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.

Technical nuances of the concealed penis repair.

Circumcision is commonly performed but anatomic variants occur and can affect outcomes if not addressed properly. The combination of concealed penis and penoscrotal webbing is fairly common and presents across a spectrum of severity. If not repaired, this can result in a buried penis that can cause penile adhesions, wound healing concerns, and make the penis appear shorter secondary to a retracted position. We present our technique that is reproducible and highly successful in addressing both of these concerns. The paraphimotic band approach is performed more commonly and is able to reliably correct webbing and concealment without an incision at the penoscrotal junction. When more severe defect is present, a Y shaped incision is made at the penoscrotal junction to mobilize skin flaps to correct the deficit. In our cohort of 885 patients, 736 were corrected using the paraphimotic band technique while 149 underwent a complex scrotoplasty. None of the patients required a secondary surgery for complications.

Comparative analysis of two methods in circumcision: a new disposable device versus classic sleeve technique.

PURPOSE: Circumcision is the most common surgical procedures performed in males. Medical circumcision is recommended for diseases such as phimosis, paraphimosis, balanoposthitis and common urinary tract infections, although there is no exact indication. Conversely, Jewish and Muslim individuals commonly undergo circumcision regardless of medical necessity. Circumcision devices are designed to shorten surgery time, achieve an aesthetic appearance and ensure safe surgery. The aim of this study is to evaluate the effectiveness of the NeoAlis clamp, a disposable circumcision device, by comparing it with the sleeve technique in children. MATERIALS AND METHODS: Between 2017 and 2023, retrospective evaluation of 2626 patients who underwent circumcision using either the NeoAlis clamp (group 1) or the sleeve technique (group 2) was conducted. Operation time, results, cost, complications were compared between the two groups. RESULTS: The study encompassed 2626 patients who fulfilled the inclusion criteria. Group 1 comprised 2403 patients, whereas Group 2 consisted of 223 patients. The overall complication rate, as denoted by n = 47, was 1.7%. Group 1 operation time was shorter than group 2. Bleeding, the most feared complication in the early period, was higher in the second group. No statistically significant difference was observed between the two groups regarding cost comparison. CONCLUSION: The primary concern during circumcision is to avoid complications related to general anesthesia in newborns and infants. The use of disposable ring devices has been facilitated by the shorter operation time and the absence of the need for sutures when performing circumcision under local anesthesia. However, knowledge of advanced surgical circumcision techniques is necessary in cases of bleeding and inappropriate ring placement.

Plastic Clamp Versus Conventional Surgical Dissection Technique in Pediatric Circumcision: A Systematic Review and Meta-Analysis.

PURPOSE: Phimosis is a common condition of the urinary system in children and often requires surgical treatment. However, the optimal method of circumcision for children has not been determined. We conducted a systematic review and meta-analysis to compare the safety and effectiveness of plastic clamp with conventional surgical circumcision in pediatric circumcision. METHODS: A literature search was carried out to compare the plastic clamp and conventional dissection technique in the pediatric population. The following search terms were used: "circumcision", "plastic clamp", "conventional", "plastibell", "children" and etc. Meta-analysis was used to pool and evaluate variables such as operative time, blood loss, wound infection, bleeding, edema, and total postoperative complications. RESULTS: The plastic clamp technique (PCT) was used in 10,412 of the 17,325 participants in the nine studies, while the conventional surgical dissection technique (CST) was used on 6913 patients. When compared to the CST approach, the PCT approach resulted in shorter operative times (mean difference (MD) -17.48, 95% CI -22 to -12.96; P < 0.001), less blood loss (MD -4.25, 95% CI -7.75 to -0.77; P = 0.02), and a higher incidence of postoperative edema (OR 2.33, 95% CI 1.34 to 4.08; P = 0.003). However, no significant difference was found in the incidence of postoperative complications, including wound infection and bleeding between PCT and CST. CONCLUSIONS: PCT is a safe and time-saving option in the pediatric population. However, this method appeared to have a significant greater rate of postoperative edema.

Foreskin neurovascular structure: A histological analysis comparing 0-3 years and 6-11 years children.

