Circumcision-related tragedies seen in children at the Komfo Anokye Teaching Hospital, Kumasi, Ghana
Appiah et al. BMC Urology
Circumcision-related tragedies seen in children at the Komfo Anokye Teaching Hospital, Kumasi, Ghana
Kwaku Addai Arhin Appiah 0
Christian Kofi Gyasi-Sarpong 2
Roland Azorliade 0
Ken Aboah 2
Dennis Odai Laryea 1
Kwaku Otu-Boateng 0
Kofi Baah-Nyamekye 0
Patrick Opoku Manu Maison 0
Douglas Arthur 0
Isaac Opoku Antwi 0
Benjamin Frimpong-Twumasi 0
Edwin Mwintiereh Yenli 3
Samuel Kodzo Togbe 0
George Amoah 0
0 Department of Surgery, Komfo Anokye Teaching Hospital , Kumasi , Ghana
1 Public Health Unit, Komfo Anokye Teaching Hospital , Kumasi , Ghana
2 Department of Surgery, School of Medical Sciences-KNUST , Kumasi , Ghana
3 Department of Surgery, Tamale Teaching Hospital , Tamale , Ghana
Background: Circumcision is a common minor surgical procedure and it is performed to a varying extent across countries and religions. Despite being a minor surgical procedure, major complications may result from it. In Ghana, although commonly practiced, circumcision-related injuries have not been well documented. This study is to describe the scope of circumcision-related injuries seen at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Methods: The study was conducted at the Urology Unit of the Komfo Anokye Teaching Hospital in Kumasi. Consecutive cases of circumcision-related injuries seen at the unit over an 18 month period were identified and included in the study. Data was collected using a structured questionnaire. Data was entered and analysed using SPSS version 16. Charts and tables were generated using Microsoft Excel. Results: A total of 72 cases of circumcision-related injuries were recorded during the 18 month period. Urethrocutaneous fistula was the commonest injury recorded, accounting for 77.8 % of cases. Other injuries recorded were glans amputations (6.9 %); iatrogenic hypospadias (5.6 %), and epidermal inclusion cysts (2.8 %). The majority of children were circumcised in health facilities (75 %) and nurses were the leading providers (77.8 %). The majority of circumcisions were conducted in the neonatal period (94.7 %). Conclusion: Circumcision-related injuries commonly occurred in the neonatal period. Most of the injuries happened in health facilities. The most common injury recorded was urethrocutaneous fistula but the most tragic was penile amputation. There is the need for education and training of providers to minimise circumcision-related injuries in Ghana.
Circumcision; Penile amputation; Circumcision injury; Urethrocutaneous fistula; Ghana
Circumcision is routinely performed in most parts of
Ghana as a tradition. While generally regarded as a
minor surgical procedure, major complications may
result from it [1–4]. Although circumcision injuries are
unintended, the prominence of circumcision as a cause
of major injury in children is not recognised, as the
world report on injury in children did not identify
circumcision-related injuries as significant causes of
injury-related morbidity and mortality in children .
This notwithstanding, some circumcision injuries may
be associated with long term social and psychological
challenges including the inability to have a fulfilling
sexual life as the case may be in penile amputations
 and even death in some cases of severe haemorrhage
[6, 7]. In Nigeria, circumcision-related injuries have been
on the ascendancy with an estimated 20 % circumcisions
resulting in one form of complication or the other .
Various degrees of circumcision-related injuries occur.
However, severe ones seldom occur in developed
countries  where circumcision is practised by
well© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
trained personnel . Circumcision injuries have been
associated with all the methods of circumcisions [1, 4]
especially in untrained hands [3, 6–8]. In Ghana, data on
circumcision-related injuries is scanty. This
crosssectional observational study was designed to describe
the scope of circumcision-related injuries seen at the
Komfo Anokye Teaching Hospital in Kumasi, Ghana.
The study was conducted at the Urology Unit of the
Directorate of Surgery, Komfo Anokye Teaching Hospital
(KATH). KATH is a major referral centre for the middle
and northern zones of Ghana.
