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Original article
Complication rate after circumcision in a paediatric surgical setting should not be neglected


Jørgen Thorup1, 2, Sebastian Cortes Thorup1 & Inge Botker Rasmussen Ifaoui1



1) Department of Paediatric Surgery, Surgical Clinic C, Rigshospitalet
2) Faculty of Health and Medical Sciences, University of Copenhagen


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Abstract

Introduction: As a consequence of the discussion on whether the health benefits of newborn male circumcision outweigh the risks and the discrepancies in reported figures of complications, we evaluated our results from a paediatric surgical department.

Material and methods: Patient file data from children who had undergone ritual circumcision in the 1996-2003- period were retrieved. Complications recorded until December 2011 were noted.

Results: Circumcision in 315 boys aged from 3 weeks to 16 years (median five years) were evaluated. A total of 16 boys (5.1%) had significant complications, including three incomplete circumcisions requiring re-surgery, two requiring re-surgery six months and five years postoperatively due to fibrotic phimosis and two requiring meatotomy due to meatal stenosis two and three year postoperatively. Acute complications included two superficial skin infections one week postoperatively and five cases with prolonged stay or re-admissions for bleeding the first or second postoperative day, whereof two underwent operative treatment. Finally, two had anaesthesiological complications leading to a need for overnight surveillance, but no further treatment.

Discussion: Parents should be counselled and be required to provide informed consent that any health benefits of childhood circumcision do not outweigh the reported complication rate and that therefore they should weigh the health benefits against the risks in light of their religious, cultural and personal preferences. As ritual circumcision is legal, a strong focus on high surgical/anaesthesiological standards is needed to avoid complications.

Funding: not relevant.

Trial registration: not relevant.

t is a topic of on-going debate whether male ritual circumcision in childhood is a violation of the United Nations’ Declaration of the Rights of the Child or whether the parents’ right to apply ritual circumcision to their boys is safeguarded by the Human Rights Council Resolution on human rights and fundamental freedoms through a better understanding of traditional values of humankind [1, 2]. This is mainly an ethical and political issue. Male ritual circumcision in childhood is performed legally in most countries, and recently The American Academy of Pediatrics changed their guidelines and stated that “evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it” [3].

A major paediatric argument for this recommendation relates to the findings from two well-conducted meta-analyses and a cohort study showing that the ur­inary tract infection incidence among boys under the age two years was reduced in those who were circumcised compared with uncircumcised boys [4-6]. Given that the risk of urinary tract infection among this population is approximately 1%, the number needed to circumcise to prevent urinary tract infection is approximately 100 [3]. The benefits of circumcision later in life includes a reduced risk of penile cancer and sexually transmitted infections such as HIV, genital herpes and genital warts [3].

But the risk of these diseases can also be reduced by other means in most parts of the world [1, 7]. Two large American studies on elective newborn circumcision estimated the risk of significant acute complications to be between 0.19% and 0.22% [8, 9]. There was, how­ever, no adequate long-term follow-up in these studies, and the data may not represent complication rates after newborn circumcision everywhere. Furthermore, in Europe ritual circumcision is very often carried out later in childhood. Moreover, based on a British analysis of the general complication rate after childhood circumcision [10], a realistic overall complication rate of 2-10% has previously been accepted in American paediatric surgery textbooks, Canadian consensus reports and national editorials [11-13].

As a consequence of the aforementioned discussion and the discrepancies in the complication figures, we evaluated our results from a paediatric surgery department with free admittance and regional health care reimbursement of the procedure to obtain further know­ledge on childhood circumcision complication rates.

MATERIAL AND METHODS

In a retrospective study, we included children aged 0-16 years who had undergone ritual circumcision in the 1996–2003-period at our department. The patient file data were retrieved using the Nordic classification procedure code of ritual circumcision: KKGV20. Re-admittance to our department until December 2011 due to circumcision complications was noted. Furthermore, the national register system was searched for patient contacts with a urological diagnosis to other hospitals. In this system, it appears clearly if a patient is dead.