BACKGROUND: Circumcision is a surgical operation that is frequently performed throughout the world due to religious, cultural, and medical reasons. The best age for circumcision is still debatable, with different procedures depending on geography, culture, and surgeon preference. OBJECTIVE: This study aims to immunohistochemical examination using S100 staining and histologically evaluate the neurovascular structures in foreskin samples obtained from children aged 0-3 years and 6-11 years. The goal is to provide guidance in determining an appropriate age for circumcision based on these data. STUDY DESIGN: Concerns regarding potential effects on glans sensitivity and sexual function led to the investigation and comparison of sensory innervation in the foreskin of children aged 0-3 and 6-11 years, a total 54 samples, divided into pre-phallic (0-3 years) and post-phallic (6-11 years) groups, were examined. The mean number of Meissner and Pacinian corpuscles, Ruffini endings, free nerve endings and the diameters of arteries were investigated. RESULTS: Our findings show that compared to the 6-11 age group, the 0-3 age group had considerably lower sensory innervation in terms of, Meissner's corpuscles, Pacinian corpuscles, Ruffini endings and free nerve endings. Additionally, the diameter of arteries was noticeably smaller in the 0-3 age group. CONCLUSIONS: In conclusion, this study supports the idea that circumcision performed in the early years of life may be associated with less adverse effects on neurovascular structures.

Wound Healing and Cosmetic Outcomes in Neonatal Circumcision Using Three Different Techniques.

BACKGROUND: Circumcision of a male child is an integral part of some African cultures. An ideal technique of neonatal circumcision should be simple, safe and heal satisfactorily with good cosmetic appeal. The aim was to compare conventional dissection (CD), Plastibell (PB) and Gomco (GM) techniques of circumcision in neonates in terms of wound healing, wound healing complications, cosmetic outcome and parental satisfaction. MATERIALS AND METHODS: A total of 144 male neonates were randomised into three study groups: CD, GM and PB groups. All procedures were performed under local anaesthesia as day case. Superficial wound healing was assessed on the 7 th post-operative day. The cosmetic outcome of the three techniques was assessed by a plastic surgeon and the parents using a 4-point Likert scale on the 4 th post-operative week. RESULTS: The three groups were comparable in terms of age ( P = 0.207) and weight ( P = 0.098) at circumcision. There was satisfactory wound healing in 48 (100%) patients in the GM group, compared to 47 (97.8%) in the CD group and 45 (93.8%) in the PB group ( P = 0.324). Wound healing complications were recorded in seven patients, 1 (2.1%) in the CD group with wound infection, 5 (10.4%) in the PB group with moderate pain despite the use of analgesia and 1 (2.1%) patient with skin bridge in the CD group. The plastic surgeon and the parents rated the cosmetic outcome of CD higher than the other two techniques. CONCLUSION: There is no significant difference in superficial wound healing amongst the three circumcision techniques. The cosmetic outcome of CD was significantly better than that of GM and PB circumcisions.

Megameatus intact prepuce variant reconstruction: Long-term outcomes and comparison to post-circumcision hypospadias repair.

BACKGROUND: Megameatus intact prepuce (MIP) variant is considered a surgical challenge with associated high complication rates. It is usually diagnosed and corrected only after neonatal circumcision, which is discouraged in non-MIP hypospadias. OBJECTIVE: In order to determine whether the features of the MIP variant or the performance of a secondary reconstruction following circumcision comprise the cause of higher complication rates, we now compared the results of post-circumcision MIP hypospadias repair to the results of children who underwent repair of non-MIP hypospadias following neonatal circumcision. STUDY DESIGN: Reoperation rates of children operated for hypospadias repair following neonatal circumcision between 1999 and 2020 were compared between those with MIP and those with classic non-MIP hypospadias. RESULTS: In total, 139 patients who had undergone neonatal circumcision underwent surgical reconstruction at a mean age of 13 months. Sixty-nine had classic hypospadias and 70 had the MIP variant. The median follow-up was 10 years (interquartile range 6,13). The classic group had a higher rate of meatal location below the corona compared to the MIP variant group (53 % vs. 28 %, respectively, p = 0.002). The reoperation rate was comparable for the two groups (32 % vs. 27 %, p = 0.58, Table). Univariate analysis for the MIP hypospadias group showed no association between reoperation and the initial patient characteristics, while a higher probability of reoperation was demonstrated in the presence of ventral curvature (odds ratio 3.5, p = 0.02), and a higher grade of hypospadias (odds ratio 3.3, p = 0.03 for meatal location lower than the coronal sulcus) in the non-MIP group. DISCUSSION: The limitations of our work include its retrospective design wherein the patients' characteristics, including classification as MIP vs. non-MIP, are derived from medical records. More patients in the non-MIP group were documented to have penile curvature. The non-MIP group was composed of more patients with meatal location under the coronal sulcus, a factor which may increase the rates for reoperation in that group. Still, with the comparison of the largest reported cohort of circumcised MIP with circumcised non-MIP patients together with an extended follow-up period, we believe that we present strong evidence of the possible role of previous circumcision in the surgical challenge of reconstructing MIP hypospadias. CONCLUSIONS: Reoperation rates in MIP hypospadias are high but similar to those of classic hypospadias, both following circumcision, suggesting that circumcision, rather than the unique features of the variant, is the cause for complications.

