Gomco vs. plastibell office circumcision: No difference in overall post-procedural complications and healthcare utilization

Evaluating Safety of Ring Versus Clamp Devices in Neonatal Circumcision: A Meta-Analysis

BACKGROUND

While device-based circumcision is considered non-inferior to traditional dissection, there is no consensus on the efficacy and safety of ring devices in comparison with clamp devices. We aimed to compare the safety outcomes of ring-based versus clamp-based circumcision techniques in neonates.

METHODS

MEDLINE, EMBASE, Scopus, and CINAHL were searched following the Cochrane collaboration (PRISMA guidelines), without language restrictions, to identify relevant randomized controlled trials. Adverse events, bleeding events, infection events, and procedure time were extracted and analyzed from the selected studies.

RESULTS

From 1661 citations, seven trials were included, encompassing 3390 patients. These studies compared ring-based to clamp-based circumcision devices in neonates. No significant difference was found in overall adverse events between the two groups. However, ring devices showed significantly fewer bleeding events compared to clamp devices. Infection events and procedure time were similar for both groups.

CONCLUSIONS

Both ring and clamp devices have similar safety profiles, with ring devices potentially offering a reduced risk of bleeding. A comprehensive understanding of ring-specific complications and cosmetic outcomes is necessary for a more complete evaluation of these circumcision techniques. Our analysis is limited from a lack of detailed examination of ring-specific complications and their impact on cosmetic results. The included studies varied in quality, and some exhibited a risk of bias.

LEVEL OF EVIDENCE

Level IV Treatment Study.

Outcome assessment of office Plastibell circumcision in infants utilizing interactive electronic health record

OBJECTIVE

To assess the outcomes of office-based circumcision performed using Plastibell devices in infants, utilizing the MyChart interactive electronic health record (iEHR) system to monitor the progress and identify potential complications.

METHODS

This is a prospective cohort study conducted between March 2021 to April 2022 on all infants undergoing office based Plastibell circumcision. Parents were encouraged to submit concerns via MyChart and to submit photos if the ring has not fallen by post-procedure day 7. Telehealth or in-person clinic visits were then made accordingly. Postoperative complications were collected and compared with existing literature.

RESULTS

Of the 234 consecutive infants, the average age was 33 days (9-126 days) and the average weight was 4.35 kg (2.5-7.25 kg). A total of 170 parents (73%) responded to MyChart messages. Fourteen (6%) complications necessitating local intervention were identified: excessive fussiness (1), bleeding (2), ring retention (11) including 2 incomplete skin division requiring repeat dorsal block and surgical completion, fibrinous adhesion (3), and proximal ring migration (6). The photo and messages submitted through iEHR facilitated early patient return for intervention. Additionally, 17 parents submitted photos which were expected postprocedural findings and were reassured through iEHR, thus omitting unnecessary return visits. The 2 patients with incomplete skin division occurred early in the series using the included cotton ties. Subsequent procedures were performed with double 0-Silk ties (n = 218) without similar finding.

CONCLUSION

The interactive utilization of iEHR communication in the post-circumcision period identified proximal bell migration and bell trapping, allowed earlier intervention and reduced complications.

LEVEL OF EVIDENCE

Level 1.

The effect of inpatient versus outpatient location on postoperative healthcare utilization after neonatal circumcision

BACKGROUND/PURPOSE

Neonatal circumcision is a common pediatric procedure performed in both the inpatient and outpatient setting. We aimed to determine if procedure location affected 30-day post-procedure healthcare utilization rates, inpatient length of stay (LOS), and amount charged.

METHODS

We performed a retrospective cohort study comparing 30-day postoperative healthcare utilization (emergency department (ED) visits, office visits, readmissions) of full-term infants who underwent an outpatient versus inpatient (same admission as birth) circumcision from 2015 to 2020. Statistical analyses included Chi-square tests, multivariable adjusted logistic regression models when appropriate.

RESULTS

3137 infants were included, 1426 (45.5%) had an outpatient circumcision, 1711 (54.5%) an inpatient. Outpatient had similar overall healthcare utilization rates as inpatients (5.7% vs. 5.6%, p = 0.933). The number of ED visits (1.5% vs 0.8%, p = 0.055), office visits (4.5% vs. 5.1%, p = 0.437), and readmissions (0.2% vs. 0.0%, p = 0.058) were not significantly different. Infants with inpatient circumcisions had longer LOS after adjusting for age, ethnicity and delivery type (Cesarean versus vaginal) with an incident rate ratio of 1.97 (95% confidence interval 1.84-2.11, p<0.001). Outpatient circumcision resulted in average charges of $372 more than inpatient.

CONCLUSIONS

Outpatient circumcision has a minimal effect on healthcare utilization rates but lead to a shorter hospital stay following birth and increased charge.

STUDY DESIGN

Retrospective LEVEL OF EVIDENCE: III.