All male children below 18 years of age referred to
the Komfo Anokye Teaching Hospital’s Urology Unit for
treatment of early and late complications of circumcision
as determined by our eligibility criteria were included
in the study. Urologists at the unit conducted penile
examinations and assigned eligible patients specific injury
categories as haemorrhage, urethrocutaneous fistula, penile
amputation, iatrogenic hypospadias, skin bridges, excess
foreskins, epidermal inclusion cysts, buried penis or any
other injury that was deemed to be as a result of
circumcision. Guardians/parents of eligible children were
approached for inclusion in the study. The aim of the
study was explained to them and informed consent
obtained. Ethical approval was obtained from the
Committee on Human Research, Publications and Ethics of the
Kwame Nkrumah University of Science and Technology
and the Komfo Anokye Teaching Hospital. Data
collection involved a structured questionnaire administered by
a trained research assistant. Data collected included
demographic information, place of circumcision, person
circumcising, age at circumcision and clinical
examination findings. Data was collected over an 18 month
period from September 2012 to February 2014.
Data was entered into SPSS version 16 and the same
was utilized for statistical analysis. Microsoft Excel was
used to generate the tables and charts.
A total of 72 cases of children with circumcision-related
complications were seen during the 18 month period.
The youngest case was recorded in a 2-day old neonate
and the oldest case recorded was in an 11-year-old boy.
The majority of the children were resident in urban
communities (54.0 %).
Over 87 % of children in this study were circumcised
before they were 2 weeks old. Only 5.6 % were
circumcised after 4 weeks of age (Table 1).
The majority of children were circumcised in a hospital
(65.3 %). The place of circumcision is as shown in Fig. 1.
Nurses accounted for the majority of circumcision-related
injuries recorded in this study, 77.8 %. Doctors and
traditional circumcisers (Wanzams) accounted for 8.3 and
20.8 % of circumcision-related injuries respectively. None
of the children seen during the period under review
reported within 24 h of injury. The majority of injuries
(80.5 %) were seen within 2 weeks of circumcision. Twelve
(16.7 %) cases presented within 3 months of circumcision
and the remaining 2.8 % presented more than a year after
In 37 (51.4 %) of the cases studied, the exact method
of circumcision could not be ascertained from the
parents of affected children. Figure 2 details the methods
of circumcision as recorded among cases seen during this
The commonest complication recorded in this study was
urethrocutaneous fistula (77.8 %). The various categories
of complications recorded in this study are as shown in
Table 2. There were five cases of glans penis
amputations accounting for 6.9 % of complications recorded.
Fig. 2 Method of circumcision among cases of circumcision-related
injuries recorded in Kumasi
Three (60 %) were complete amputations of the glans
penis, with the remaining 40 % being partial amputations.
Circumcision remains one of the oldest and commonest
surgical procedures performed on young boys worldwide
[9, 10]. It is widely practiced in the United States  and
especially in Israel where virtually every male child is
circumcised . However in Europe it is rarely
performed . The notable advantages of circumcision
include: reduction in early childhood urinary tract
infections, which is also noted in adult men [13–17],
reduction of HIV transmission by almost 60 % [18–21],
and reduction in the incidence of penile cancer [22–24].
Ghana’s circumcision rate is estimated to be on the high
side as the majority of ethnic groups and religions identify
Table 2 Categories of complications among children with
circumcision-related injuries recorded in Kumasi
Type of Complication
Complete Penile Amputation
Partial Penile Amputation
circumcision as an appropriate religious or cultural
practice for males to undergo .
The timing of circumcision among children in this
study suggests an early age of circumcision in Ghana as
over 87 % of cases had circumcision done in the
neonatal period (Table 1). This is similar to findings by
Osifo and Oraifo  and Chaim et al. . However, in
Eastern and Southern Africa and some parts of the
pacific, circumcision is performed far beyond the neonatal
period [6, 25, 26]. For some, it is a rite of passage into
adulthood [6, 25]. Only 5.6 % of our cases were
circumcised beyond the neonatal period. While our study
population may not be representative of the population
of Ghana, it provides an indication that most
circumcisions are being performed during the neonatal period.
