HIV prevention services for adolescent boys and men [Internet] WHO [2018May17]; Available from: http://www.who.int/hiv/pub/maleci rcumcision/male-circumcision-guide-2018/en/]. Medically, circumcision has shown a benefit in reducing urinary tract infection in children [6Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomised trials and observational studies. Arch Dis Child 2005; 90(8): 853-8.
[http://dx.doi.org/10.1136/adc.2004.049353] [PMID: 15890696]
], in reducing HIV infections by about 50 to 60% [7Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet Lond Engl 2007; 369(9562): 657-66.
[http://dx.doi.org/10.1016/S0140-6736(07)60313-4] [PMID: 17321 311]
, 8Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet Lond Engl 2007; 369(9562): 643-56.
[http://dx.doi.org/10.1016/S0140-6736(07)60312-2] [PMID: 17321 310]
], herpes simplex virus type 2 (HSV-2) infections [9Tobian AAR, Serwadda D, Quinn TC, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med 2009; 360(13): 1298-309.
[http://dx.doi.org/10.1056/NEJMoa0802556] [PMID: 19321868]
], and Human Papillomavirus (HPV) High risk [10Auvert B, Sobngwi-Tambekou J, Cutler E, et al. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: Results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis 2009; 199(1): 14-9.
[http://dx.doi.org/10.1086/595566] [PMID: 19086814]
, 11Gray RH, Serwadda D, Kong X, et al. Male circumcision decreases acquisition and increases clearance of high-risk human papillomavirus in HIV-negative men: A randomized trial in Rakai, Uganda. J Infect Dis 2010; 201(10): 1455-62.
[http://dx.doi.org/10.1086/652184] [PMID: 20370483]
] in the male sexually active adult population. Other studies have also shown the reduction of sexually transmitted infections, including HPV and trichomonas vaginalis infections among female partners of men who were circumcised [12Gray RH, Kigozi G, Serwadda D, et al. The effects of male circumcision on female partners’ genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda. Am J Obstet Gynecol 2009; 200(1): 42.e1-7.
[http://dx.doi.org/10.1016/j.ajog.2008.07.069] [PMID: 18976733]
-14Tobian AAR, Quinn TC, Gray RH. Male circumcision for prevention of oncogenic HPV infection. Lancet Lond Englauthor reply 315 2011; 378(9788): 314-5.
[http://dx.doi.org/10.1016/S0140-6736(11)61162-8]
]. Like all surgical procedures, circumcision can be associated with the number of minor to severe complications that can be life-threatening such as massive hemorrhage or sepsis [15Shittu OB, Shokunbi WA. Circumcision in haemophiliacs: The Nigerian experience. Haemoph Off J World Fed Hemoph 2001; 7(5): 534-6.
[http://dx.doi.org/10.1046/j.1365-2516.2001.0537b.x] [PMID: 1155 4949]
, 16Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of male circumcision in Ibadan, Nigeria. BMC Urol 2006; 6: 21.
[http://dx.doi.org/10.1186/1471-2490-6-21] [PMID: 16934157]
]. Weiss [17Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol 2010; 10: 2.
[http://dx.doi.org/10.1186/1471-2490-10-2] [PMID: 20158883]
] in a systematic review performed in 2010 reports a median of 1.5% (0-16%) as a rate of minor complications and a median of 0% (0-2%) of major complications following a circumcision [17Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol 2010; 10: 2.
[http://dx.doi.org/10.1186/1471-2490-10-2] [PMID: 20158883]
]. The most frequent are pain, bleeding, glans edema, excessive penile skin loss, strictures of the urethral meatus, the formation of a fibrous ring covering the glans, amputations of the glans and uretro cutaneous fistulas [17Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol 2010; 10: 2.
[http://dx.doi.org/10.1186/1471-2490-10-2] [PMID: 20158883]
]. The surgical technique used, asepsis, traditional practitioner carrying out circumcision [17Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol 2010; 10: 2.
[http://dx.doi.org/10.1186/1471-2490-10-2] [PMID: 20158883]
, 18Diabaté I, Ondo CZ, Diallo HD, Thiam M, Bâ A. Prise en charge des complications de la circoncision /data/revues/11581360/v26i3 /S115813601630069X/ [Internet] 2017 [cited 2018 May 17]; Available from: http://www.em-consulte.com/en/article/1135422] and even paramedical personnel [17Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol 2010; 10: 2.
[http://dx.doi.org/10.1186/1471-2490-10-2] [PMID: 20158883]
] are factors in the occurrence of severe complications.

