Neonatal Circumcision Research Articles

Repair-oriented categorization of circumcision urethral injury in Benin city, Nigeria

BackgroundThe wide spectrum of circumcision urethral injury/fistula makes selection of appropriate repair methods challenging in sub-Saharan Africa. This paper reports on the outcome of repair-oriented categorization in a Nigerian center. MethodsConsecutive children presenting with circumcision urethral injury/fistula at the University of Benin Teaching Hospital were categorized into six repair-oriented groups in 2009–2011. Results21 children were treated. Except in 2 cases, early neonatal circumcision at an average age of 8 days (range 4–14 days) had been performed, the majority (52%) by paramedics at home. Categories of injury/fistula based on severity ranged from isolated fistula (38%) which required fistula excision and repair (category A) to severe ventral urethral/coronal/glanular avulsion (29%) which required urethral plate tubularization/ventral penile reconstruction (category F). Overall, successful first-stage repair was achieved in 19 (91%) children. Meatal stenosis (2), urethral stricture (1), which responded to serial dilatation, and minor urinary leakage (2), which was closed at second stage, were the post-repair complications. Adequate penile size and straight penis on erection were achieved in all cases. Cosmetic outcome was excellent in 16 (76%) cases, good in 4 (19%) and fair in 1 (5%). ConclusionRepair-oriented categorization, which could be useful to practitioners in similar settings, was satisfactory in managing urethral injury/urethrocutaneous fistula.

Pediatric sutureless circumcision without using skin closure adhesives: a new technique for poor setting.

INTRODUCTION ircumcision is one of the most common procedures performed worldwide. Neonatal circumcision is mostly done due to social, cultural, personal, and religious reasons.(1) cised.(2,3) World Health Organization has introduced medical male circumcision as a human (4) Nevertheless, inadequate funding and concerns about the safety of the surgical procedure, as well as diverse tance to circumcision. Many various methods can be used for circumcision, but the two commonly used are the sleeve technique and use of the Plastibell® device. With the sleeve technique, the skin edges are approximated by interrupted stitches using non-absorbable suture materials. The main disadvantage of this method is unsatisfactory cosmesis.(5,6) On the other hand, proximal migration of the Plastibell® ring, due to use of an inappropriate size, may occur causing serious penile injury.(7) For the skin closure in sleeve technique, the long chain derivatives of cyanoacr-

A New Simulation Model for Teaching Neonatal Circumcision.

Objective: The objective of this paper is to present a new model for simulation of neonatal circumcision and to present data verifying the utility of the model as a tool in residency surgical-skills training. Methods: Forty-seven academic obstetricians at the March 2010 CREOG/APGO Annual Meeting watched an instructional DVD, assembled the model and performed a circumcision on the model using their usual techniques. After performing the circumcision, they completed a brief survey about the model. Results: Of the 47 responding physicians, 42 reported that the model simulated infant circumcision well. All 47 physicians felt that residents would benefit from practicing on this model before performing an actual circumcision and were at least considering adding the model to their residency training program. The instructional DVD was found to be helpful in teaching the assembly of the model by 34 of the 40 physicians who viewed it. Discussion: Overall, respondents found this model of circumcision to be a promising tool in training residents outside the procedure room. The model is inexpensive, easily constructed with common materials, and allows trainees to practice neonatal circumcisions in a safe setting.

Epidemiology of Circumcision-Related Mortality in Iran: A 10-year Survey.

Epidemiology of Circumcision-Related Mortality in Iran: A 10-year Survey.

The Cost of Medicaid Savings: The Potential Detrimental Public Health Impact of Neonatal Circumcision Defunding

Objective. To project the increased incidence of HIV and subsequent costs resulting from the expected decreased rate of circumcision due to Medicaid defunding in one southeastern state. Methods. Using 2009 South Carolina (SC) Medicaid birth cohort (n = 29, 316), we calculated expected heterosexually acquired HIV cases at current circumcision rates. To calculate age/race/gender specific HIV incidence rates, we used 2009 South Carolina Department of Health and Environmental Control reported gender and race specific HIV cases, CDC reported age distribution of HIV cases, and 2009 S.C. population data. Accounting for current circumcision rates, we calculated the change in incidence of heterosexually acquired HIV assuming circumcision provides 60% protection against HIV transmission to males and 46% protection against male to female transmission. Published lifetime cost of HIV was used to calculate the cost of additional HIV cases. Results. Assuming Medicaid circumcision rates decrease from current nationally reported levels to zero secondary to defunding, we project an additional 55 male cases of HIV and 47 female cases of HIV among this birth cohort. The total cost discounted to time of infection of these additional HIV cases is $20,924,400 for male cases and $17,711,400 for female cases. The cost to circumcise males in this birth cohort at currently reported rates is $4,856,000. Conclusions. For every year of decreased circumcision rates due to Medicaid defunding, we project over 100 additional HIV cases and $30,000,000 in net medical costs.

