Rates of Complications After Newborn Circumcision in a Well-Baby Nursery, Special Care Nursery, and Neonatal Intensive Care Unit

Serious and Fatal Complications after Neonatal Circumcision

Neonatal circumcision (NNC) is the most frequently performed surgical procedure worldwide and is generally considered safe in Western societies. Deaths attributed to NNC are seldom reported and are mostly explained by lack of adherence to medical standards. We reviewed our emergency department database for circumcision-related emergency admissions. During 2000-2013, 19 previously healthy neonates were admitted for acute complications after circumcision. Four were admitted for bleeding, with hemophilia identified in two cases and von Willebrand disease in one. Eight boys required emergency surgery, three for severe bleeding. Four boys with amputation of the glans underwent immediate surgical reconstruction. One infant was taken to the operating room to remove an obstructing Plastibell ring. Seven boys were admitted to the intensive care unit with severe bleeding or sepsis, three of whom ultimately progressed to hemorrhagic or septic shock. Two of these children died of their complications. We estimate that the annual incidence of severe complications requiring hospitalization after NNC in the Greater Toronto Area was approximately 0.01%, and the incidence of fatalities over the 14-yr review period was approximately 0.0012%. Our results indicate that the risk of serious complications and death as a result of NNC is greater than generally assumed.

Broadening candidate office circumcision patients: A comparison of outcome in children based on age and weight

INTRODUCTION

Office circumcision with a clamp or Plastibell device is often restricted in practice by patient age and size. This is thought to ensure the patient fits appropriately on the restraining device and limit complications.

OBJECTIVE

To compare the outcomes of office circumcision in children ≤3 months of age and ≤5.1 kg in weight to those who do not fit this criterion.

STUDY DESIGN

A retrospective chart review was performed of all office circumcisions in children ≤6 months of age performed in our urology clinic between January 2015-August 2018. Patients were divided into two groups: Group 1 (≤3 months old and ≤5.1 kg) and Group 2 (all others). Patient demographics and circumcision technique were recorded. The number of patients with complications and requiring an intervention related to circumcision were compared between groups, as well as the number of patients requiring unplanned hospital visits. Differences in outcomes were evaluated using Pearson's chi-square test.

RESULTS

A total of 205 circumcisions were performed in Group 1 and 498 circumcisions were performed in Group 2. All circumcisions were performed by either Gomco clamp or Plastibell device with no significant difference in method between groups (p = 0.5). There was no difference in median follow-up between groups (Group 1: 19 days [IQR 14; 34]; Group 2: 19 days [IQR 14; 36]; p = 0.6). There were no significant differences between groups in the number patients with complications or requiring an intervention (p = 0.08 and p = 0.12, respectively). Significantly more patients in Group 2 required an unplanned hospital visit (p = 0.02) (Table). After categorizing those composing Group 2 into three disjoint sets (children >3 months and ≤5.1 kg, or ≤3 months and >5.1 kg, or >3 months and >5.1 kg), no significant difference across all four groups in regards to complications (p = 0.12) or intervention (p = 0.2) was found. There was a significant difference in unplanned hospital visits (p < 0.001).

DISCUSSION

Performing office circumcisions in children outside of age and weight restrictions of ≤3 months and ≤5.1 kg did not significantly increase the risk of complications or need for interventions. Those outside of age and weight restrictions, however, had more unplanned hospital visits. Tailoring parent expectations in this patient group may be needed.

CONCLUSIONS

While we found older and heavier children had more unplanned post-procedural related hospital visits, their rates of overall complications and need for subsequent interventions were not significantly higher than younger and lighter children.

Systematic review of complications arising from male circumcision

Background

Neonatal male circumcision is the most common procedure performed on paediatric patients (Simpson et al., 2014) and one of the most common surgical procedures in the world (American Academy of Pediatrics, 2012).

Methods

A search was conducted for articles about complications arising from male circumcision surgeries by entering the term ‘male circumcision’ into PubMed on June 16, 2020. Six thousand six hundred forty‐one articles published from 1945 to 2020 were found. Seventy‐eight articles were ultimately selected for the systematic review.

Results

The 78 articles selected from the literature search were entered into one of three tables. The first table includes 15 articles pertaining to chart reviews and cohort studies and report complication rates. The second table reports specific complications from 51 case reports and case series, and the third table is a summary from 12 articles regarding physician questionnaires and society recommendations. Additionally, the 78 articles were used to compile a list of 47 specific complications arising from male circumcision surgeries.

