Immediate Complications of Elective Newborn Circumcision

Need for Increased Awareness of International Male Circumcision Variations and Associated Complications: A Contemporary Review

Male circumcision is a prevalent, straightforward procedure. Cultural, religious, and/or social factors are the main determinants in the decision to undergo circumcision. The method of circumcision and age of the patient at the time of circumcision varies, dependent on the deciding determinant: cultural or religious tradition, personal hygiene, preventive health, or medical need. While circumcision is a relatively simple operation for a trained medical professional with low rates of adverse events, the safety of the operation varies when performed by non-medically trained (traditional) practitioners. This review aims to inform physicians of international circumcision variations and associated complications and to provide history-taking considerations during the review of the genitourinary system. The review revealed a wide variety in 1) training of practitioners performing circumcisions, 2) methods of circumcision, and 3) sterility during the procedure contributing to differing rates of complications. Findings suggest circumcisions should not be viewed equally, and greater emphasis should be placed on genitourinary history, especially circumcision, with patients from areas where traditional circumcisions are prevalent.

What is the medical evidence on non-therapeutic child circumcision?

Non-therapeutic circumcision refers to the surgical removal of part or all of the foreskin, in healthy males, where there is no medical condition requiring surgery. The arguments for and against this practice in children have been debated for many years, with conflicting and conflicted evidence presented on both sides. Here, we explore the evidence behind the claimed benefits and risks from a medical and health-related perspective. We examine the number of circumcisions which would be required to achieve each purported benefit, and set that against the reported rates of short- and long-term complications. We conclude that non-therapeutic circumcision performed on otherwise healthy infants or children has little or no high-quality medical evidence to support its overall benefit. Moreover, it is associated with rare but avoidable harm and even occasional deaths. From the perspective of the individual boy, there is no medical justification for performing a circumcision prior to an age that he can assess the known risks and potential benefits, and choose to give or withhold informed consent himself. We feel that the evidence presented in this review is essential information for all parents and practitioners considering non-therapeutic circumcisions on otherwise healthy infants and 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.

The Length of Gomco Clamp Timing and Its Effect on Bleeding

BACKGROUND

Bleeding is the most common complication of circumcisions in newborns. Gomco clamps are used to perform neonatal circumcisions. Although a clamp time of 5 minutes is recommended, there is no evidence to support this recommendation.

METHODS

Circumcisions performed by attending physicians from the Division of Pediatric Hospital Medicine at an academic children's hospital were split into 2 groups. Group 1 had a clamp time of 5 minutes. Group 2 did not have a clamp time minimum. Nursing staff examined for bleeding at intervals of 15- and 30-minutes' postprocedure. Bleeding was determined to be significant if pressure and/or a microfibrillar collagen hemostat agent was applied.

RESULTS

The study sample contained 23 physicians who saw a total of 1252 patients: 13 physicians (647 patients) in group 1 and 10 physicians (605 patients) in group 2. The average clamp time in group 2 was 2 minutes, 5 seconds. The estimated percentage of circumcisions that required microfibrillar collagen hemostat application was 5.1% (95% confidence interval [CI], 3.1-8.1) for group 1 and 5.6% (95% CI: 3.5-8.8]) for group 2. Circumcisions that had pressure applied were estimated to be 0.6% (95% CI: 0.2-1.7) for group 1 and 1.3% (95% CI: 0.5-3.1) for group 2. The difference between groups, in both categories, was not statistically significant.

CONCLUSIONS

In this prospective study we evaluated clamp time duration and bleeding outcomes for neonatal circumcision. Clamp time does not appear to have an association with bleeding risk. Providers need not maintain a 5-minute clamp time to decrease postprocedural bleeding.

To wrap or not to wrap: A retrospective review of circumcision dressing and post-procedural bleeding

INTRODUCTION

Bleeding is an infrequent, but important, complication after circumcision. Our aim was to examine postoperative bleeding events after circumcision comparing patients managed with a circumferential wrap to ointment alone.

METHODS

Boys ≤18 years of age who underwent circumcision at a tertiary children's hospital were retrospectively reviewed between 2017 and 2018. Postoperative bleeding was defined by phone calls, clinic or Emergency Department visits, or return to the operating room. Outcomes were examined by univariate association and multivariable modeling.

RESULTS

Of 681 boys undergoing circumcision, 503 (74%) patients received a wrap dressing and 178 (26%) only ointment. There were 28 (4%) patients who had a postoperative bleeding event: 14/503 (2.7%) among wrap dressings and 14/178 (7.8%) among ointment alone (p < 0.01). The majority of events were phone calls related to bleeding (75%). Univariate analysis demonstrated no association between postoperative bleeding and surgeon specialty (p = 0.72), age at circumcision (p = 0.44) or technique type (p = 0.09). After controlling for age, technique type, and surgeon specialty, dressing type remained significantly associated with postoperative bleeding (OR = 2.81, p < 0.01).

CONCLUSION

This single-center, retrospective review found circumferential wrap dressings are associated with a decrease in bleeding events after circumcision.

LEVEL OF EVIDENCE

III - retrospective case-control study.

Management of pain in newborn circumcision: a systematic review

Male circumcision (MC) is one of the most common surgical procedures performed on neonates. In the last decades, there have been consistent advances in the understanding of pain mechanisms in newborns, and analgesia has become a fundamental part of neonatal care. MC is still often performed with inappropriate analgesic methods, and there is still great variability among the various centers about surgical and anesthethic techniques to do it. The purpose of this review is to summarize the findings in the literature about pain management and analgesia during newborn MC. We performed a systematic review of neonatal MC studies published in the last 20 years. The most effective technique appeared to be the combination of pharmacological and non-pharmacological methods of analgesia.Conclusion: Combining local anesthesia with non-pharmacological analgesic strategies appears to be effective preventing procedural pain during MC. However, a standardized protocol for analgesia during MC is yet to be determined. Sensorial saturation appeared to help when used in conjunction with the local anesthesia techniques. What is Known: • Male circumcision is a painful procedure and it is frequently performed with inappropriate analgesic methods. • A gold standard practice in analgesia during male circumcision is still lacking and there is a great variability in the modus operandi between centers. What is New: • The combination of RB + EMLA + sucrose appears to be an analgesic strategy superior to other approaches. • We advocate for the integration of sensorial saturation during male circumcision in order to improve the efficacy of current analgesic practices.

Experience and outcomes for PAs in a neonatal circumcision clinic

OBJECTIVE

To evaluate the outcomes of neonatal circumcision performed by a PA in pediatric urology.

METHODS

A retrospective review was performed of infants evaluated for neonatal circumcision by a single PA in pediatric urology over 30 months. Technique, age and weight at circumcision, presence or absence of genital anomalies, and complications were gathered.

RESULTS

Of the 371 male infants evaluated for neonatal circumcision, 276 underwent the procedure. Complications included retained Plastibell (2.1%), penile adhesions (1.1%), swelling (1.8%), and cosmetic concerns (0.73%). Eighteen unanticipated postprocedure visits occurred-four in the ED and 14 in the outpatient clinic. No acute procedural complications occurred. One patient (0.3%) underwent lysis of penile adhesions at age 19 months.

CONCLUSION

Neonatal circumcisions are commonly performed by nonsurgeons with variable formal circumcision training. These data support that well-trained PAs can perform neonatal circumcisions with low complication rates.