165: Serum biomarker glial fibrillary acidic protein in the identification of periventricular white matter injury in preterm neonates with intraventricular hemorrhage at birth

165: Serum biomarker glial fibrillary acidic protein in the identification of periventricular white matter injury in preterm neonates with intraventricular hemorrhage at birth

166: Does penile ring block anesthesia make a difference in pain response to Neonatal circumcision?

166: Does penile ring block anesthesia make a difference in pain response to Neonatal circumcision?

Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect?

Does sexual function survey in Denmark offer any support for male circumcision having an adverse effect?

The Medical Benefits of Male Circumcision

The Medical Benefits of Male Circumcision

Neonatal circumcision: healthy practice or barbaric procedure?

Neonatal circumcision: healthy practice or barbaric procedure?

The Relationship Between Obesity and Complications After Neonatal Circumcision

Penile adhesions with hidden penis and penile skin bridges are complications after neonatal circumcision that seem to develop more often in overweight children. They could possibly be avoided if there were neonatal parameters predicting circumcision complications. We hypothesized that penile adhesions with hidden penis and skin bridges may be predicted by the height and weight of a newborn. We performed an institutional review board approved case-control study. Boys younger than 5 years who presented for evaluation of penile adhesions with hidden penis and/or penile skin bridges after newborn circumcision were compared to boys of the same age who were circumcised at birth and did not have penile adhesions with hidden penis and/or skin bridges when evaluated for cryptorchidism or hernia/hydrocele. Weight for length percentiles were compared at birth and at urological evaluation. We evaluated 51 patients with penile adhesions and hidden penis after newborn circumcision, and compared them to 33 age matched controls. Boys with hidden penis had a statistically higher weight for length percentile at birth and at urological evaluation. However, in boys with penile skin bridges there was no statistical difference in the weight for length percentile at either time. An increased weight for length percentile in male infants before and after circumcision may be associated with penile adhesions with hidden penis but not penile skin bridges. These parameters should be considered before newborn circumcision when counseling parents, and after circumcision since early recognition of obesity might indicate the need for diligent genital hygiene to try to prevent post-circumcision complications.

Acceptability of neonatal male circumcision in Lusaka, Zambia

Neonatal male circumcision (NMC) is being scaled up in Zambia and elsewhere in Southern Africa as a long-term HIV prevention strategy. We conducted 12 focus group discussions with 129 parents and grandparents in Lusaka, recruited from two sites providing free NMC services and information about NMC, to explore the acceptability of circumcising newborn boys. Most participants recognized the benefits of circumcision for HIV prevention, and the advantages of circumcising their children and grandchildren at a young age. Fear of negative outcomes, concerns about pain, and issues around cultural identity may challenge NMC uptake. To effectively promote the service, the upper age limit for NMC must be emphasized, and fathers must be targeted by messaging campaigns.

Neonatal circumcision – violation of children’s rights or public health necessity?

There is a growing body of scientific evidence that medical male circumcision substantially reduces the risk of contracting HIV and other sexually transmitted infections. The procedure has been hailed as offering partial protection against HIV infection for men during sexual intercourse, raising the hope that widespread male circumcision could significantly reduce the incidence of HIV transmission in South Africa. The literature also suggests that this procedure may prevent transmission of the human papillomavirus to women. Neonatal circumcision, which is considered to carry the lowest risk, is viewed as a vital component of the goal of realising generalised circumcision in the population. This paper investigates the ethical, legal and public health considerations underlying an HIV prevention strategy that includes neonatal circumcision. It reviews the impact of the practice on the rights of children to bodily integrity, and explores whether proxy consent by a parent or guardian on behalf of a child is appropriate and justifiable on grounds of parental preference, religion, culture or public health policy. This is a complex debate and transcends routine classifications when exploring ethical dilemmas. The article concludes that the rights of neonates to bodily integrity should not be tampered with lightly, and that only a severe public health hazard such as the HIV/AIDS pandemic may justify incursion into this constitutionally protected right.