This may have implications for interventions in the areas
of circumcision such as persons to target for training,
timing of educational messages on circumcision and
the location of circumcision services.
In this study, over 65 % of children with the
complications recorded had their circumcisions done in a
hospital. The proportion is even higher (75 %) when
lower level health facilities (health centres and clinics)
are included. Similarly in Nigeria, more circumcisions
were done in orthodox medical centres (66.9 %) than
traditional settings (33.1 %) . Our findings
however, contrast sharply with studies from Southern and
Eastern Africa where virtually all circumcisions are
performed outside hospitals as part of traditional rites
of passage into manhood with high complication rates
[6, 25]. In Israel, however, although a significant
proportion of circumcisions are undertaken outside health
facilities by the ritual circumciser, a lower proportion of
complications have been recorded because they are well
trained and the practice is regulated .
In this study, nurses accounted for the majority of
circumcision-related injuries - 77.8 % of cases. Doctors
and traditional circumcisers (locally referred to as
Wanzams) accounted for 8.3 and 20.8 % of the
circumcision-related complications respectively.
Likewise in Nigeria, nurses were found to account for the
majority of complications (55.9 %) with doctors and
traditional circumcisers accounting for 35.1 and 9 %
respectively . In a comparative study by Atikeler et
al., it was found that circumcisions done by unlicensed
circumcisers resulted in more early phase complications as
well as late lifelong complications compared with
licensed surgeons . Even among physicians performing
circumcisions, there is evidence that there a is lack of
formal training amongst them as to how to perform
circumcision correctly and providers also lack the
requisite skills to manage the complications of circumcisions
[4, 7]. Our findings indicate gaps either in knowledge
and/or practice among persons providing circumcision
services in health facilities in Ghana and it is therefore
imperative that training workshops are organised for all
providers especially nurses to reduce the incidence of
circumcision-related injuries in the future.
The method of circumcision was unknown in 37
(51.4 %) of the cases. A significant proportion (91.4 %)
of the cases for which the method of circumcision was
known underwent surgical circumcision with a scalpel
and this is still consistent with other studies that have
examined circumcision-related injuries and
complications in the West African sub-region [3, 7]. Due to the
high proportion (51.4 %) of cases for which the method
of circumcision was unknown in this study, we are
unable to associate the method of circumcision with the
complications observed. However, there is evidence that
the Plastibel device poses a higher risk of complication
compared with conventional dissection .
The majority of our cases (77.8 %) had
urethrocutaneous fistulae. Urethrocutaneous fistulae have largely
been associated with hypospadias repair in developed
countries [28, 29] and not circumcision. The proportion
of urethrocutaneous fistulae recorded in this study
contrasts sharply with findings in Nigeria by Osifo and
Oraifo et al. in which urethrocutaneous fistula accounted
for only 21 % of complications recorded  and that of
Okeke et al., where no fistula was recorded . The
urethrocutaneous fistulae in the present study ranged
in sizes from pinhole defects (<5 mm) to very big
defects (>10 mm) on the ventral aspect of the glans penis
(Fig. 3a-c). We think the management of haemorrhage/
bleeding during circumcision may be accounting for the
high numbers of urethrocutaneous fistulae observed. The
ligation of bleeding sites with larger-sized sutures and
direct laceration into the urethra during circumcision may
be responsible for the high numbers of urethrocutaneous
fistulae observed in this study . The occurrence of
urethrocutaneous fistula has also been associated with
the Plastibel device .
There were four cases (5.6 %) of iatrogenic
hypospadias (Fig. 4a-b). This is one of the worse forms of
circumcision-related injuries. Complete ligation of the
artery to the frenulum may cause extensive tissue
necrosis on the ventrum of the glans penis leading to the
iatrogenic hypospadias . Isolated cases of iatrogenic
hypospadias have been reported after the circumciser
performed a ventral rather than a dorsal slit prior to
the start of circumcision. It is imperative that the
proper plane is entered into for the initial separation
of adhesions so that the meatus is not inadvertently
entered into, and then damaged .