Circumcision was performed as a surgical procedure in general anaesthesia with caudal block. After lancet or scissor preputial resection and haemostasis made by bipolar electrocautery, the inner and outer layer of the foreskin was anastomosed with interrupted absorbable 6-0 sutures. If present, a short ventral frenulum was divided with bipolar electrocautery. Paracetamol was used for postoperative pain management for a couple of days.

RESULTS

We excluded 47 patients from evaluation of complication rates: seven had presented with urinary tract infection before admittance for circumcision, 16 were registered with phimosis before circumcision, four had circumcision after a primary glanular hypospadias repair, one had epidermolysis bullosa and 19 boys had a circumcision performed after a previous circumcision had been performed elsewhere. The indications were excessive residual skin with or without phimosis issues. The results of circumcision in 315 boys aged from three weeks to 16 years (median five years) were left for evalu­ation (34 boys were younger than two years of age). There were no complications recorded in 295 cases (93.7% (95% confidence interval (CI): 90-97%)). No major complications such as glans or penile amputation, ureth­ral cutaneous fistula and death were recorded. Among 20 patients with recorded complications, four were absolutely minor, including two patients presenting three days and two weeks, respectively, after operation with oedema of the penis that needed no treatment, and two patients with complaints of excessive residual skin 15 and 19 month postoperatively needing no further treatment. So 16 boys (5.1%) had significant complications including three incomplete circumcisions requiring re- surgery three,12 and 18 months postoperatively, two requiring re-surgery six months and five years postoperatively due to fibrotic phimosis, two requiring meatotomy due to haematuria and meatal stenosis two and three years postoperatively (in children aged 11 and 8 year, respectively). Acute complications included treatment of two superficial skin infections one week postoperatively, five cases with prolonged stay or re-admissions for bleeding the first or second postoperative day, whereof three needed compression for haemostasis and two required operative treatment. Finally, two had anaesthe­siological complications (one case of suspected aspir­ation and one larynx spasm) requiring overnight surveillance in ward, but no further treatment.





DISCUSSION

In this material, 2.9% of the boys had acute complications after circumcision, but none septicaemia or major irreversible penile damage. An additional 2.2% had late complications during an 8-15-year follow-up period. These complication rates are in line with those reported by other comparable studies [10]. Excessive bleeding is the most common acute complication, and a rate of 1.6% could be expected [3, 10]. Among late complications, skin bridges and insufficient removal of the foreskin are the most common complaints [14, 15]. Unsatisfactory cosmetic appearance may be an indication for re-operation, and MacCarthy et al [15] reported this figure to be 1% in a British study. Insufficient excision of the foreskin and inner preputial epithelium may result in wound contraction and cicatrisation of distal foreskin. The fibrotic ring so produced may result in true phimosis, an event observed in 2% of the cases in another British series [16]. Interestingly, we had 19 referral cases for excessive residual skin with or without phimosis issues.

The referrals concerned reoperation following primary circumcision carried out elsewhere during the study period. However, the exact incidence of circumcision in our catchment area remains unknown. In our ser­ies, no serious complications were seen. But the literature describes other acute complications such as penile denudation injuries and septicaemia; the latter in some cases even causing death [3]. Also penile and glance amputation have been described and among late complications, concealed penis, urthrocutaneous fistula and glans atrophy have been seen [3, 17].

Meatal stenosis is a well-described late complication, which occurred in 0.6% of our own material. This figure is in accordance with the 0.5% rate reported in a study by Van Howe [18], but much higher rates have been described in the literature [10]. Meatal stenosis is generally a direct consequence of circumcision or hypospadias surgery that is seldom seen in non-operated boys. The aetiology is thought to be irritation of the external urethral meatus by the surrounding textile tissue. Such irritation is unlikely in the presence of a normal prepuce, which serves to protect the glans from irritant substances. Meatal stenosis may be a more common late complication after neonatal circumcision due to irritant ammoniacal substances present in wet nappies [10, 19]. The majority of our boys were circumcised after the age of two years and would therefore not benefit from a reduced risk of urinary tract infection before two years of age. However, one cannot exclude that by ritual circumcision a few boys from the total material may have avoided phimosis-related symptoms and balanitis xerot­ica obliterans which is seen in a significant proportion of phimosis cases needing surgery [20]. Still, it is likely that less than 1.5% of boys need surgery, and those who need it can be treated when their phimosis is becoming symptomatic [20].

