Buccal mucosa glansplasty as a salvage procedure for a circumcision-related glans amputation in an infant: a case report and literature review

¹University of Health and Allied Sciences, School of Medicine, Faculty of Surgery, Ho, Ghana, ²Department of Surgery, Ho Teaching Hospital, Ho, Ghana

^&Corresponding author
Frank Obeng, University of Health and Allied Sciences, School of Medicine, Faculty of Surgery, Ho, Ghana

Introduction    

Accidental amputation of the glans penis is a rare but critical complication of circumcision, necessitating urgent and skilled surgical intervention to prevent long-term consequences [1]. Such injuries can lead to functional and anatomical pathologies, especially in paediatric patients [1]. This case report describes an 11-week-old male infant who suffered a partial glans amputation (Figure 1) following a circumcision performed by health personnel. The infant was treated with buccal mucosa grafting for glans reconstruction, a technique that has shown promising results in salvaging penile tissue and restoring function [1-3]. By reviewing this case, we aim to emphasize the importance of prompt management and the effectiveness of buccal mucosa grafting in the repair of glans amputation, even in an under-1-year-old.

Patient and observation     

Patient information: an 11-week-old male infant, born at 38 weeks of gestation with a birth weight of 3.1 kg, was presented with accidental glans amputation during circumcision performed by a non-surgeon. The infant had a normal early neonatal course, with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. He had no genetic anomalies, dysmorphic features, or family history of bleeding disorders. He had bilateral fully descended testicles and no congenital penile anomalies. There was no history of bleeding disorders, and his platelet count and clotting profile were normal.

Clinical findings: upon examination at the district hospital, the infant was pale (Hb = 7.2 g/dL) but well-hydrated, with stable vitals (temperature 36°C, pulse 78 bpm, SpO2 99%). Physical examination revealed a 1 cm flush amputation of the glans penis, with visible absorbable haemostatic sutures in the wound bed and no active bleeding (Figure 1). The infant was unable to void per urethra initially.

Timeline of current episode: the patient initially underwent circumcision performed by a health personnel, resulting in accidental penile glans amputation, uncontrolled bleeding, and an inability to void (due to acute urine retention from pain). He was rushed to a district hospital, where haemostasis was achieved using haemostatic sutures. On the same day, he was referred to the teaching hospital for specialized care, with a diagnosis of glans amputation.

Diagnostic assessment: upon admission to the teaching hospital, further diagnostic workup was performed, including a complete blood count (Hb = 7.2 g/dL, no leucocytosis, platelet counts normal) and clotting profile (INR, normal). The patient underwent a physical examination, revealing a flush amputation of the glans penis with no active bleeding (Figure 1). The infant was transfused with 90 mL of concentrated red blood cells, and his condition stabilized. He voided per urethra after receiving analgesia (intravenous paracetamol).

Diagnosis: the final diagnosis was partial glans amputation secondary to circumcision. There were no other diagnoses considered, and the prognosis was guarded.

Surgical interventions: the infant underwent buccal mucosa grafting (Figure 2) for glansplasty, combined with meatoplasty. Under general anaesthesia (with a cuffed endotracheal tube), a 2 cm x 1.5 cm buccal mucosa graft was harvested from the left cheek, carefully preserving the Stensen's duct. The graft was used to repair and re-fashion the amputated glans, secured with absorbable sutures (polyglactin 910, vicryl, size 3-0, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6). A meatoplasty was performed to appose the inner border of the graft with the distal aspects of the nascent urethra. An 8-French urethral catheter was inserted to safeguard the meatoplasty during the early healing phase. The patient was given maintenance intravenous fluids, intravenous antibiotics (cefuroxime, metronidazole), and analgesia (intravenous paracetamol) for 120 hours postoperatively.

Follow-up and outcome of interventions: postoperatively, the infant experienced mild respiratory distress after extubating. This was managed with respiratory support and adjusted medication. Over the following days, the infant's condition improved progressively, and by postoperative day 1, he was stable with no further respiratory issues. The infant resumed normal breastfeeding by postoperative day 2, demonstrating adequate oral suction and no difficulty with feeding. Wound healing was satisfactory at both the donor and recipient sites, and the graft took well, with no signs of rejection (Figure 4, Figure 5). The donor site oedema was minimal, and there were no complications noted at this site. The recipient site (reconstructed glans, Figure 2, Figure 3, Figure 4, Figure 5) showed good healing, with the graft maintaining its shape and function. The urethral catheter was removed on postoperative day 10, following adequate healing of the meatoplasty and urethra (Figure 5).