We report a case of successful reconstruction of the penile skin loss using a scrotal flap as a result of a complete resection by a traditional healer.

2. CASE PRESENTATION

This is the case of a 20-year-old black male. He presented in the emergency department of Douala Laquintinie Hospital (DLH) two hours after circumcision with persistent bleeding from the circumcision site. This was done by a traditional healer using the technique of the guillotine. The patient had no history of chronic conditions, and never described abnormal and persistent bleeding following any wound. He has never undergone any surgical intervention.

During clinical examination, he was conscious and alert. His vital signs were a blood pressure of 134/86 mmHg, heart rate of 88 beats per minute, a respiratory rate of 19 cycles per minute and a temperature of 37.6°C. Examination of the external genitalia showed a wound on the penis with loss of skin over the whole penile shaft Fig. (1). There was no more active bleeding. There were no abnormalities of the glans and the urethral meatus. The rest of the examination was unremark-able, with no signs of circulatory shock.

At the end of the clinical examination, we made the diag-nosis of accident on circumcision achieving minor bleeding associated with complete denudation of the penile shaft. It was therefore a delayed emergency indication to surgery. With regard to pre-operative work-up, the hemoglobin level was 12.2 g/dl, a platelet count of 245 109 /l. The rest of the examinations were unremarkable. Initial management consisted of the administration of analgesics, antibiotics, and tetanus immunoglobulin.

Twelve hours after admission, the patient underwent surgery under spinal anesthesia. He was installed supine; we achieved asepsis followed by sterile field placement. Subsequently, we found absence of hair on the scrotal skin, so we opted for a single step scrotal advancement flap. The main operating steps were: Skin incision on the scrotal median raphe; subcutaneous dissection of the scrotal skin on both sides of the median raphe respecting the vascular pedicles (posterior and anterior scrotal arteries). Subsequently, we realized a detachment of the scrotal skin while respecting the tunica vaginalis; followed by mobilization of the scrotal flap. This last was advanced gently over the penile and covering the penile shaft Fig. (2a). The sutures were made with absorbable Poly-glactin 3/0 thread by separate points Fig. (2b). A transurethral urinary catheter was placed and the bandage of the operative wound made Fig. (2c). Analgesic was continued postoperatively, as were as the antibiotics; Amoxicillin-clavulanic acid received for 5 days. The evolution in the postoperative period was marked by the occurrence of several episodes of spontaneous painful erection, which resolves spontaneously and of variable duration (30 to 45 minutes). The patient has benefited from anti androgenic: Cyproterone Acetate and a muscle relaxant with favorable evolution. A good evolution of the operative wound was noted Fig. (3). The discharge from the hospital was made on the 19th day after surgery, he had no more painful erections and the wound healing was complete. During the outpatient follow-up the patient reports a resumption of sexual activities 2 months after surgery with satisfactory erection and a satisfactory aesthetic appearance of the penis.

Fig. (1)
Appearance of the naked penis.


Fig. (2)
Surgical steps.


Fig. (3)
Post operative appearance.


