Death due to circumcision? Interest of circumcision campaigns in Africa

Male circumcision involves removing the foreskin that normally covers the glans of the penis [1]. It is practised for social, cultural and medical reasons including HIV prevention. There is currently an increased interest in male circumcision services, since three randomized controlled trials have confi rmed that circumcision reduces the risk of acquiring HIV infection in males [2]. This surgery is one of the oldest and most common surgical procedures performed globally. It is estimated that one in three males worldwide are circumcised, with almost universal coverage in some settings. However, in low income settings, circumcision is trivialized and sometimes done by an untrained traditional medical practitioner in the community.

Citation: Thomas  health personnel. We report a serial repair of three circumcision accident cases performed at home by a supposed health provider in a poor neighbourhood in Yaounde (Cameroon), encountered during a free circumcision campaign at Bethesda Full Gospel mission hospital in Yaounde (Cameroon).

Methodology
We conducted a descriptive study over a period of one month, the time of the campaign, in the surgical ward of Bethesda hospital. Infants above 2years were included; the exclusion criterion was refusal to sign the consent form. The study variables were: age, Prothrombin test, bleeding time, surgical technique, per operative and post-operative complications. Details of the procedure: There were 3 phases: a population awareness phase, training of hospital staff and patient registration, clinical evaluation, surgery.

Before the campaign
Sensitization: Awareness-raising was carried out within the hospital by the creation of banners in the French and English languages posted at the main crossroads of the hospital; it was also carried out via social networks and shared printed posters with religious bodies for dissemination in churches.

Staff training:
Staff was trained during a 3-hours training session on the theoretical principles of safe circumcision, according to WHO recommendations and the guidelines on circumcision designed by the national urology society.

Patient registration:
The patients were normally registered; each interested patient received a patient info sheet about circumcision, preparation for the intervention, the technique and its risks, potential complications as well as contact with additional questions. All patients received a reminder SMS and were called by telephone to recall their child's date and time of circumcision.
Coordination meetings: Coordination meetings were held the month before the campaign. All direct or indirect actors in the campaign could have the same level of information and take decisions in council. Participants during these meetings were: the campaign coordinator, medical doctors, nurses and the pharmacist.

Pre-procedure preparation & Clinical evaluation:
We systematically carried out a medical consultation for each patient wishing to have a circumcision, supplemented by biological investigations in order to detect coagulation disorders. Coagulation assessment included the Prothrombin Time (PT) test and the bleeding time. Prior to performing circumcision, examination of the penis and scrotum aimed to make an operative plan and rule out contraindications to surgery which fall under exclusion criteria: Infants with serious medical conditions, Bleeding diathesis and congenital penile anomalies.

Procedure:
A briefi ng in the presence of the entire team at the start of the campaign was carried out and debriefi ngs at the end of the day to adjust our strategy day by day.
-After obtaining consent for all patients and guardians requesting circumcision, we premedicated with Paracetamol suppositories 15 to 30min before the intervention.
-The procedure is done under local anesthesia. We performed a penile nerve block for all patients (Dorsal penile block or ring block) using Lidocaine 1% or 2% with the maximum dose of 3mg/kg of body weight as recommended by WHO. We have provided resuscitation kit and trained personnel in resuscitation in the event of an incident.
-The surgical technique adopted was the "Dorsal slit method with 4 Forceps" for all patient.
The steps are: skin preparation (with povidone iodine) and draping; local anesthesia; marking the intended line of incision; degloving of the foreskin and adequate removal of any adhesions; applying forceps to the foreskin (4 small haemostats); cutting 02 lateral slits enabling a very minimal risk of injuring the glans as well as being easily reproducible; circumferential cutting at the foreskin; haemostasis with 3/0 absorbable sutures and reconstruction using the 4 cardinal points with absorbable 3/0 sutures and penile dressing.
There were no circumcision using devices.

Case considerations:
For specifi c cases of slight anomalies in the Prothrombin (Tp) level, they were performed by the surgeon himself; we used a bloodless technique by carefully dissecting the fatty tissue between the mucosa and the prepucial skin, followed by good haemostasis. Exploration of these anomalies was planned later.

Post-circumcision care:
Postoperative care consisted of antibiotic and sitz bath.

Results
The surgical health campaign indeed started with an awareness phase according to the methods described above. Awareness was raised in meetings, churches and other assembly points after agreement by administrative authorities. This awareness lasted almost a month before initiation of the hospital phase.
Concerning the training of practitioners, practice sessions were organized the week of August 5 to 9, 2019 during which the surgeon demonstrated and supervised the staff in the practices; a video was made and a montage was designed for the memory boost. Twenty-eight practitioners have been trained including doctors, nurses and nursing assistants from the emergency room, surgery, paediatrics and neonatology units.
The third and fi nal phase of the campaign was the practical phase itself. We registered 80 children. Twenty-fi ve (25) were excluded: 15 children were less than 2years old, 10 children presented with pulmonary, digestive and other medical pathologies as well as penile malformations following clinical evaluation. During our free circumcision health campaign, we Citation: Thomas    territory. In Cameroon the prevalence is 94% [4].

Special cases presentation
The Incidence of complications is variable, depending on whether or not it has been systematically recorded in health facilities [2]. This incidence of associated adverse events is thus estimated at 2 to 6 per 1000 male circumcision in neonates [5]. This rate is multiplied by 10 if circumcision is done in children over 10 years old. They are most often due [6] to a lack of knowledge concerning the precise anatomy of the penis and associated variations; we also cite an incomplete preoperative assessment aimed at looking for contraindications to surgery (genital abnomalities, coagulation disorders); poor surgical technique, lack of proper training and inexperienced operator as we have seen in our series of cases reported. Atikeler [7], showed that the frequency of the complications from    haemostats with 02 lateral slits enabling a very minimal risk of injuring the glans as well as being easily reproducible; haemostasis with 3/0 absorbable sutures; reconstruction using the 4 cardinal points with absorbable 3/0 sutures; For the cases with mild abnormalities in prothrombin time, we used a bloodless technique consisting of careful dissection of the connective tissue between the mucosa and skin of the prepuce, suture ligation and dressing with haemostatic gauze, followed by further investigation of the underlying abnormality later. During our health campaign, we had a single case of preoperative bleeding which was managed by suture ligation using an X stitch with 3/0 absorbable suture, a case presenting as mild purulent exsudation due to poor hygiene by the patient and it was managed by regular sitz baths. As found in the published literature [6], the most commonly