Low-dose caudal versus dorsal penile nerve block for postoperative analgesia after circumcision: a randomized comparative study.

INTRODUCTION: Paediatric male circumcision is a painful surgical procedure, which is usually carried out under general anaesthesia. Regional analgesic techniques, including dorsal penile nerve block (DPNB) and caudal nerve block (CNB), are superior to opioid and non-opioid systemic analgesia for postoperative pain control after circumcision. MATERIAL AND METHODS: The purpose of our study was to compare the efficacy, duration of postoperative analgesia, and complications of DPNB, CNB, and the combination of 2 blocks. Eighty-one male patients aged from 3 to 12 years scheduled for circumcision were distributed into 3 groups, each consisting of 27 patients; group 1 (DPNB group), group 2 (CNB group), and group 3 for combined blockade. This study compared the 3 groups in terms of intraoperative vital signs: heart rate and blood pressure, postoperative Wong-Baker score, and complications (nausea, vomiting, pruritus, urinary retention, and constipation). RESULTS: The intraoperative haemodynamics did not differ between the 3 groups of the study. There is significant difference in the Wong-Baker scale postoperatively at 1, 3, and 24 hours, being significantly less in the CNB group and combined blockade group than in the DPNB group, but there was no significant difference between the CNB group and the combined blockade group. The incidence of complications showed no significant intergroup difference, except for urinary retention being lower with DPNB. CONCLUSIONS: Both caudal and combined blockade were superior to DPNB for intraoperative and postoperative analgesia after circumcision. CNB and combined blockade was associated with significantly higher incidence of urinary retention compared to DPNB. Also, there was no additional benefit to the analgesic efficacy from combining both blocks.

Frenulum Protection Technique in Disposable Circumcision Suture Device for Adult Males.

PURPOSE: To evaluate the efficacy of frenulum protection technique of the disposable circumcision suture device (DCSD) in adult males. MATERIALS AND METHODS: Atotal of 53 adult males were diagnosed with redundant prepuce and underwent circumcision with DCSD using frenulum protection technique. The main preoperative and postoperative measure of the length of penile frenulum was evaluated. Other data such as edema rate, intraoperative blood loss, operation time, postoperative pain, staple falling off time, incision infection rate, and evaluation of satisfaction rate with penis appearance were documented in the study. RESULTS: There was no significant difference in preoperative and postoperative frenulum length for each patient. The mean length of the penile frenulum before and after surgery was 2.25 ± 0.36 cm and 2.23 ± 0.39 cm, respectively (p = .31). The rate of frenulum length preservation was 100%. All the patients had no excessive resection of the frenulum and no serious complication happened after surgery. The satisfaction rate of postoperative penis appearance from patients' evaluation was 98.1% (52/53). CONCLUSION: The frenulum protection technique was simple and operable, which could help the operator to accurately identify the most distal position of the frenulum and retain a sufficient length of frenulum during DCSD circumcision.

Comparative study of mechanical vs. manual circumcision in the pediatric population: An alternative to the conventional technique? / Estudio comparativo entre circuncisión mecánica y manual en población pediátrica: ¿una alternativa a la técnica convencional?

