Male Circumcision Policy Programming AdultAdolescent MC Surgical Techniques

Male Circumcision: Policy & Programming Adult/Adolescent MC Surgical Techniques

Knowledge Check Answer the following questions to see how much you know about this topic. 1. The World Health Organization recommends that male circumcision providers should do all of the following EXCEPT: a. Master all three adult male circumcision procedures b. If appropriate, master one neonatal technique c. Become expert in the technique most suited to their circumstances d. Master one adult technique 2. Match the adult/adolescent male circumcision technique with a characteristic associated with that technique. a. Forceps-guided b. Dorsal Slit c. Sleeve Resection § Requires high level of surgical skill § Preferred for men with phimosis § Simplest of the three techniques 3. Which of the following is the fastest surgical method for male circumcision? a. Sleeve resection b. Forceps-guided c. Dorsal slit 4. The World Health Organization has endorsed several devices for adult/adolescent male circumcision. a. True b. False

Surgical Techniques for Foreskin Removal Three surgical techniques are widely used for adult/adolescent medical male circumcision (MC): forceps-guided, dorsal slit, and sleeve resection. * These techniques are generally equivalent in terms of safety but vary in the time required to complete the procedure. It is recommended that nursing, clinical, or medical officers become a master of one adult technique, and if appropriate, one neonatal technique. Providers should become expert in the technique most suited to the circumstances of their practice or the preferred technique adopted nationally. This will produce the best results with the least complications. (WHO, UNAIDS, and Jhpiego 2009) *There also four medical MC surgical techniques that are widely used for neonates (dorsal slit, Plastibell, Mogen clamp, Gomco clamp). These will be discussed in a separate course devoted to neonatal MC.

Adult/Adolescent Medical MC – Are There Contraindications? There are few medical contraindications to adult/adolescent MC under local anesthesia. However, as for all elective surgery, MC should not be performed on anyone suffering from an acute disorder, infection, or febrile illness (fever). MC clients should be assessed for contraindications to surgery and conditions that need treatment or referral. MC should be postponed until the problem has been resolved. Source: WHO, UNAIDS, and Jhpiego 2009 Did You Know? Although adult/adolescent MC can be done under general or local anesthesia, local anesthesia is preferred because it is less risky and less expensive, and the client can return home the same day.

Three Surgical Techniques for Adult/Adolescent Foreskin Removal Forceps-guided: Forceps are attached to the foreskin to guide the cut and a scalpel is used to cut off the foreskin. Dorsal slit: Dissection scissors are used to make a slit in the foreskin, which is then pulled back and cut off. Probably the most widely used technique worldwide. Sleeve resection: A scalpel is used to make cuts around the base of the foreskin leaving a sleeve (tube) of foreskin. Scissors are used to dissect the sleeve of skin away from the shaft of the penis and the foreskin is pulled off over the glans. All three of these procedures produce a good long-term result. But they require different levels of skill. Source: WHO, UNAIDS, and Jhpiego 2009

Forceps-guided MC Technique: Attributes § A simple technique that can be learned by MC providers or nursing, § § clinical, and medical officers who are relatively new to surgery Can be used in clinics with limited resources, and can be done without an assistant Although the other two surgical techniques produce a better cosmetic result immediately after surgery, the forceps-guided technique is adequate – and appearance improves over time. The forceps-guided technique has been shown in clinical trials to produce consistently good results with low complication rates. The forceps-guided is the fastest MC surgical technique. (WHO 2010) Cannot be used for men with phimosis, whose foreskin cannot be fully retracted Source: WHO, UNAIDS, and Jhpiego 2009

Dorsal Slit MC Technique: Attributes § Requires more surgical skill than the forceps-guided method § It is helpful to have an assistant, although it can be done without one. § There is a risk that the result will be uneven (i. e. , more skin will be cut away from one side than the other). § Preferred for use in clients with phimosis Source: WHO, UNAIDS, and Jhpiego 2009