The iatrogenic hypospadias seen in this study may not
necessarily be as a result of complications of
circumcision but may have been missed mega meatus with intact
prepuce variants before circumcision and only found
thereafter. This study is unable to determine whether
the iatrogenic hypospadias observed had megameatus
with intact prepuce before circumcision. Clinically, these
are difficult to distinguish after circumcision .
The most tragic form of circumcision-related injury is
penile amputation and it was the second leading
complication recorded in this study, accounting for 6.9 %
overall. Complete penile amputation accounted for 4.1 %
of all complications. This is higher compared with the
3.1 % recorded in Nigeria by Okeke et al.  but lower
than the 8 % recorded in a study in Turkey by Ceylan et
al. . One case of partial penile amputation recorded
Fig. 3 a A small (<5 mm) sized urethrocutaneous fistula (arrowed). b Medium sized (5–10 mm) urethrocutaneous fistula (arrowed). c Large sized
(>10 mm) urethrocutaneous fistula (arrowed)
Fig. 4 a Iatrogenic hypospadias (arrowed). b Iatrogenic hypospadias (arrowed)
in this study was reported within 48 h and this was
repaired successfully (Fig. 5a-c). However, the other case
reported after six months and presented with a healed
wound with a constriction band and urethrocutaneous
fistula (Fig. 6). In all the cases of complete penile
amputations, the parents of the babies were falsely reassured
that all was well by the circumcisers either because of
ignorance on their part or for fears of litigation against
them. As a result they all presented late with difficulty
passing urine as wound healing with scarring at the
stump ends caused meatal stenosis (Fig. 7a-c). Penile
glans amputation like many others is a preventable
complication of circumcision if proper attention is paid to
detail and the circumcision is carried out by properly
trained personnel [32–34]. Again if the practitioners were
trained to recognise these complications, they would have
referred such patients immediately with the severed penile
tissue properly preserved on ice so that penile
reattachment could be attempted. This may have resulted in better
cosmetic outcomes for such patients [32, 35, 36].
There were four cases of epidermal inclusion cysts
(Fig. 8) with the youngest aged 7 months presenting
with a painless swelling on the dorsum of the penis.
Epidermal inclusions cysts are known to result from
the implantation of skin in the subcutaneous tissue
during circumcision . They are considered rare in
some countries [36, 37]. Our findings may suggest that
these may not be rare. They are known to be usually
asymptomatic and may not be reported unless issues
bordering on aesthetics or pain from infection emerge
. Skin bridges (Fig. 9) are also recognised minor
complications of circumcision and are easily treated
Fig. 5 a Partial penile amputation from tourniquet effect of a suture material (arrowed) seen within 48 h. b Patient urinating immediately
after release of tourniquet. c Immediate post-repair
Fig. 6 a Complete glans penis amputation seen 3 years post circumcision with scarred stump end. b near total penile amputation seen 2 years
post circumcision. c Complete glans penis amputation from plastibel circumcision seen 3 months post circumcision with meatal occlusion
. They may go unnoticed unless cosmetic issues or
pain and infection occur. In our study, these two
categories of complications each accounted for 2.8 % of all
complications. There were two cases of excess foreskin.
This results from inadequate excision of the foreskin. The
parents brought them because they were dissatisfied with
the cosmetic appearance of the penis. In other studies,
excess foreskin constituted the predominant late
complication of circumcision .
Our study did not record any case of haemorrhage
which was among the leading complications recorded by
Gee and Ansell . Haemorrhage, most likely, will
occur in the first few hours of circumcision. We surmise
that late reporting may account for the non-recording of
haemorrhage as a complication in our study. It may also
be due to clients accessing acute care in lower level health
facilities and only reporting severe complications to the
Urology Unit. This may also imply that the complete
spectrum of circumcision-related injuries may not have
been fully covered in our study, thus a bigger burden
Circumcision has social, cultural and religious
implications and this may account for the high uptake of the
procedure despite the associated complications [1, 6, 8].