OBJECTIVE: Circumcision is one of the most common surgical procedures in pediatric surgery. Even though manual suture (MANS) is regarded as the gold standard technique, easy-to-use mechanical suture (MECS) devices have been recently developed, with better postoperative results in the adult population. The objective of our study was to compare the operating time and incidence of postoperative complications between both techniques in our environment. MATERIALS AND METHODS: A retrospective study of patients undergoing circumcision in our institution from October 2021 to December 2022 was carried out. Operating time and complications observed in the first 14 postoperative days (edema, hematoma, dehiscence) were analyzed according to the technique used (MANS vs. MECS) and patient age (< 12 and ≥ 12 years old). RESULTS: 173 patients (147 MANS, 26 MECS) were included. Mean operating time was significantly lower in MECS patients, both in patients < 12 years old (16 min vs. 10 min, p= 0.002) and in patients ≥ 12 years old (23 min vs. 12 min, p< 0.001). Regarding complications, MECS patients ≥ 12 years old had a lower rate of suture dehiscence (23.5% vs. 0%, p< 0.001), with no significant differences in the younger group. CONCLUSIONS: MECS circumcision is a simple and effective technique involving shorter operating times than MANS circumcision, regardless of age. It has a lower rate of complications in older children (≥ 12 years), which means it stands as a valid alternative to the conventional technique.

OBJETIVOS: La circuncisión es una de las intervenciones quirúrgicas más realizadas en cirugía pediátrica. Aunque la técnica con sutura manual (SMAN) se considera el gold standard, recientemente se han desarrollado dispositivos de sutura mecánica (SMEC) de fácil manejo y con mejores resultados postoperatorios en la población adulta. El objetivo de nuestro estudio es comparar el tiempo quirúrgico y la incidencia de complicaciones postoperatorias entre ambas técnicas en nuestro ámbito. MATERIAL Y METODOS: Estudio retrospectivo de pacientes circuncidados en nuestro centro entre octubre 2021 y diciembre 2022. Se analizó el tiempo quirúrgico y las complicaciones observadas en los primeros 14 días postoperatorios (edema, hematoma, dehiscencia), en función de la técnica empleada (SMAN vs SMEC) y la edad de los pacientes (< 12 y ≥ 12 años). RESULTADOS: Se incluyeron 173 pacientes (147 SMAN, 26 SMEC). El tiempo quirúrgico medio fue significativamente menor en los pacientes con SMEC, tanto en < 12 años (16 min vs. 10 min, p= 0,002) como en ≥ 12 años (23 min vs 12 min, p< 0,001). En cuanto a las complicaciones, los pacientes con SMEC del grupo ≥ 12 años presentaron menor tasa de dehiscencia de sutura (23,5% vs 0%, p< 0,001), sin observarse diferencias significativas en el grupo de menor edad. CONCLUSIONES: La circuncisión con SMEC es una técnica sencilla y eficaz, que precisa un tiempo quirúrgico más reducido que la sutura manual, independientemente de la edad. Presenta menor tasa de complicaciones en los niños de mayor edad (≥ 12 años), por lo que se plantea como una alternativa válida a la técnica clásica.

Gomco circumcision in the office in patients heavier than 5.5 Kg and/or older than 3 months.

INTRODUCTION: Although most pediatric urologists do not perform clamp circumcisions in boys older than 3 months or heavier than 5.5 kg, there are no universally accepted guidelines on the optimal patient age or weight. OBJECTIVE: To compare outcomes of office circumcision within and outside these traditional patient parameters. METHODS: This is a retrospective review of circumcisions performed by a single surgeon from 2019 to 2022. Demographics reviewed include age and weight at time of circumcision, gestational weeks at birth, as well as post-procedure: bleeding, planned and unplanned visits, adhesions/concealment, and interventions related to the circumcision. "Active Bleeding" was defined as bleeding occurring after discharge requiring intervention with pressure, sutures, or cautery. "All Bleeding" included Active Bleeding, and cases where bleeding was controlled at home with pressure, stopped by the time of arrival at clinic or emergency department, and immediate bleeding after circumcision controlled before discharge. RESULTS: During the study period, 773 Gomco circumcisions were performed. A total of 603 patients (78%) had post-procedure evaluation 2 weeks after circumcision. 574 patients (74%) were less than 5.5 kg and 199 (26%) over. Only age corrected for gestation was used in the study: 658 (85%) were younger than 3 months and 115 (15%) older. There was no significant difference in Active Bleeding based on weight (p = 0.3819) or age (p = 0.2798), and no difference in All Bleeding based on weight (p = 0.2072). There was a significant difference (p = 0.0258) in All Bleeding based on age. There was also a significant difference in unexpected visits based on weight (p = 0.0258) and age (p = 0.0131). With regards to adhesions, there was no statistical significant differences when comparing weight or age. However, older and heavier boys had significantly more concealment (5% vs <1%). DISCUSSION: Our study showed Active Bleeding rates 0.5-0.9% higher in the older and heavier group, although the difference did not reach statistical significance. We found a significantly increased rate of unexpected post-procedure visits of around 3.5-4.7% in those patients older than 3 months and heavier than 5.5 kg. Also, post -procedure concealment was significantly increased in the older and heavier boys. Modifications of the dressing for high risk groups could reduce the risk of bleeding, and efforts on pre-circumcision education of the families might ameliorate unexpected visits. Exlcuding patients with hidden penis or performing penoscrotal skin tacking at the time of the gomco circumcision could decrease concealment rates in the higher risk patients. CONCLUSIONS: Gomco clamp circumcision is safe in patients over 5.5 kg and older than 3 months, with a less than 1% higher risk of bleeding, which in the current study was controlled without the need for general anesthesia or transfusions. Broadening the inclusion criteria for office clamp circumcisions could reduce costs and make the procedure available to patients who cannot afford to have the surgery under general anesthesia.