3. DISCUSSION

It was a case of circumcision performed in a 20-year-old adult by a traditional healer with the complication of a complete denudation of the penile shaft that required plastic reconstruction with a scrotal advancement flap. Circumcision is the most common surgical procedure in the world [1WHO. Manual for male circumcision under local anaesthesia and HIV prevention services for adolescent boys and men [Internet] WHO [2018May17]; Available from: http://www.who.int/hiv/pub/maleci rcumcision/male-circumcision-guide-2018/en/, 19WHO. Male circumcision: global trends and determinants of prevalence, safety and acceptability [Internet] [cited 2018 May 17]; Available from: http://www.who.int/reproductivehealth/publications/ rtis/9789241596169/en/] and one of the oldest interventions described. One out of three adult males is subjected to this procedure at some point in their lives [2Morris BJ, Wamai RG, Henebeng EB, et al. Estimation of country-specific and global prevalence of male circumcision. Popul Health Metr 2016; 14: 4.
[http://dx.doi.org/10.1186/s12963-016-0073-5] [PMID: 26933388]
]. Like all surgical procedures, complications are common, they can reach 50% in some series [15Shittu OB, Shokunbi WA. Circumcision in haemophiliacs: The Nigerian experience. Haemoph Off J World Fed Hemoph 2001; 7(5): 534-6.
[http://dx.doi.org/10.1046/j.1365-2516.2001.0537b.x] [PMID: 1155 4949]
, 17Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol 2010; 10: 2.
[http://dx.doi.org/10.1186/1471-2490-10-2] [PMID: 20158883]
]. Unskilled practitioner, poor preparation and poor technique are the factors involved in the occurrence of complications that may affect the functional and vital prognosis in case of major sepsis or massive bleeding [17Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol 2010; 10: 2.
[http://dx.doi.org/10.1186/1471-2490-10-2] [PMID: 20158883]
].

As major complications, infections and urethral fistulas are the most common [18Diabaté I, Ondo CZ, Diallo HD, Thiam M, Bâ A. Prise en charge des complications de la circoncision /data/revues/11581360/v26i3 /S115813601630069X/ [Internet] 2017 [cited 2018 May 17]; Available from: http://www.em-consulte.com/en/article/1135422, 20Infantile Chirurgie, et al. Les complications de la circoncision. A propos de 63 cas<br/>Complications of circumcision. Report of 63 cases<br/>. Prog En Urol Paris 2003; 13(2): 266-72.] followed by hemorrhages, skin bridges and stenosis of the urethral meatus. Denudation of the penile shaft as a complication is relatively uncommon. Sylla and Diabate [18Diabaté I, Ondo CZ, Diallo HD, Thiam M, Bâ A. Prise en charge des complications de la circoncision /data/revues/11581360/v26i3 /S115813601630069X/ [Internet] 2017 [cited 2018 May 17]; Available from: http://www.em-consulte.com/en/article/1135422, 20Infantile Chirurgie, et al. Les complications de la circoncision. A propos de 63 cas<br/>Complications of circumcision. Report of 63 cases<br/>. Prog En Urol Paris 2003; 13(2): 266-72.] report respectively a frequency of 1 and 3% while Okeke report a frequency of 16% [16Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of male circumcision in Ibadan, Nigeria. BMC Urol 2006; 6: 21.
[http://dx.doi.org/10.1186/1471-2490-6-21] [PMID: 16934157]
]. Several mechanisms may explain skin loss in the penile region following a circumcision. It can occur after direct excision during the major surgical procedure or following a postoperative skin infection or during postoperative debridement indicated for skin necrosis [21İnce B, Dadacı M, Altuntaş Z, Bilgen F. Rarely seen complications of circumcision, and their management. Turk J Urol 2016; 42(1): 12-5.
[http://dx.doi.org/10.5152/tud.2016.78972] [PMID: 27011875]
]. This loss of substance exposes the penis with subsequent major risk of infection and erectile dysfunction [19WHO. Male circumcision: global trends and determinants of prevalence, safety and acceptability [Internet] [cited 2018 May 17]; Available from: http://www.who.int/reproductivehealth/publications/ rtis/9789241596169/en/].