Sleeve Resection MC Technique: Attributes § Produces an excellent result, but requires the highest level of surgical skill § Better suited to a hospital than to a clinic setting § Requires an assistant § Better cosmetic results than the other two techniques, but more room for surgical error – either by cutting too deep when making the two circular incisions or cutting too deep when dissecting the skin flap free Source: WHO, UNAIDS, and Jhpiego 2009

Considerations for Efficiency, Safety, and Public Health Impact Highlights: To guide MC program implementation, time and safety implications need to be assessed by provider cadre and by method. An MC procedure in Iringa, Tanzania

Considerations for Efficiency, Safety, and Public Health Impact (continued) As MC services are scaled up, operations research will need to evaluate these surgical techniques to ensure that safety is maintained while efficiency is improved. All three MC surgical methods are equal in terms of safety and outcome; however, the forceps-guided method is fastest; it is a simple technique that can be easily taught; it can be used in clinics with limited resources; and it can be done without an assistant. To achieve a public health impact – in settings where financial and human resources are limited – providers will need to be trained to perform large numbers of medical MCs in a short period of time. For these reasons, and in these settings, the forceps-guided method is being recommended.

Hand Hygiene Hand hygiene is the single most important and costeffective measure to eliminate disease-causing microorganisms that contaminate hands, and to limit the spread of infection. The picture shows a simple method used to ensure running water at an MC facility in Tanzania. Ideas in Action Problem: No running water, and nonfunctional tap Solution: Running water machine (RWM)

Stopping Bleeding (Hemostasis) Is One of the Key Steps in MC Surgery The following techniques can be used during MC surgery to stop bleeding: § Compression § Temporary occlusion (blocking, closing) of blood vessels § Tying and under-running § Diathermy The first three techniques are explained in detail in an excerpt from the Manual for Male Circumcision under Local Anaesthesia. (WHO, UNAIDS, and JHPIEGO 2009) Diathermy is discussed on the next slide.

Using Diathermy (Electrocautery) to Stop Bleeding Saves Time. Using diathermy (electrocautery) to stop the flow of blood can reduce adult/adolescent MC by five to eight minutes per procedure, which can add up to a significant savings of time during the course of an MC scale-up program. The reliability of electricity should not be a barrier to using diathermy. Battery-powered options for diathermy devices, as well as generators, are available and can be used where electricity is not reliable. (WHO 2010) Pictured above are examples of diathermy units that can be used for MC. Did You Know? Program managers should consider investing in diathermy equipment and providing specific training for this technique.

Complete Wound Healing Is Important. Highlights: Complete wound healing prior to resumption of sexual activity is important for preventing HIV transmission. The client should be counseled to abstain from sexual activity for six weeks after the operation. Ideally, he will return to the clinic at that time for medical wound inspection to insure that healing is complete – before resuming sexual activity. Source: WHO, UNAIDS, and Jhpiego 2009

Three MC Techniques: Time to Complete Surgery May Vary. The chart compares estimated average times required to perform the main MC surgical steps in each of three MC surgical methods. In gold: Individual steps performed by a surgeon and the total surgeon time* In light blue: Individual steps performed by surgical assistants and the total surgical assistant time In orange: Total procedure time (surgeon time plus surgical assistant time) *In this course, the term surgeon refers to the person on the MC surgical team who does the cutting. This could be an appropriately trained doctor, nurse, or clinical officer. Source: WHO 2010

Three MC Techniques: Time to Complete Surgery May Vary. (continued) Highlights Sharing MC tasks with surgical assistants can reduce the amount of time a surgeon needs to spend on each procedure. In terms of speed, the forceps-guided technique is fastest, followed by dorsal slit, followed by sleeve resection. Source: WHO 2010

Assessing Time and Safety of MC by Method The chart above shows the results of an analysis of time savings between the three surgical MC methods (based on time-motion observations). Times are based on an efficiency model that uses diathermy (electrocautery) to stop bleeding. Highlights Conclusion: Forceps-guided is the fastest surgical method, and it is as safe as the dorsal slit or sleeve resection methods.

