Checklist assessment tool to evaluate suitability and success of neonatal clamp circumcision: A prospective study

Recommendations to Improve Neonatal Circumcision Training

BACKGROUND

Although multiple specialties perform neonatal circumcision (NC), overall NC proceduralist availability is limited. The approach to training new practitioners varies. This study aims to describe NC training experiences, current practices, and make suggestions for future improvements.

METHODS

Perinatal physicians across 11 hospitals in a large Midwestern United States city who perform NC or who conduct newborn examinations and provide circumcision counseling were recruited for semistructured interviews about NC care. Interviews were transcribed; training-related comments underwent inductive and deductive qualitative coding. Themes related to circumcision training and recommendations for improving the experience of future circumcision learners were summarized.

RESULTS

Twenty-three physicians (10 family medicine, 8 pediatrics, and 5 obstetrics; 78% currently perform circumcision) participated. All participants conducted newborn examinations and provided circumcision counseling, but only 21/23 were trained to perform circumcision. Several themes related to training emerged: (1) personal training experience, (2) training others to perform circumcision, and (3) current training needs and barriers. Most reported learning in residency by a "see one, do one, teach one" approach with minimal formal didactic or structured training. Compared with their personal experience, participants noted a shift toward more direct supervision and preprocedure preparation for current trainees. However, most reported that circumcision learning continues to be "hands-on." Participants desired a more structured approach for future trainees.

CONCLUSIONS

Perinatal physicians noted a shift in the current NC training to a more hands-on approach than they experienced personally. Development of a structured NC curriculum was recommended to improve training.

Correction of hidden penis during Gomco clamp circumcision in the office

Hidden penis is considered to be a contraindication for clamp circumcision due to high likelihood of healing with concealment. A new technique was created for penoscrotal skin tacking during Gomco circumcision, where the sutures are placed externally instead of internally. Of 716 boys who did not have penoscrotal skin tacking performed, 11 (1.5%) developed concealment. None of the 57 boys who had penoscrotal skin tacking developed concealment. Adding just a couple of minutes to the procedure and with no documented side effects, external penoscrotal skin tacking during Gomco circumcision appears to be a promising addition to the pediatric urology armamentarium.

Comparing the effects of current circumcision techniques on dorsal root ganglia: an experimental study

Background

Circumcision is a surgical removal process of the preputium. Surgical excision and electric current cause neurodegeneration in the excised tissue-related neural network. This study investigates if circumcision and current surgical methods would cause histopathological changes in the penile tissue innervating pudendal nerve dorsal root ganglia.

Results

Vascular congestion occluded the microvessels, and degenerative changes were detected in postexcised penile tissue. Neuronal angulation, cytoplasmic condensation, nuclear shrinkage, and condensed nuclei were observed in the pudendal nerve ganglia. Moreover, the degenerated neuron (DN) densities of the pudendal nerve ganglia were 5 ± 2, 98 ± 22, 1093 ± 185, 236 ± 43 and 151 ± 19 in the control, the surgical circumcision, the monopolar cautery, the bipolar cautery and the thermocautery groups, respectively.

Conclusions

Although only the pudendal nerve endings are affected secondary to prepusium excision another pudendal axons can be damaged during bleeding control with cautery, the destruction of the neuron that sends this axon initiates a general inflammation in that ganglion. As a result, there may be a somatosensitive innervation defect in extrapenile tissues innervated by this ganglion. High-voltage electric devices should not be used unless obligatory.

Is the simple webbed penis a contraindication to circumcision?

Background

Surgical correction of the webbed penis is challenging. We presented the safety and feasibility of webbed penis correction for neonates under local anesthesia using a simple principle of leaving equal cylindrical shaft skin.

Methods

This retrospective study included 530 patients who presented for circumcision to three pediatric surgery centers between May 2017 and January 2020. We included male patients aged less than four weeks old who had circumcision with a minimum of 6 months follow-up. We compared patients with normal penile anatomy (n = 451, Group 1) to a simple webbed penis (n = 79, Group 2).

Results

There were no differences in age and weight between groups. The procedure time was significantly longer in Group 2 (8.05 ± 3.11 vs. 7.48 ± 2.07 min; P = 0.04). There were no differences in bleeding (P = 0.38), redundant foreskin (P > 0.99), need for corrective surgery (P = 0.38), and re-suturing (P = 0.28) between groups. The procedure success was significantly higher in Group 1 (449 (99.56%) vs. 70 (88.6%); P < 0.001). Parents' satisfaction was measured at two weeks with no difference between both groups.