Severe penile fibrotic reaction secondary to a non-absorbable suture: a case report. / Reacción fibrótica peneana severa secundaria a una sutura no absorbible: reporte de un caso.

INTRODUCTION: Circumcision is one of the most frequent urological surgical procedures in the pediatric population globally. Complications, although rare, can be severe. CLINICAL CASE: We present the case of a Senegalese 10-year-old male patient who had undergone ritual circumcision in his early childhood and developed a progressive circumferential tumor in the penile body with no further associated symptoms. Surgical exploration was carried out. A fibrotic-looking penile ring, which was interpreted as an injury secondary to the non-absorbable suturing material used in the previous surgery, was identified. The tissue involved was removed, and on-demand preputioplasty was conducted. Due to technical limitations, the resected tissue could not be analyzed, which means diagnosis could not be histopathologically confirmed. The patient had a favorable progression. CONCLUSIONS: This case demonstrates that the medical personnel in charge of performing circumcisions should be adequately trained in order to prevent severe complications.

INTRODUCCION: La circuncisión es uno de los procedimientos quirúrgicos urológicos más frecuentemente realizados en la población pediátrica en todo el mundo. Las complicaciones, aunque infrecuentes, pueden ser graves. CASO CLINICO: Presentamos el caso de un paciente varón senegalés de 10 años que fue sometido a una circuncisión ritual en la primera infancia y que desarrolló una tumoración circunferencial progresiva en el cuerpo del pene sin otra sintomatología asociada. Se realizó una exploración quirúrgica y se identificó un rodete peneano de aspecto fibrótico que se interpretó como lesión secundaria al material de sutura no absorbible utilizado en la cirugía anterior. Se realizó una exéresis del tejido afecto y una prepucioplastia a demanda. Por limitaciones técnicas, no se pudo analizar el tejido resecado y por tanto no se pudo confirmar histopatológicamente el diagnóstico. El paciente evolucionó favorablemente. CONCLUSIONES: Este caso pone de manifiesto la necesidad de formar adecuadamente al personal que realiza la circuncisión para evitar complicaciones severas.

Lack of Medicaid Coverage of Routine Newborn Circumcision Leads to Increased Operative Circumcisions, Chordee Procedures, and Balanitis.

OBJECTIVE: To compare proportions of newborn circumcisions, operative circumcisions, chordee procedures, and cases of balanitis in states where Medicaid covers newborn circumcision (covered states) versus states that do not (noncovered states) using the pediatric health information system database. METHODS: A retrospective review of pediatric health information system data was conducted from 2011 to 2020. The proportions and median ages of newborn circumcision current procedural terminology (CPT 54,150, 54,160), operative circumcision (CPT 54,161), chordee (CPT 54,360), and balanitis (ICD-9 607.1, ICD-10 N48.1, N47.6) were compared in covered versus noncovered states. RESULTS: A total of 118,530 circumcisions were reviewed. Covered states had significantly higher proportions of circumcision overall (9.7% vs 7.1%, P < 0.0001). Noncovered states had significantly higher proportions of Medicaid-covered operative circumcisions (54.9% vs 47.7%, P < 0.0001). Compared to covered states, noncovered states had significantly higher median ages of all types of circumcisions. Noncovered states also had higher numbers of balanitis cases and double the incidence of balanitis compared with covered states. The median age of chordee (1.07 vs 0.79 years, P < 0.0001) and proportion of chordee repairs (15.2% vs 12.9%, P < 0.0001) were also significantly higher in noncovered states. CONCLUSION: The lack of Medicaid coverage of circumcision increases the number of foreskin procedures done in the operating room. In addition, in states without Medicaid coverage of circumcision, there is an increased burden of disease related to the foreskin. These findings represent a need to further investigate the costs of healthcare associated with Medicaid coverage of circumcision or the lack thereof.