At the six-month follow-up, the patient´s condition remained stable. He exhibited satisfactory functional and anatomic outcomes, with normal voiding and no complications related to the reconstructed glans or urethra.

Patient perspective: the parents of the infant expressed satisfaction with the surgical intervention and the outcome. They appreciated the careful diligence in the management of their child´s condition and were relieved by the positive recovery.

Informed consent: informed and written consent was obtained from the parents of the infant for the surgical intervention and for the publication of this case report. The parents were fully informed of the risks and benefits of the procedure and consented to the use of their child´s medical information and clinical pictographs for educational purposes.

Discussion     

Accidental glans amputation is a severe complication with implications for both immediate and long-term management [1]. Current literature highlights that buccal mucosa grafting is a viable reconstructive technique due to its rich blood supply and relative toughness [2]. A case report by Tawaranurak et al. (2018) suggests that prompt surgical intervention and appropriate postoperative care are crucial for preventing complications and achieving favourable outcomes [1]. Appiah et al. (2014 and 2024) support the use of buccal mucosa grafts, noting that they offer good outcomes in penile reconstruction due to their compatibility with penile tissue [2]. In their work, Appiah et al. (2014 and 2024) reviewed various reconstructive techniques and found buccal mucosa grafting to be effective in preserving penile function and aesthetics [2,3]. It has also been made amply clear that postoperative care, including antibiotic prophylaxis and regular follow-up, is essential to mitigate risks such as infection or graft rejection [4] (Table 1).

Nasr et al. (2013) reported on a novel technique and complications following penile reconstruction and emphasized the importance of early intervention and meticulous postoperative management [5]. Pappas et al. (2019) and Appiah et al. (2024) in their work on glans reconstruction surgeries, found that skin graft, or buccal mucosa grafting, respectively, provides favorable long-term outcomes for penile reconstruction [2,3,6]. These are potentially useful for the myriad of penile anatomic complications, as outlined by Iacob et al., 2021 in their systematic review [7]. Mazza et al. (2001) discussed surgical techniques for penile reconstruction and highlighted scrotal flap glansoplasty as a viable option for managing severe penile injuries [8]. Tawaranurak et al. (2023) and Shaeer et al. (2024) explored advances in managing penile amputation injuries, underscoring the critical nature of timely surgical treatment [1,9]. Table 1 and Table 2 summarise pertinent literature on this case.

The successful use of buccal mucosa grafting in this case highlights its effectiveness as a salvage procedure for accidental glans amputation. The technique is supported by current literature, which emphasizes the importance of early intervention and comprehensive postoperative care [2,3,6,8,9]. Despite the rarity of such complications, the insights gained from this case and the reviewed literature provide valuable guidance for managing similar situations. Whilst re-training would improve circumcision outcomes [10], further research and clinical experience will refine strategies and improve outcomes for circumcision mishaps [9].

In addition, we acknowledge limitations such as the single-case nature and the short follow-up period (6 months), as they may impact the generalizability and long-term implications of the findings.

Conclusion     

Buccal mucosa graft glansoplasty proves to be a viable and effective salvage technique for accidental glans amputation during circumcision. The successful outcome in this case, supported by literature, underscores the need for prompt surgical intervention and thorough postoperative management to achieve the best possible results, even in an infant. However, a longer follow-up and additional case studies would be necessary to draw more definitive conclusions.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Frank Obeng: conceptualization, methodology, writing-whole manuscript original draft preparation; Aishah Fadila Adamu: data collection, writing-review and editing; Karen Michelle A. Whittal: literature review and data curation; Kekeli Kodjo Adanu: supervision, writing-review and editing; Ali Mamudu Ayamba: supervision, methodology, writing-review and editing. All the authors read and approved the final version of this manuscript.

Tables and figures     

Table 1: a review of penile complications at circumcision in existing literature (Iacob et al. 2012)

Table 2: range of salvage surgeries for penile amputations at circumcision

Figure 1: client as he presented to us at the emergency room, about 1 cm of glans amputation clearly shown

Figure 2: buccal mucosal graft being sutured into position during the reconstructive procedure

Figure 3: immediate post-operative outcome of the glansplasty-meatoplasty procedure

Figure 4: post-operative day 7; a small island of dry area in the glansoplasty graft: but most of the graft is still viable; good take of graft

Figure 5: early outcome of the glansplasty and meatoplasty procedure; graft healed

Figure 6: looking back: how it looked like on day-1 post-operative outcome of the glansplasty-meatoplasty procedure

References