Circumcision is one of the important public surgeries performed globally. It is a popular non-therapeutic procedure that can be performed by people of various abilities and skills, ranging from trained medical practitioners to non-specialists, depending on their cultural and social backgrounds. Consequently, this surgery may cause varying types and frequencies of complications. Glans amputation and death due to severe bleeding, as a complication of this procedure, are rare, and the patients are left with morbidity and life-long complications. Here, we describe two cases of catastrophic complications due to ritual circumcision (one penile glans amputation and one death).

Background: In the tubularized incised plate (TIP) procedure, flap interposition between the skin and neourethra is highly recommended to decrease the postoperative fistula rate. However, there is no consensus regarding the ideal flap for this procedure. This study aimed to report our experiences in the one-stage TIP hypospadias surgery utilizing dartos flap (DF) (penile skin subcutaneous tissue) and tunica vaginalis flap (TVF) (parietal layer of the testis) as a tissue coverage of neourethra. Methods: In a retrospective study from Sep 2018 to May 2021, 16 cases of hypospadias with different types, ranging from midpenile to penoscrotal types, were managed with TIP urethroplasty using DF or TVF as a tissue coverage of neourethra were enrolled. The demographic characteristics of the participants, type of hypospadias, outcome, and complications were analyzed and compared. Results: We used TVF and DF as soft tissue coverage in 11 (68.8%) and 5 (31.3%) patients, respectively. The mean age was 56.38 ± 47.83 months. Mid-penile, proximal, and penoscrotal hypospadias were presented in 3 (18.8%), 8 (50.0%), and 5(31.2%) patients, respectively. The total success rate was 14 (87.5%), while 2 (12.5%) patients developed a urethrocutaneous fistula, which required delayed closure later. In comparison between TVF and DF groups: the TVF was applied in all patients with moderate and severe chordee and all patients with penoscrotal hypospadias, and six patients with proximal hypospadias, while only three patients with mild chordee and two patients with proximal hypospadias used the DF and showed statistical significance between groups (p < 0.001 and 0.012) respectively. The success rate was 90.9% vs. 80.0% in TVF and DF groups, respectively, with no statistical significance between groups (p = 1.000). Conclusions: In the primary TIP repair, the TVF is a practical option as a DF for the interposition cover of a neourethra, especially in penoscrotal and proximal hypospadias with severe chordee.

Background: Recently, biological dressings have become popular in treating burn injuries. Fish skin has non-infectious microbiota, high levels of type 1 and type 3 collagen, and a structural property similar to human skin, making it a promising xenograft for managing burn wounds. In this study, we aimed to evaluate the effectiveness of fish skin as a physiological dressing cover in patients with burn injuries. Method: From June 2017 to June 2021, 18 patients who were admitted to our center within 3 days from a thermal injury, burns with a partial thickness of approximately 20% of the total body surface area (TBSA) or complete partial-thickness burns ranging from 5% to 15% of the TBSA, and treated with the Shaour (Lethrinus lentjan) fish skin xenografts were enrolled in this retrospective study. The demographic characteristics of the participants, wound healing process, and final outcome were analyzed. Results: The mean age of the patients was 31.86 ± 9.14 years (range 19–46) which encompassed 12 (66.7%) men and 6 (33.3%) women. Superficial partial-thickness burns were seen in 13 (72.2%) patients, whereas full-thickness burns were seen in five (27.8%) patients. The mean time to 90% epithelialization and 100% epithelialization were 11.05 ± 2.57 days and 17.27 ± 2.05 days, respectively. The mean pain scores were 6.94 ± 0.72 and 5.22 ± 0.64 on days 7 and 15, respectively. Neither negative consequence nor allergic reaction was associated with using the fish skin grafts. The main reduction in the pain score from the first visit (7 days) to the second visit (15 days) was 1.72 ± 0.95 (p <  0.001). Conclusion: Acellular fish skin is a useful tool for wound healing treatment in complete and partial thickness burns. To validate this result, prospective cohort studies with long-term post-procedural follow-up are needed.

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Ritual circumcision is associated with a high rate of complications, mainly if performed by an untrained practitioner. Furthermore, excessive skin removal is a rare complication of this procedure that results in penis “trapping” underneath the skin and future sexual dysfunction. Here, we presented a 45-day-old Yemeni newborn with a trapped penis due to total loss of penile skin during a ritual circumcision performed by a traditional untrained practitioner using the guillotine technique one month ago. The patient underwent surgical exploration, and the penis was deliberated, released, and the skin defect was repaired with a single-step scrotal flap advancement over the penile shaft. At the six-month follow-up, the outcome was both functional and cosmetically satisfying. In conclusion, we recommend that the circumcision procedure be performed at the very least by an educated and skilled health professional. Additionally, a scrotal advancement flap is still an option in significant penile skin loss cases.