It is imperative that the procedure is made safe in order
to ensure that children undergoing the procedure in the
future do not develop complications. Persons who have
not been circumcised have been ostracised in some parts
of Africa; this can take the form of denial of marriage
since uncircumcised men were frowned upon [6, 35, 36]
in the past and such stereotypes may still exist.
Fig. 7 Healed partial penile amputation from tourniquet effect
with a constriction ring and urethrocutaneous fistula
Fig. 8 Skin bridges in an 8year old boy
Fig. 9 Epidermal inclusion cyst seen 7 months post circumcision
Neonatal circumcision, a common practice in Ghana is
associated with several and sometimes tragic
complications such as penile amputations. The high proportion
of urethrocutaneous fistulae recorded in this study
requires further investigation to determine the underlying
causes and allow for the institution of appropriate
preventive measures. There is the need for further studies
focusing on the immediate or early complications
following circumcision including injuries related to specific
methods of circumcision. The training of providers in order
to reduce the incidence of injuries is also recommended.
HIV: Human Immunodeficiency virus; KATH: Komfo Anokye Teaching
Hospital; SPSS: Statistical Software Package for Social Sciences
We would like to acknowledge the immense contributions of Prof
Francis Abantanga and Prof Peter Donkor both of KATH for critically
reviewing this manuscript before final submission. We are grateful to
them for their words of wisdom and encouragement. We will also like
to thank Ms Portia Adutwumwaa, our research assistant who typed and
administered the questionnaires and helped enter them into SPSS.
Location of Work: Komfo Anokye Teaching Hospital.
KAAA: Conceived and designed the study and was involved in all stages
of the manuscript writing. RA: drafting of manuscript, literature search
and critical revision of manuscript for important intellectual content.
CKG-S: Literature search, drafting of manuscript and helped in the
analysis and interpretation of data. KA: Literature search, manuscript
drafting and final approval for submission of manuscript. PM: Helped
in data acquisition and was involved in drafting the manuscript at all
stages. DOL: Helped in designing the manuscript, was involved in the
drafting as well as the critical revision for important intellectual content
and approved the final submission of the manuscript. KNB: Was involved
in data collection and helped with data analysis and interpretation and
approved the final submission of manuscript. KO-B: Data acquisition
and interpretation of data. Approved the final submission of manuscript.
BF-T: Data acquisition and interpretation, drawing of figures and approval of
final submission of manuscript. DA: Data acquisition and analysis, drafting of
manuscript and approval for final submission of manuscript. IOA: Data
acquisition and analysis, drafting of manuscript and approval for final
submission of manuscript. EMY: Data acquisition and interpretation,
helped generate the tables and figures. He approved the final submission
of manuscript. GA: Was involved in designing the study, helped with data
acquisition and interpretation, was involved in drafting of the manuscript
and revised it critically for important intellectual content. He also gave
approval for the final submission of manuscript. SKT: Data acquisition and
interpretation, helped generate the tables and figures. He approved the
final submission of manuscript. All authors read and approved the final
Consent for publication
Written informed consent was obtained from the parents/guardians of
all children enrolled for participation in the study and for publication of
the accompanying images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Ethics approval and consent to participate
Ethical approval was obtained from the Committee on Human Research,
Publications and Ethics of the Kwame Nkrumah University of Science
and Technology and the Komfo Anokye Teaching Hospital.
1. Mousavi SA , Salehifar E. Circumcision complications associated with the Plastibell device and conventional dissection surgery: a trial of 586 infants of ages up to 12 months . Adv Urol [Internet]. 2008 [cited 2014 Nov 9]; 2008 . Available from: http://www.ncbi. nlm.nih.gov/pmc/articles/PMC2581731/
2. Krill AJ , Palmer LS , Palmer JS . Complications of circumcision . Sci World J . 2011 ; 11 : 2458 - 68 .
3. Okeke LI , Asinobi AA , Ikuerowo OS . Epidemiology of complications of male circumcision in Ibadan, Nigeria . BMC Urol . 2006 ; 6 ( 1 ): 21 .