[Development of circumcision rates in Germany since the approval of ritual circumcision : A population-based analysis from 2013 to 2018]. / Entwicklung der Zirkumzisionszahlen in Deutschland seit Billigung der rituellen Beschneidung : Eine bevölkerungsbezogene Analyse von 2013 bis 2018.

INTRODUCTION: The religious and cultural circumcision of male infants in Germany is controversially discussed. After the passing of the religious circumcision bill in 2012, an increase of infant circumcisions without medical indication was feared. The aim of this study was to analyze the development of the circumcision case numbers. MATERIALS AND METHODS: We used the research database of the German Institute for Applied Health Research with a representative anonymous sample of 4.9 million insured persons to estimate the annual circumcision numbers in Germany from 2013-2018. We stratified the data according to age (< 18 vs. ≥ 18 years). The number of male adolescents in the study period was taken from the database of the German Federal Statistical Office. RESULTS: In the study period, 673,819 circumcisions were performed. From 2014, there was a significant decrease in the number of cases across all age groups (p = 0.049). Thereby, circumcisions in minors significantly increased (p = 0.002) and procedures in adults significantly decreased (p = 0.01) during the entire study period. The number of male minors increased by 4% from 6,709,137 (2013) to 6,992,943 (2018). The corresponding population-based number increased from 7.5 circumcisions per 1000 minors in 2013 to 8 in 2018 (p = 0.037). CONCLUSIONS: After the passage of the circumcision bill in 2012, there was a significant increase of circumcisions in the age group of < 18 years in Germany. A major limitation of our study is that presumably many ritual circumcisions might not be provided within the health care system.

Reducing costs of referrals for non-neonatal circumcision in Florida Medicaid population.

INTRODUCTION: Florida Medicaid will only cover a non-neonatal circumcision if it meets the specified Medicaid medical indications or the patient is 3 years or older and has failed a 6-week trial of topical steroid therapy (TST). Referral of children who do not meet guideline criteria results in unnecessary costs. OBJECTIVE: We sought to evaluate the cost savings if the initial evaluation and management were performed by the primary care provider (PCP) with referral to a pediatric urologist of only those males meeting the guidelines. STUDY DESIGN: An institutional review board-approved retrospective chart review of all male pediatric patients ≥3 years of age presenting for phimosis/circumcision from September 2016 to September 2019 at our institution was performed. Data extracted included (1) presence of phimosis, (2) presence of medical indication for circumcision on presentation, (3) circumcision performed without meeting criteria, (4) use of topical steroid therapy prior to referral. The population was stratified into 2 groups based on whether criteria were met at the time of referral. Those with a defined medical indication on presentation were excluded from cost analysis. Cost savings were based on costs incurred for PCP visit(s) versus initial referral to a urologist using estimated Medicaid reimbursement rates. RESULTS: Of the 763 males, 76.1% (581) did not meet Medicaid criteria for circumcision on presentation. Of these, 67 had a retractable foreskin with no medical indication, 514 had phimosis with no documented topical steroid therapy (TST) failure. A savings of $95,704.16 would have been incurred if the PCP initiated the evaluation and management and referred only those who met the criteria (Table 2). DISCUSSION: These savings would only be feasible if there were proper education of PCPs in the evaluation of phimosis and the role of TST. Limitations are assuming cost savings in the setting of well-educated pediatricians for clinical exam and believing they are aware of and comply with the guidelines. CONCLUSIONS: Education of PCPs on the role of TST in phimosis and current Medicaid guidelines may reduce unnecessary office visits, health care costs, and family burden. The most impactful method to reduce the cost of non-neonatal circumcision would be for states that do not currently cover neonatal circumcision to acknowledge affirmative policies from the American Academy of Pediatrics regarding circumcision and realize the cost savings associated with providing coverage for neonatal circumcision and reducing significantly the number of more expensive non-neonatal circumcisions.

