European Journal of Cardiovascular Medicine

Circumcision, the surgical removal of the prepuce (foreskin) covering the glans penis, is among the oldest and most commonly practiced surgical procedures worldwide. It is performed for a variety of medical, cultural, religious, and personal reasons. Medically, circumcision is indicated in conditions such as phimosis, paraphimosis, recurrent balanitis, and as a preventive measure for certain sexually transmitted infections and penile carcinoma (1,2).

Conventional circumcision, typically performed using a scalpel or surgical scissors followed by suturing, has long been considered the standard technique. However, it is associated with longer operative time, increased intraoperative bleeding, postoperative pain, and occasionally suboptimal cosmetic results (3). With the advancement of surgical technology, stapler circumcision has emerged as a minimally invasive alternative. This technique employs a disposable circumcision device that simultaneously resects and staples the prepuce, thereby potentially minimizing surgical duration and improving wound healing (4).

Several studies have compared these two techniques, focusing on outcomes such as operative time, blood loss, pain scores, complication rates, and patient satisfaction. Results suggest that stapler circumcision may offer faster recovery, better hemostasis, and superior cosmetic outcomes, although it may be costlier and associated with certain device-related limitations (5,6). Despite these potential benefits, data from Indian surgical centers comparing both approaches remain limited.

This study was undertaken to compare stapler circumcision with conventional circumcision in terms of operative efficiency, clinical outcomes, and patient-reported satisfaction, in order to provide evidence-based recommendations for optimal surgical management of foreskin-related disorders

Study Population:
A total of 60 male patients between the ages of 5 and 40 years, who were clinically indicated for circumcision due to conditions such as phimosis, recurrent balanitis, or personal/cultural preference, were enrolled. Patients were randomly allocated into two groups of 30 each using a computer-generated randomization table.

Inclusion Criteria:

• Male patients aged 5–40 years
• Indication for elective circumcision
• No active genital infection at the time of surgery

Exclusion Criteria:

• Bleeding disorders
• Previous penile surgery
• Active local infection or ulceration
• Patients unwilling to participate

Group Allocation:

• Group A (Conventional Circumcision): Underwent traditional circumcision using scalpel dissection and absorbable sutures.
• Group B (Stapler Circumcision): Underwent circumcision using a disposable stapler device suitable for age and penile size.

Surgical Procedure:
All procedures were performed under appropriate anesthesia—local for adults and general anesthesia for children. In Group A, the prepuce was retracted, excised manually, and hemostasis achieved using electrocautery and sutures. In Group B, the stapler device was applied, activated to resect the foreskin, and automatically staple the wound edges.

Parameters Assessed:
The following parameters were evaluated and recorded:

• Operative Time (in minutes): Time from initial incision to completion of dressing.
• Intraoperative Blood Loss (in mL): Estimated by gauze weighing and suction bottle measurement.
• Postoperative Pain: Assessed on Day 1, Day 3, and Day 7 using a Visual Analogue Scale (VAS) ranging from 0 (no pain) to 10 (worst pain).
• Complications: Including bleeding, infection, edema, wound dehiscence, and delayed healing.
• Cosmetic Outcome: Evaluated at 4 weeks postoperatively using a 5-point Likert scale by a blinded observer.

Statistical Analysis:
Data were compiled and analyzed using SPSS version 25.0. Continuous variables were presented as mean ± standard deviation and compared using the independent t-test. Categorical variables were expressed as percentages and compared using the chi-square test. A p-value <0.05 was considered statistically significant.

A total of 60 male patients were included in the study, with 30 in each group. The age distribution ranged from 6 to 38 years, with a mean age of 21.4 ± 7.2 years in Group A and 20.9 ± 6.8 years in Group B, showing no statistically significant difference (p=0.76).

Operative Parameters

The mean operative time was significantly shorter in the stapler group (Group B) compared to the conventional group (Group A). Blood loss was also notably reduced in the stapler group (Table 1).