4. Moslemi MK , Abedinzadeh M , Aghaali M. Evaluation of epidemiology, safety, and complications of male circumcision using conventional dissection surgery: experience at one center . Open Access J Urol . 2011 ; 3 : 83 - 7 .
5. Peden M , Ozanne-Smith J , Branche C , Fazlur Rahman AKM , Rivara F , Kidist Bartolomeos. World report on child injury prevention [Internet] . Geneva , Switzerland; 2008 [cited 2014 Nov 9] . Available from: http://www. preventionweb.net/files/8438_9789241563574eng1.pdf
6. Mogotlane SM , Ntlangulela JT , Ogunbanjo BGA . Mortality and morbidity among traditionally circumcised Xhosa boys in the Eastern Cape Province , South Africa . Curationis [Internet]. 2004 Sep 28 [cited 2014 Nov 9]; 27 ( 2 ). Available from: http://www.curationis. org.za/index.php/curationis/article/ view/980
7. Osifo OD , Oriaifo IA . Circumcision mishaps in Nigerian children . Ann Afr Med . 2009 ; 8 ( 4 ): 266 - 70 .
8. Atikeler MK , Geçit I , Yüzgeç V , Yalçin O. Complications of circumcision performed within and outside the hospital . Int Urol Nephrol . 2005 ; 37 ( 1 ): 97 - 9 .
9. Hutcheson JC . Male neonatal circumcision: indications, controversies and complications . Urol Clin North Am . 2004 ; 31 ( 3 ): 461 - 7 . viii.
10. Nelson CP , Dunn R , Wan J , Wei JT . The increasing incidence of newborn circumcision: data from the nationwide inpatient sample . J Urol . 2005 ; 173 ( 3 ): 978 - 81 .
11. Ben Chaim J , Livne PM , Binyamini J , Hardak B , Ben-Meir D , Mor Y. Complications of circumcision in Israel: a one year multicenter survey . Isr Med Assoc J IMAJ . 2005 ; 7 ( 6 ): 368 - 70 .
12. Schoen EJ . Benefits of newborn circumcision: is Europe ignoring medical evidence? Arch Dis Child . 1997 ; 77 ( 3 ): 258 - 60 .
13. Craig JC , Knight JF , Sureshkumar P , Mantz E , Roy LP. Effect of circumcision on incidence of urinary tract infection in preschool boys . J Pediatr . 1996 ; 128 ( 1 ): 23 - 7 .
14. Crain EF , Gershel JC . Urinary tract infections in febrile infants younger than 8 weeks of age . Pediatrics . 1990 ; 86 ( 3 ): 363 - 7 .
15. Spach DH , Stapleton AE , Stamm WE . Lack of circumcision increases the risk of urinary tract infection in young men . JAMA . 1992 ; 267 ( 5 ): 679 - 81 .
16. Wiswell TE , Geschke DW . Risks from circumcision during the first month of life compared with those for uncircumcised boys . Pediatrics . 1989 ; 83 ( 6 ): 1011 - 5 .
17. Wiswell TE , Miller GM , Gelston HM , Jones SK , Clemmings AF . Effect of circumcision status on periurethral bacterial flora during the first year of life . J Pediatr . 1988 ; 113 ( 3 ): 442 - 6 .
18. Bailey RC , Egesah O , Rosenberg S. Male circumcision for HIV prevention: a prospective study of complications in clinical and traditional settings in Bungoma, Kenya . Bull World Health Organ . 2008 ; 86 ( 9 ): 669 - 77 .
19. Gray RH , Kigozi G , Serwadda D , Makumbi F , Watya S , Nalugoda F , et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial . Lancet . 2007 ; 369 ( 9562 ): 657 - 66 .
20. Millett GA , Flores SA , Marks G , Reed J , Herbst JH . Circumcision status and risk of hiv and sexually transmitted infections among men who have sex with men: a meta-analysis . JAMA . 2008 ; 300 ( 14 ): 1674 - 84 .