Conclusion

Simple penoscrotal web is not a contraindication for neonatal circumcision. Circumcision of the penoscrotal web had good esthetic results with comparable outcomes to those with a normal penis without a web.

Outcome of circumcision for newborns with penoscrotal web: oblique skin incision followed by penis shaft skin physical therapy shows success

SHORT INTRODUCTION/BACKGROUND: and objectives: Although it is widely agreed that newborn circumcision complications are low when the penile anatomy is normal, outcomes are uncertain when a web of skin attaches the penis to the scrotum. This anomaly, called a penoscrotal web or webbed penis, often leads to surgical reconstruction instead of newborn circumcision.

OBJECTIVE

With this study, the authors compare the circumcision success rate for webbed penis circumcisions using a new, alternate method vs that using the traditional method.

STUDY DESIGN

Data from circumcision patients presenting to the Division of Urology's circumcision clinic from January 2014 to April 2018 were reviewed. All patients who met the checklist criteria for suitability to circumcise were enrolled in the study. They were grouped into the 'normal' group if they had no penile anomalies or the 'web' group if they had a web with a straight penis. Cases with penile anomalies were excluded. The new circumcision method includes altering the circumcision site planned to be oblique, slant up, to compensate for the web, retaining slightly more ventral than dorsal shaft skin, and including home care skin physical therapy as 'push down' the shaft skin. Postcircumcision evaluation was completed within 2 weeks after circumcision, and families were followed up as needed over the study period, six months after circumcision. Circumcision success was defined as the penis shaft no longer attached to the scrotum and circumcision line below the glans corona.

RESULTS

Of 828 boys who presented for circumcision, 652 (79%) were enrolled as they were suitable for circumcision: 355 (43%) in the normal group and 297 (36%) in the web group. The remaining 176 (21%) were excluded because they presented with a penile anomaly: buried penis (125), chordee (40), and hypospadias (11). Follow-up was carried out for 6 months. In the web group, follow-up data were obtained for 263 of 297 (89%) cases, with 261 of 263 (99%) showing success, and in the normal group, follow-up data were obtained for 327 of 355 (92%) cases, with all 327 (100%) showing success. The two web group cases (0.7%) who failed had surgical reconstruction.

DISCUSSION

It is believed the high success rate for penoscrotal web circumcisions with oblique incision followed by penis shaft skin physical therapy establishes that surgical reconstruction is not required in most of these cases.

CONCLUSION

It was found that newborns with a penoscrotal web and straight shaft show 99% success for circumcision, which is not different from boys without any penile anomalies (p = not significant). The authors believe the adoption of these new, alternate circumcision methods will enable boys with a web to avoid surgical reconstruction.

Scrotal injuries during neonatal circumcision

OBJECTIVE

To report very rarely encountered scrotal injuries during neonatal circumcision. Hospitals and physicians in the authors' country are mandated to report circumcision complications to the Ministry of Health. Those reports include the discharge summary from the emergency room or the admitting department. This is believed to be the first case series describing scrotal injuries during ritual circumcision.

PATIENTS AND METHODS

Reports of all circumcision complications between 2007 and 2014 were evaluated. Retrieved data on cases of scrotal injuries included patient's age, time between injury and hospital admission, nature of the injury, and administered treatment.

RESULTS

Twelve of a total of 489 reports of circumcision injuries involved the scrotum (2.5%). All circumcisions were performed during the neonatal period, and the infants were admitted on the day of injury. The only related genital injury was significant shortage of penile skin reported in six patients. Scrotal exploration and skin closure in the operating room was undertaken in six cases, five under general anesthesia. Suture closure in the emergency department was performed in three patients, and the scrotal skin was left to heal with secondary intention in three other patients. Scrotal content injury that extended to the tunica vaginalis of the testis was noted in one exploration.

DISCUSSION

The injuries sustained by the 12 study infants were mostly superficial and are not expected to cause long-term damage, although half of the patients required treatment under general anesthesia in the operating room or under sedation in the emergency department. While all reported patients emerged unscathed from the anesthetic procedures, the possible immediate complications of anesthesia as well as its long-term effects are not to be taken lightly, especially when treating a newborn. Further education of medical providers as well as performers of ritual circumcisions may help lower the risk of this rare injury as well as other more severe complications.

CONCLUSION

Scrotal injury during neonatal circumcision is rare. While half of the 12 reported patients required exploration in the operating room, the injuries were mostly superficial and did not involve scrotal content, although they often involved extensive resection of penile skin.