MC Devices under Investigation Although devices for use in adult/adolescent MC are being researched, none are endorsed by WHO at this time. At present, devices for adult/adolescent MC – similar to those used for neonatal MC – are either not available or not suitable for adult/adolescent MC. Further evidence on safety and acceptability is needed before such devices can be recommended for adult/adolescent MC. (WHO, UNAIDS, and Jhpiego 2009) Did You Know? Circumcision devices should not be used in MC programs unless they are specifically recommended for this use by WHO.

MC Devices under Investigation (continued) In March 2009, a meeting was convened in Nairobi, Kenya, to review MC devices and their potential to support rapid program scale-up in high HIV incidence settings in Africa. See the full WHO report, "Consultation to Review Manufacturing, Clinical and Regulatory Requirements for Male Circumcision Devices to Support Programme Expansion in High HIV Incidence Settings in Africa. " (van der Straten and Farley 2009)

Important Device Functions and Features § § § Protects glans Positions foreskin for tissue removal Provides a guide for tissue removal Controls the amount of tissue removed Results in minimal blood loss (hemostasis) Is easy to learn and easy to use Results in a low adverse event rate Has an acceptable cosmetic result Saves time Is low in cost Is sterile Allows sutureless closure

Knowledge Recap Answer the following questions to see how much you know about this session. 1. The World Health Organization recommends that male circumcision providers should do all of the following EXCEPT: a. Master all three adult male circumcision procedures b. If appropriate, master one neonatal technique c. Become expert in the technique most suited to their circumstances d. Master one adult technique 2. Match the adult/adolescent male circumcision technique with a characteristic associated with that technique. a. Forceps-guided b. Dorsal Slit c. Sleeve Resection § Requires high level of surgical skill § Preferred for men with phimosis § Simplest of the three techniques

Knowledge Recap (continued) Answer the following questions to see how much you know about this session. 3. Which of the following is the fastest surgical method for male circumcision? a. Sleeve resection b. Forceps-guided c. Dorsal slit 4. The World Health Organization has endorsed several devices for adult/adolescent male circumcision. a. True b. False 5. Which of the following techniques used to stop the flow of blood during male circumcision surgery can reduce time required to perform adult/adolescent male circumcision by five to eight minutes per procedure? a. Compression b. Temporary occlusion (blocking, closing) of blood vessels c. Tying and under-running d. Diathermy (electrocautery)

Adult/Adolescent MC Surgical Techniques Knowledge Recap Answer Key Please note that the questions and answers match those in the Knowledge Recap. The number and order of questions in the Knowledge Check may differ. 1. The World Health Organization recommends that male circumcision providers should do all of the following EXCEPT: a. Master all three adult male circumcision procedures The World Health Organization recommends that nursing, clinical, or medical officers become a master of ONE adult male circumcision technique, and if appropriate, one neonatal technique. 2. Match the adult/adolescent male circumcision technique with a characteristic associated with that technique. a. Forceps-guided – Simplest of the three techniques b. Dorsal slit – Preferred for men with phimosis c. Sleeve resection – Requires high level of surgical skill

Adult/Adolescent MC Surgical Techniques Knowledge Recap Answer Key (continued) Please note that the questions and answers match those in the Knowledge Recap. The number and order of questions in the Knowledge Check may differ. 3. Which of the following is the fastest surgical method for male circumcision? b. Forceps-guided 4. The World Health Organization has endorsed several devices for adult/adolescent male circumcision. b. False Although devices for use in adult/adolescent male circumcision are being researched, none are endorsed by the World Health Organization at this time. 5. Which of the following techniques used to stop the flow of blood during male circumcision surgery can reduce time required to perform adult/adolescent male circumcision by five to eight minutes per procedure? d. Diathermy (electrocautery)