21. Young MR , Odoyo-June E , Nordstrom SK , Irwin TE , Ongong'a DO , Ochomo B , et al. Factors associated with uptake of infant male circumcision for HIV prevention in western Kenya . Pediatrics. 2012 ; 130 ( 1 ): e175 - 82 .
22. Kochen M , McCurdy S. Circumcision and the risk of cancer of the penis. A life-table analysis . Am J Dis Child 1960 . 1980 ; 134 ( 5 ): 484 - 6 .
23. Morris BJ , Gray RH , Castellsague X , Bosch FX , Halperin DT , Waskett JH , et al. The strong protective effect of circumcision against cancer of the penis . Adv Urol . 2011 ; 2011 , e812368.
24. Schoen EJ . The relationship between circumcision and cancer of the penis . CA Cancer J Clin . 1991 ; 41 ( 5 ): 306 - 9 .
25. 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 .
26. Afsari M , Beasley SW , Maoate K , Heckert K. Attitudes of pacific parents to circumcision of boys . Pac Health Dialog . 2002 ; 9 ( 1 ): 29 - 33 .
27. Osarumwense DO , Ovueni EM . Current views, levels of acceptance, and practice of male circumcision in Africa subregion . Ann Pediatr Surg . 2009 ; 5 ( 4 ): 254 - 60 .
28. Elbakry A. Management of urethrocutaneous fistula after hypospadias repair: 10 years' experience . BJU Int . 2001 ; 88 ( 6 ): 590 - 5 .
29. Richter F , Pinto PA , Stock JA , Hanna MK . Management of recurrent urethral fistulas after hypospadias repair . Urology . 2003 ; 61 ( 2 ): 448 - 51 .
30. Ikuerowo SO , Bioku MJ , Omisanjo OA , Esho JO . Urethrocutaneous fistula complicating circumcision in children . Niger J Clin Pract . 2014 ; 17 ( 2 ): 145 - 8 .
31. Ceylan K , Burhan K , Yilmaz Y , Can S , Kuş A , Mustafa G . Severe complications of circumcision: an analysis of 48 cases . J Pediatr Urol . 2007 ; 3 ( 1 ): 32 - 5 .
32. Kaplan GW . Complications of circumcision . Urol Clin North Am . 1983 ; 10 ( 3 ): 543 - 9 .
33. Mazza ON , Cheliz GM . Glanuloplasty with scrotal flap for partial penectomy . J Urol . 2001 ; 166 ( 3 ): 887 - 9 .
34. Shaeer O , El-Sebaie A. Construction of neoglans penis: a new sculpturing technique from rectus abdominis myofascial flap . J Sex Med . 2005 ; 2 ( 2 ): 259 - 65 .
35. Gluckman GR , Stoller ML , Jacobs MM , Kogan BA . Newborn penile glans amputation during circumcision and successful reattachment . J Urol . 1995 ; 153 ( 3 Pt 1 ): 778 - 9 .
36. Essid A , Hamzaoui M , Sahli S , Houissa T. Glans reimplantation after circumcision accident . Prog En Urol J Assoc Fr Urol Société Fr Urol . 2005 ; 15 ( 4 ): 745 - 7 .
37. Hamoudi A , Shier M. Late complications of childhood female genital mutilation . J Obstet Gynaecol Can JOGC J Obstétrique Gynécologie Can JOGC . 2010 ; 32 ( 6 ): 587 - 9 .
38. Naimer SA , Peleg R , Meidvidovski Y , Zvulunov A , Cohen AD , Vardy D. Office management of penile skin bridges with electrocautery . J Am Board Fam Pract Am Board Fam Pract . 2002 ; 15 ( 6 ): 485 - 8 .
39. Gee WF , Ansell JS . Neonatal circumcision: a ten-year overview: with comparison of the Gomco clamp and the Plastibell device . Pediatrics . 1976 ; 58 ( 6 ): 824 - 7 .