Several reconstruction techniques are possible, they are functions of the extent of the loss of substance, ranging from directed healing to skin grafts using thin or thick flaps [21İnce B, Dadacı M, Altuntaş Z, Bilgen F. Rarely seen complications of circumcision, and their management. Turk J Urol 2016; 42(1): 12-5.
[http://dx.doi.org/10.5152/tud.2016.78972] [PMID: 27011875]
]; fasciocutaneous advancement flap using a flap from the inguinal, femoral [22Seleim HM, Elbarbary MM. Major penile injuries as a result of cautery during newborn circumcision. J Pediatr Surg 2016; 51(9): 1532-7.
[http://dx.doi.org/10.1016/j.jpedsurg.2016.04.014] [PMID: 27185337]
] and even scrotal region. In the case presented, the authors opted for a skin advancement flap using the scrotal skin. The mobilization of the scrotal flap during surgery was done respecting the vascularization of the tissues. Early post-operative care aimed to ensure proper flap healing while avoiding infections. The patient received frequent dressings with the use of normal saline. The frequent occurrence of spontaneous painful erections initially in the morning and then daily, motivated the administration of anti-androgens for the control of erections to allow proper healing tension-free. With regard to the resumption of sexual activity, there was no consensus on the duration of abstinence. In our case, sexual relations were allowed after complete healing of the penis and amendment of spontaneous painful erections.

In our context, traditions, lack of legal regulation as to the qualification required for this surgical procedure, the low cost of surgery proposed by the paramedical personnel expose low-income populations to go out of specialized centers to undergo circumcision. The prevention will start by the sensitization of the population and the training of all the persons implied in the practice of circumcision: traditional practitioner, paramedical personnel, medical doctors, and surgeons.

CONCLUSION

Circumcision is a simple surgical procedure and safe when performed by qualified personnel under strict aseptic conditions. Beliefs and traditions which are deeply rooted in mentalities, favor the rise to the malpractice of circumcision by traditional ways.

In cases of large penile skin loss, scrotal advancement flap remains a good option. It has many advantages in terms of aesthetic scar, functional skin and short hospital stay.

LIST OF ABBREVIATIONS

DLH = Douala Laquintinie Hospital
dl = deciliter
g = gram
HIV = Human Immunodeficiency Virus
HPV = Human Papillomavirus
HSV = Human Simplex Virus
l = liter
mmHg = millimeter of mercury

AUTHORS' CONTRIBUTIONS

NM and TWL, contributed in design of the study and writing of the manuscript.

ST, DG, KG, AF, contributed in critical reading.

NW, collected the pictures, and obtained the patient’s consent.

All authors have read and approved the final version of the manuscript.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

AVAILABILITY OF DATA AND MATERIAL

Not applicable.

FUNDING

No funding.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The authors would like to thank all the clinicians and staff of the Douala Laquintinie Hospital for the care of the patient.