Epidemiological aspects of penile cancer in Rio de Janeiro: evaluation of 230 cases

To determine epidemiological characteristics of penile cancer in Rio de Janeiro, its associated risk factors and clinical manifestations. Between 2002 and 2008 we evaluated 230 patients at three public institutions, considering age, ethnicity, birthplace, marital status, educational level, religion, tobacco smoking, presence of phimosis and practice of circumcision. The ages ranged from 25 to 98 years, with an average of 58.35 years. Of the 230 patients, 167 (72.7%) were from the southeast region of Brazil (which includes Rio de Janeiro) and 45 (19.5%) were from the northeast of the country. Most patients were white (67.3%), married (58.6%), smokers (56.5%) and had not completed primary school (71.3%). The predominant religion was Catholic (74.8%). Of the 46 (20%) circumcised patients, only 1 (2.2%) had undergone neonatal circumcision. Grade I tumors were present in 87 (37.8%) of the patients, grade II in 131 (56.9%) and grade III in 12 (5.3%). Lymphovascular embolization was observed in 63 (27.3%) and koilocytosis in 124 (53.9%) patients. Of the total, 41.3% had corpora cavernosa or corpus spongiosum infiltration, and 40 (17.4%) had urethral invasion. Prophylactic lymphadenectomy was performed on 56 (36.1%), therapeutic lymphadenectomy on 84 (54.2%) and hygienic lymphadenectomy for advanced disease on 15 (9.7%) patients. The median time between the lesion onset and clinical diagnosis was 13.2 months. The mean follow up was 28.8 months. Most of our patients were born in this state and had low socioeconomic status. Most of them were white men, married, smokers, uncircumcised, of the Catholic faith and in their sixties or older. Their disease was in most cases diagnosed only in the advanced stages.

Does neonatal circumcision alter behavioral pain response during subsequent routine immunizations?

Pain experienced during infancy may have long-term effects on future pain response. Study objectives were to determine whether neonatal circumcision altered behavioral pain response during subsequent immunizations compared to uncircumcised infants and whether pretreatment of circumcision pain affected subsequent immunization response. Using data from our previously reported randomized clinical trial, 97 male infants presented for immunizations at 4 and 6-months of age, 82 were circumcised. Seventy-five infants received analgesia prior to circumcision; seven infants did not receive preemptive analgesia.

564 RESIDENCY TRAINING IN NEONATAL CIRCUMCISION - COMPARATIVE NEEDS ASSESSMENT OF UROLOGY AND OB-GYN RESIDENTS

You have accessJournal of UrologyPediatrics: Congenital Anomalies - Lower Urinary Tract & Genitalia1 Apr 2011564 RESIDENCY TRAINING IN NEONATAL CIRCUMCISION - COMPARATIVE NEEDS ASSESSMENT OF UROLOGY AND OB-GYN RESIDENTS Brian Le, Dae Kim, Vidit Sharma, Max Maizels, Jennie Mickelson, and Dana Gossett Brian LeBrian Le Chicago, IL More articles by this author , Dae KimDae Kim Chicago, IL More articles by this author , Vidit SharmaVidit Sharma Chicago, IL More articles by this author , Max MaizelsMax Maizels Chicago, IL More articles by this author , Jennie MickelsonJennie Mickelson Vancouver, Canada More articles by this author , and Dana GossettDana Gossett Chicago, IL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1289AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In practice, primary care physicians are the routine providers of neonatal circumcision, yet urologists commonly manage the complications. We previously identified a need for improved formalized training in the contraindications to, evaluation and performance of neonatal circumcisions among ob-gyn residents. Here we use the same tools to conduct a needs assessment for urology residents in neonatal circumcision. METHODS An on-line survey of ob-gyn and urology residents in Chicago was conducted from Nov 2008 to Nov 2009. Using images of uncircumcised penises, residents were asked to identify which patients were candidates for routine neonatal circumcision. Residents then rated their own comfort and formal education in circumcisions. Data was analyzed using t-tests to compare the 2 groups. RESULTS 75% of ob-gyn and 65% of urology residents responded to the survey. The majority (63%) of ob-gyn residents planned to perform neonatal circumcisions once in practice, while only 27% of urology residents planned to do so. Both groups of residents described having little formal training in neonatal circumcision; with “no formal training” described by 44% of ob-gyn residents and 45% of urology residents, and a “casual briefing” by 52% and 45%, respectively. Ob-gyn residents felt significantly more comfortable than urology residents in performing neonatal circumcisions (mean of 5.9 vs. 4.4, p=0.003 - range 1 (very uncomfortable) to 7 (very comfortable)), though urology residents increased in comfort-level as PGY increased. Ob-gyn residents felt less comfortable than urology residents (mean 3.9 vs. 5.1 on scale of 7, p = 0.04) evaluating if the penis of a newborn may undergo circumcision safely. Urology residents performed better than ob-gyn residents at identifying contraindications to routine circumcision in our 10 scenarios (mean 63% vs. 43% p = 0.001). Both felt that an online-module was a good alternative to practical experience. CONCLUSIONS This needs assessment outlines that the majority of ob-gyn and urology residents have little formalized training in the contraindications and performance of neonatal circumcision. While ob-gyn residents are comfortable performing routine neonatal circumcisions, they feel significantly less comfortable evaluating the newborn penis. By contrast, urology residents are more confident with their evaluation and are better at identifying contraindications, but are less comfortable performing the procedure. This needs assessment highlights the need for further curriculum development and formalized training. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e227-e228 Peer Review Report Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brian Le Chicago, IL More articles by this author Dae Kim Chicago, IL More articles by this author Vidit Sharma Chicago, IL More articles by this author Max Maizels Chicago, IL More articles by this author Jennie Mickelson Vancouver, Canada More articles by this author Dana Gossett Chicago, IL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Prevalence and factors associated with knowledge of and willingness for male circumcision in rural Zimbabwe