Conclusions

Complications from neonatal male circumcisions are common and healthcare providers need to be better informed of the potential complications of the surgery so that they can more effectively counsel their patients about potential risks, likelihood of complications and what can be done to prevent them. While experienced providers who practice in sterile settings have better outcomes with fewer complications, encouraging parents to take into account who is performing their son's circumcision, what was their training, how clean is their practice and how much experience they have and reminding them they have the option to decline the procedure entirely allow the parents to get a more complete picture and play an essential role in the decision‐making process.

Neonatal Circumcision

Neonatal circumcision is one of the most common elective surgical procedures in the United States and globally. This procedure, to remove part of the penile prepuce or foreskin, is done for a variety of personal, social, and medical reasons. There are several proposed benefits, risks, and ethical considerations to discuss with parents before the procedure. Three equally safe and effective methods are used for circumcision, and each uses unique equipment: the Gomco clamp, the Mogen clamp, and the Plastibell device. Choice of technique should be guided by operator training and comfort.

Immediate Complications of Elective Newborn Circumcision

OBJECTIVES

To determine the incidence of immediate complications of elective newborn circumcision in 2 community teaching hospitals.

METHODS

We performed a retrospective chart review of all term neonates who had circumcision performed between August 2011 and December 2014 at 2 community hospitals in New York. Neonatal hospital records and subsequent inpatient and outpatient records were reviewed. We classified complications as minor, intermediate, and major.

RESULTS

Out of a total of 1115 circumcisions, 1064 met inclusion criteria. There were 41 complications (3.9%), all involving hemorrhage. Sutures were used to control hemorrhage in 3 patients (0.3%). Local pressure or application of hemostatic chemical agents controlled bleeding in the remainder of patients. Bleeding was more common with the use of the Gomco clamp than with the Mogen clamp. Circumcisions performed with Gomco clamp represented 73.2% of the total complications compared with 26.8% with the Mogen clamp. There were no injuries to structures outside the prepuce or problems requiring medical treatment after discharge from the neonatal hospitalization.

CONCLUSIONS

The most common immediate complication encountered during an elective neonatal circumcision was bleeding that required only pressure or topical thrombin to achieve hemostasis. Bleeding was more common with the use of the Gomco versus the Mogen clamp. To conclude, our data support the theory that elective infant circumcision can be performed safely in a hospital setting.

Assessment of risk factors for surgical complications in neonatal circumcision clinic

INTRODUCTION

Despite the widespread use of circumcision, there is little understanding regarding risk factors associated with its complications. This investigation assesses potential risk factors contributing to complications of circumcision.

METHODS

A retrospective review of all males who underwent a neonatal circumcision in our institution's pediatric urology clinic between January 2015 and June 2017 was performed. Continuous variables were dichotomized to determine a clinically relevant cutoff value. Multivariate regression analyses were used to identify risk factors for primary outcomes (early/late complications) and secondary outcomes (emergency room [ER] visitation, return to operating room, post-circumcision communications).

RESULTS

A total of 277 patients were identified. The mean age and weight were 28.4 days and 4.3 kg, respectively; 93.1% of cases were elective and 12.3% of patients had comorbidities. Circumcisions were performed using Mogen (61.4%) or Gomco clamps (39.6%) under local anesthesia. Overall, 35 patients experienced complications (12.6%). There were 18 patients (6.5%) with bleeding requiring sutures at time of circumcision. Twenty-six patients (9.4%) experienced long-term complications, with penile adhesions being the majority (84.6%). One (0.4%) of these patients had a Clavien-Dindo 3 complication requiring surgery for a skin bridge that could not be separated. One patient (0.4%) visited the ER due to postoperative bleeding from the circumcised area, which was managed conservatively. Multivariate regression analysis identified weight >5.1 kg as a risk factor for bleeding requiring sutures (odds ratio [OR] 4.145; 95% confidence interval [CI] 1.246-13.799) and long-term complications (OR 3.738; 95% CI 1.356-10.306). No risk factors were identified for other outcomes (return to operating room, ER visitation, post-circumcision email/telephone communications).

CONCLUSIONS

This investigation of neonatal circumcision revealed that patients weighing >5.1 kg may be at higher risk of bleeding and long-term complications, such as adhesions.