REFERENCES

[1] WHO. Manual for male circumcision under local anaesthesia and HIV prevention services for adolescent boys and men [Internet] WHO [2018May17]; Available from: http://www.who.int/hiv/pub/maleci rcumcision/male-circumcision-guide-2018/en/
[2] Morris BJ, Wamai RG, Henebeng EB, et al. Estimation of country-specific and global prevalence of male circumcision. Popul Health Metr 2016; 14: 4.
[http://dx.doi.org/10.1186/s12963-016-0073-5] [PMID: 26933388]
[3] Kenu E, Sint TT, Kamenga C, Ekpini R. Early infant male circumcision in cameroon and aenegal: Demand, aervice provision, and cultural context. Glob Health Sci Pract 2016; 4(Suppl. 1): S18-28.
[http://dx.doi.org/10.9745/GHSP-D-15-00185] [PMID: 27413080]
[4] Wilcken A, Keil T, Dick B. Traditional male circumcision in eastern and southern Africa: A systematic review of prevalence and complications. Bull World Health Organ 2010; 88(12): 907-14.
[http://dx.doi.org/10.2471/BLT.09.072975] [PMID: 21124715]
[5] Douglas M, Maluleke TX, Manyaapelo T, Pinkney-Atkinson V. Opinions and perceptions regarding traditional male circumcision with related deaths and complications. Am J Men Health 2018; 12(2): 453-62.
[http://dx.doi.org/10.1177/1557988317736991] [PMID: 29072123]
[6] Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomised trials and observational studies. Arch Dis Child 2005; 90(8): 853-8.
[http://dx.doi.org/10.1136/adc.2004.049353] [PMID: 15890696]
[7] Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: A randomised trial. Lancet Lond Engl 2007; 369(9562): 657-66.
[http://dx.doi.org/10.1016/S0140-6736(07)60313-4] [PMID: 17321 311]
[8] Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet Lond Engl 2007; 369(9562): 643-56.
[http://dx.doi.org/10.1016/S0140-6736(07)60312-2] [PMID: 17321 310]
[9] Tobian AAR, Serwadda D, Quinn TC, et al. Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med 2009; 360(13): 1298-309.
[http://dx.doi.org/10.1056/NEJMoa0802556] [PMID: 19321868]
[10] Auvert B, Sobngwi-Tambekou J, Cutler E, et al. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: Results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis 2009; 199(1): 14-9.
[http://dx.doi.org/10.1086/595566] [PMID: 19086814]
[11] Gray RH, Serwadda D, Kong X, et al. Male circumcision decreases acquisition and increases clearance of high-risk human papillomavirus in HIV-negative men: A randomized trial in Rakai, Uganda. J Infect Dis 2010; 201(10): 1455-62.
[http://dx.doi.org/10.1086/652184] [PMID: 20370483]
[12] Gray RH, Kigozi G, Serwadda D, et al. The effects of male circumcision on female partners’ genital tract symptoms and vaginal infections in a randomized trial in Rakai, Uganda. Am J Obstet Gynecol 2009; 200(1): 42.e1-7.
[http://dx.doi.org/10.1016/j.ajog.2008.07.069] [PMID: 18976733]
[13] Wawer MJ, Tobian AAR, Kigozi G, et al. Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: A randomised trial in Rakai, Uganda. Lancet Lond Engl 2011; 377(9761): 209-18.
[http://dx.doi.org/10.1016/S0140-6736(10)61967-8] [PMID: 21216 000]
[14] Tobian AAR, Quinn TC, Gray RH. Male circumcision for prevention of oncogenic HPV infection. Lancet Lond Englauthor reply 315 2011; 378(9788): 314-5.
[http://dx.doi.org/10.1016/S0140-6736(11)61162-8]
[15] Shittu OB, Shokunbi WA. Circumcision in haemophiliacs: The Nigerian experience. Haemoph Off J World Fed Hemoph 2001; 7(5): 534-6.
[http://dx.doi.org/10.1046/j.1365-2516.2001.0537b.x] [PMID: 1155 4949]
[16] Okeke LI, Asinobi AA, Ikuerowo OS. Epidemiology of complications of male circumcision in Ibadan, Nigeria. BMC Urol 2006; 6: 21.
[http://dx.doi.org/10.1186/1471-2490-6-21] [PMID: 16934157]
[17] Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol 2010; 10: 2.
[http://dx.doi.org/10.1186/1471-2490-10-2] [PMID: 20158883]
[18] Diabaté I, Ondo CZ, Diallo HD, Thiam M, Bâ A. Prise en charge des complications de la circoncision /data/revues/11581360/v26i3 /S115813601630069X/ [Internet] 2017 [cited 2018 May 17]; Available from: http://www.em-consulte.com/en/article/1135422
[19] WHO. Male circumcision: global trends and determinants of prevalence, safety and acceptability [Internet] [cited 2018 May 17]; Available from: http://www.who.int/reproductivehealth/publications/ rtis/9789241596169/en/
[20] Infantile Chirurgie, et al. Les complications de la circoncision. A propos de 63 cas<br/>Complications of circumcision. Report of 63 cases<br/>. Prog En Urol Paris 2003; 13(2): 266-72.
[21] İnce B, Dadacı M, Altuntaş Z, Bilgen F. Rarely seen complications of circumcision, and their management. Turk J Urol 2016; 42(1): 12-5.
[http://dx.doi.org/10.5152/tud.2016.78972] [PMID: 27011875]
[22] Seleim HM, Elbarbary MM. Major penile injuries as a result of cautery during newborn circumcision. J Pediatr Surg 2016; 51(9): 1532-7.
[http://dx.doi.org/10.1016/j.jpedsurg.2016.04.014] [PMID: 27185337]
Society Affiliation


Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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