To explore male circumcision (MC) prevalence, knowledge, attitudes and intentions among rural Zimbabweans. Representative survey of 18-44 year olds in two provinces, as part of an evaluation of the Zimbabwe National Behaviour Change Programme. We conducted univariate, bivariate and multivariate analyses. Linear regression was employed to predict knowledge of MC (composite index) and logistic regression to predict knowledge that MC prevents HIV, willingness (oneself or one's partner) to undergo MC, and willingness to have son circumcised. Two thousand seven hundred and forty-six individuals participated in the survey (87% of eligibles). About two-thirds were women (64%). Twenty per cent of men reported being circumcised, while 17% of women reported having a circumcised partner. Knowledge of MC and its health benefits was low. Attitudes towards MC were relatively positive. If it could prevent HIV, 52% of men reported that they would undergo MC and 58% of women indicated that they would like their partners to be circumcised. Seventy-five per cent of men who reported being HIV positive were willing to undergo MC, against 52% of those who reported HIV negative status. Reported acceptability of neonatal circumcision was high with 58% of men and 60% of women reporting that they would have their sons circumcised if it protected them against HIV. Fear of adverse effects was highlighted as a barrier to MC acceptability. More knowledge about MC's health benefits positively affects people's attitudes towards MC. The relatively high MC acceptability suggests an enabling environment for the scale-up programme.

Neurodevelopmental Risks of Pediatric Anesthesia: What Do We Know, and What Should We Do?

First demonstrated in 1846, general anesthesia remains a singular advance of modern medicine. Anesthesia for children has dramatically alleviated pain and stress in pediatric patients, and now permits surgical care of even the youngest and smallest infants. By the mid-20th century, however, it was first suggested adverse postoperative behaviors in children might be due, at least in part, to general anesthesia [1]. Subsequent studies demonstrated abnormal neuropathology and adverse behavioral changes in rodents following in utero exposure to volatile agents, and in 1999, data demonstrating widespread neuronal apoptosis in rat pups following postnatal exposure to anesthetics were first published [2]. The resultant debate in the medical literature regarding human relevance of such findings has been extensive, and dissemination of alarm over potential deleterious effects of pediatric anesthesia in the general media has been widespread. What do we know, and what should we do? Neuronal apoptosis, or programmed cell death, is a normal part of neurodevelopment. Up to 1% of neurons in a developing mammalian brain normally will be pruned via apoptosis after failing to meet anatomic or functional milestones. Numerous factors may dramatically increase this percentage, potentially inducing abnormal neuropathology and adverse clinical outcomes [3]. Untreated neonatal pain in animals is associated with increased neuronal apoptosis and sustained behavioral disturbances [4, 5], and even seemingly minor procedures in human infants such as neonatal circumcision are associated with increased subsequent pain behaviors if performed without anesthesia [6]. Provision of adequate analgesia during painful interventions attenuates abnormal neuropathology and adverse clinical outcomes [7, 8]: anesthetic exposure to treat pain is neuroprotective, not neurotoxic. Anesthetic agents are thought to induce apoptosis through γ-aminobutyric acid (GABA)–receptor agonism, N-methyl-D-aspartate (NMDA)–receptor antagonism, or both [9]. Such apoptosis is characterized histopathologically by breakdown of nuclear membranes and condensation of nuclear contents, and functionally by marked disruption of synaptogenesis [10]. All currently available general anesthetics possess some combination of GABA agonism and/or NMDA antagonism, and virtually all have been shown to cause enhanced apoptosis and subsequent behavioral disturbances in animals [11]. Most animal data to date derive from rodents, primarily rats, although available data from nonhuman primates are concordant. Immature animals of all species studied demonstrate increased neuronal apoptosis and subsequent abnormal behaviors following exposure to anesthetics. Anesthetic neurotoxicity, however, appears limited to a critical neurodevelopmental window, and to demonstrate threshold doses and durations [11–13]. Anesthetic exposure outside this critical neurodevelopmental window, or below threshold doses and durations, is not neurotoxic. Further, and of critical relevance to human surgical practice, neurotoxicity in S. R. Hays (*) Departments of Anesthesiology & Pediatrics, Vanderbilt University School of Medicine; Pediatric Anesthesia, Monroe Carell Jr. Children’s Hospital at Vanderbilt, 2200 Children’s Way, Suite 3115, Nashville, TN 37232-9070, USA e-mail: stephen.hays@Vanderbilt.Edu