Circumcision and Sexual Medicine.

INTRODUCTION: Male circumcision is one of the most frequently performed and debated urological procedures due to its possible implications for sexual health. OBJECTIVES: The objective of this article is to review the literature on male circumcision and reconcile the scientific evidence to improve the quality of care, patient education, and clinician decision-making regarding the effects on sexual function of this procedure. METHODS: A review of the published literature regarding male circumcision was performed on PubMed. The criteria for selecting resources prioritized systematic reviews and cohort studies pertinent to sexual dysfunction, with a preference for recent publications. RESULTS: Despite the conflicting data reported in articles, the weight of the scientific evidence suggests there is not sufficient data to establish a direct association between male circumcision and sexual dysfunction. CONCLUSION: This review provides clinicians with an updated summary of the best available evidence on male circumcision and sexual dysfunction for evidenced-based quality of care and patient education.

Post-circumcision urethrocutaneous fistulae: presentations, repairs and outcomes in a tertiary centre.

Background: Circumcision is regarded as the most common surgical procedure world over. It is also perceived to be a simple and safe procedure; however, it could be fraught with major urological complications such as urethrocutaneous fistula (UCF). Repair of these fistulae poses a great reconstructive challenge to the paediatric surgeon/urologist with varied outcomes. Aim: We seek to review the presentations, repair and outcome of post-circumcision UCFs managed in a tertiary centre. Patients and Methods: This is a retrospective review of all the consecutive cases of repaired post-circumcision UCFs in Nnamdi Azikiwe University Teaching Hospital, Nnewi, South-East Nigeria, over a period of 9 years (January 2012-December 2020). Data on demography, size of fistula, type of repair and outcome were retrieved from the Records Department and patients' case notes and were analysed using SPSS (version 22, Chicago, Illinois). Results: A total of 22 boys had post-circumcision UCF repair within the period, and they were aged between 2 weeks and 108 months with a median age of 4 months at presentation and aged between 8 months and 144 months with a median age of 24 months at the time of surgery. Circumcisions were by freehand technique in 21 (95.5%). Nurses performed most of the circumcisions in 19 (86.4%), and most of the circumcisions were performed in private hospitals 7 (31.8%), maternity homes 3 (13.6%) and general hospitals in 10 (45.5%) each, respectively. Most 17 (77.3%) fistulae were coronal, and the size of defect ranged from 1 mm to 10 mm. The most commonly employed technique of repair was simple closure in 16 (72.2%). Meatal stenosis and re-fistulation occurred in 2 (9.1%) and 4 (18.2%), respectively. Only two (12.5%) required reoperation. There was no relationship between the size of defect and re-fistulation, P = 0.377. Conclusion: Majority of the Post-circumcision urethrocutaneous fistulae were from free hand technique of circumcisions . These were performed mostly by nurses in general, private hospitals and maternity homes. Hence, there is a need to ramp up training of providers of neonatal circumcision in our environment. Most UCF in children could be repaired with simple closure technique reinforced with dartos flap.

Foreskin restorers: insights into motivations, successes, challenges, and experiences with medical and mental health professionals - An abridged summary of key findings.

Demographically diverse surveys in the United States suggest that 5-10% of non-voluntarily circumcised American males wish that they had not been circumcised. Similar data are unavailable in other countries. An unknown proportion of circumcised males experience acute circumcision-related distress; some attempt to regain a sense of bodily integrity through non-surgical foreskin restoration. Their concerns are often ignored by health professionals. We conducted an in-depth investigation into foreskin restorers' lived experiences. An online survey containing 49 qualitative and 10 demographic questions was developed to identify restorers' motivations, successes, challenges, and experiences with health professionals. Targeted sampling was employed to reach this distinctive population. Invitations were disseminated to customers of commercial restoration devices, online restoration forums, device manufacturer websites, and via genital autonomy organizations. Over 2100 surveys were submitted by respondents from 60 countries. We report results from 1790 fully completed surveys. Adverse physical, sexual, emotional/psychological and self-esteem impacts attributed to circumcision had motivated participants to seek foreskin restoration. Most sought no professional help due to hopelessness, fear, or mistrust. Those who sought help encountered trivialization, dismissal, or ridicule. Most participants recommended restoration. Many professionals are unprepared to assist this population. Circumcision sufferers/foreskin restorers have largely been ill-served by medical and mental health professionals.

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.