Table 1: Comparison of Operative Parameters Between Groups

(Table 1 demonstrates a significantly faster and less bloody procedure in Group B.)

Postoperative Pain

Pain scores measured using the Visual Analogue Scale (VAS) showed significantly lower values in the stapler group across all three time points (Table 2).

Table 2: Postoperative Pain Assessment (VAS Score)

(Table 2 highlights the consistently lower pain levels reported in the stapler group.)

Complications

Postoperative complications such as edema, mild bleeding, and delayed wound healing were recorded. Group A experienced more minor complications than Group B (Table 3).

Table 3: Postoperative Complications

(Table 3 shows a lower overall complication rate in the stapler group.)

Cosmetic Outcomes

Cosmetic satisfaction assessed at 4 weeks postoperatively using a 5-point Likert scale revealed higher satisfaction in Group B (Table 4).

Table 4: Cosmetic Outcome Ratings at 4 Weeks

(Table 4 supports the superior cosmetic outcome observed in the stapler group.)

In summary, stapler circumcision was associated with reduced operative time, minimal blood loss, lower postoperative pain, fewer complications, and better aesthetic results when compared to the conventional technique.

Circumcision remains one of the most frequently performed urological surgeries globally, particularly in pediatric and adult male populations, either for medical or socio-cultural reasons. Traditionally, the procedure has been conducted using the conventional scalpel method, but recent innovations like stapler-assisted circumcision have prompted a shift toward minimally invasive alternatives offering enhanced efficiency and cosmetic results (1,2).

In the present study, the stapler circumcision group demonstrated significantly reduced operative time and intraoperative blood loss compared to the conventional group, consistent with prior studies (3,4). Peng et al. reported that the use of a disposable stapler device reduced surgical time by more than half and resulted in superior hemostasis due to immediate mechanical sealing of vessels (5). Similarly, a randomized trial by Sun et al. found that the average operative duration was significantly shorter in the stapler group (6).

Postoperative pain was notably lower in the stapler group in our study, particularly on the first and third postoperative days. This observation is aligned with the findings of Liu et al., who reported reduced postoperative discomfort and early resumption of daily activities in patients undergoing stapler circumcision (7). The decreased tissue handling and absence of multiple sutures likely contribute to this improvement in pain scores (8).

Our analysis also highlighted a lower incidence of postoperative complications such as bleeding, edema, and delayed healing in the stapler group. These findings are in agreement with previous literature. A study by Zhang et al. demonstrated a significantly lower infection rate and faster healing time with stapler circumcision compared to conventional techniques (9). Moreover, fewer wound-related complications were noted due to the uniform stapling and reduced manual tissue manipulation (10).

In terms of cosmetic outcomes, the stapler method was superior, as evidenced by higher satisfaction scores. Patients and their guardians preferred the cleaner suture-less appearance, a trend also noted in prior studies (11,12). The circular stapling approach offers more symmetrical healing margins, which enhances the final aesthetic result (13).

Despite its advantages, the stapler device has certain limitations, notably the higher cost, which may restrict its routine use in low-resource settings. Additionally, technical familiarity is necessary to avoid complications such as retained staples or incomplete resection of the prepuce (14). While our study did not encounter serious device-related complications, previous reports have cited occasional issues like staple line dehiscence or staple retention requiring manual removal (15).

A limitation of this study is the relatively small sample size and short-term follow-up. Longitudinal studies with larger populations and cost-effectiveness analyses are warranted to further establish the clinical superiority and feasibility of stapler circumcision on a wider scale.

In conclusion, our findings reinforce the growing body of evidence supporting stapler circumcision as a faster, safer, and cosmetically superior technique compared to the conventional method. Its incorporation into routine surgical practice could enhance patient satisfaction and reduce operative burden, provided that cost and accessibility are appropriately addressed.

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2. Huo ZC, Liu G, Wang W, He DG, Yu H, Fan WJ, et al. [Clinical effect of circumcision stapler in the treatment of phimosis and redundant prepuce]. Zhonghua Nan Ke Xue. 2015;21(4):330-3.
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