Primary Vesico-Ureteral Reflux: Comparison of Factors between Infants and Children

PurposeThe association of age, sex and renal parenchymal damage (RPD) in vesicoureteral reflux (VUR) is well known. We compared various factors between infants and children in a cohort of patients with primary VUR.Materials and MethodsMedical records of 147 patients diagnosed as VUR between 1997 and 2010 were reviewed. Of these children 91 (61.9%) were boys and 56 (38.1%) were girls. 99 (67.3%) of the 147 patients were younger (Group 1), and 48 (32.7%) were older than 1 year (Group 2). The impact of patient's gender and age as well as VUR grade on RPD were analyzed in each patient. The Fisher's exact test and chi square test was done with SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA).ResultsVUR was unilateral in 88 patients (59.9%) and bilateral in 59 patients (40.1%). Abnormal renal scan was found in 78 (37.7%) renal units. The incidence of VUR was significantly higher in male in group 1 (p<0.01) and in female in group 2 (p<0.01). The incidence of abnormal renal scan was significantly higher in intermediate and high grade VUR comparing low grade VUR in group 1 (p=0.042). In both group, abnormal renal scan didn't show any difference between male and female statistically (p>0.05).ConclusionsOur data showed that VUR in infant was significantly higher in male than in female, whereas VUR in children was significantly higher in female. This may be due to that characteristic of a population where neonatal circumcision is not a common procedure in infant and urinary tract infections are more common in female children. Further study may be needed to identify gender difference in RPD in infant with high grade reflux.

Meatotomy Using Local Anesthesia and Sedation or General Anesthesia With or Without Penile Block in Children: A Prospective Randomized Study

Meatotomy is a simple, common procedure for the treatment of meatal stenosis. We compared the outcomes of meatotomy performed using local anesthesia and sedation, and general anesthesia with and without penile block. A prospective comparative design was used. Participants included 76 boys 1.5 to 10 years old treated for meatal stenosis at a tertiary, university affiliated, pediatric medical center in 2008. Children were randomly allocated to undergo surgery with sedation and local anesthesia, or general anesthesia with or without penile block. All procedures were performed with the same method by the same surgeon. For local anesthesia EMLA 5% cream (lidocaine 2.5% and prilocaine 2.5%) covered with an occlusive dressing was applied 1 hour preoperatively, and midazolam (in patients younger than 5 years) or nitrous oxide (older than 5 years) was used for sedation. General anesthesia was induced with inhaled sevoflurane, and ropivacaine was used for dorsal penile nerve block. There was no difference among the groups in pain level intraoperatively (no pain in 92% to 93% of patients), 24 hours postoperatively (no pain in 81% to 88%) or after 1 month, or in complication rates (bleeding in 3 patients, laryngospasm in 2). General anesthesia with penile block was associated with a trend of less dysuria. Quality of void was excellent in 87% of patients at 24 hours and in 70% at 1 month, and parental satisfaction was high (88% to 92%). Meatotomy performed using local anesthesia and sedation has an equally good outcome to meatotomy performed using general anesthesia with or without penile block.