Our patients are operated by skilled surgeons in a paediatric surgery department. From a surgical point of view, our complication rate seems acceptable. No major complications were seen. But there is no doubt that in a paediatric population as ours, the possible health benefits of childhood circumcision do not outweigh the reported complication rate. Furthermore, the weakness of our study includes the risk of under-reporting complications during follow-up if treated privately or abroad, and because we have taken no psychological or late sexual complications into consideration. Given that ritual circumcision in childhood is legal and accepted as a fundamental part of traditional values of humankind, the best thing we can do to protect these asymptomatic healthy boys against complications is probably to focus on high surgical and anaesthesiological standards.

Before surgery, parents should be counselled in detail and should be required to provide their informed consent that the possible health benefits of childhood circumcision do not outweigh the reported complication rate, and that they have weighed the health benefits against the risks in the light of their religious, cultural, and personal preferences.

Correspondence: Jørgen Thorup, Børnekirurgisk Afdeling 4272, Kirurgisk Klinik C, Rigshospitalet, 2100 Copenhagen, Denmark. E-mail: j-thorup@rh.dk

Accepted: 30 May 2013

Conflicts of interest: Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk



Literature
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Brian J MorrisReport
Sven Felsby | 15. December 2013
- titulates himself as "prof". That certainly must be in theology.
Not worth losing foreskin over scare tacticsReport
Sonny | 20. October 2013
Aren't scare tactics like Brian Morris's wonderful? They get us to sacrifice our children's human rights to their own bodies!

Concerning urinary tract infections, if the foreskin is forcefully retracted, caregivers can introduce infections. Thus, studies comparing circumcised to intact, uncircumcised males cannot be considered valid if this confounding factor has not been taken into consideration. Please, see the following websites:
http://www.cirp.org/library/disease/UTI/cunningham/
http://www.circumstitions.com/Utis.html

Human papillomavirus (HPV) is the virus that cause cervical cancer in women. "Circumcision does not prevent HPV." "Researchers at the University of Washington find no relation between circumcision status and HPV infections, and that high HPV infection sites are ignored in previous studies, leading to false claims of the protection benefits of circumcision."
http://www.intactnews.org/node/119/1314979135/circumcision-does-not-prevent-hpv-infection-rct-data-039inflated039-study-finds

I think Brian Morris cannot understand what human rights means.
Human rights is more important than circumcision excuses!Report
Sonny Vizzle | 6. October 2013
The unfortunate thing about this article is that it does not respect the human rights of the child, and it resorts to the unethical law of the land that permits ritualistic genital mutilation. How can a council on human rights protect a ritual over and above the human being that has not yet reached the age of consent? How? Through a "better understanding of traditional values of humankind." That's how! Just because a practice may have been a tradition for many years, it does not mean that the practice has not gone against human rights. The best thing that you can do is to align the law with human rights and change the current law to protect children instead of traditions.

Now for the excuses! If the foreskin is forcefully retracted, caregivers can introduce infections. Thus, studies comparing circumcised to intact, uncircumcised males cannot be considered valid if this confounding factor has not been taken into consideration. Please, see the following websites:
http://www.cirp.org/library/disease/UTI/cunningham/
http://www.circumstitions.com/Utis.html

As for AIDS, here is a quote:
"If we were to express the efficacy of delayed washing [of uncircumcised natural males] in the same way that the results of PrEP trials were reported, that is as relative risk reductions, this would mean that not washing immediately, but waiting for at least 10 minutes after intercourse before washing can reduce the risk of infection by 83%."
http://dontgetstuck.wordpress.com/2012/05/09/have-we-ignored-a-very-simple-procedure-that-could-significantly-reduce-the-risk-of-sexual-transmission-of-hiv-to-men-from-women/
Benefits outweigh risks by over 100 to 1Report
Prof Brian J Morris | 30. September 2013
Rather than this small regional study, if one considers a proper risk-benefit analysis and the entire medical literature published peer-reviewed data show that benefits exceed risk by over 100 to 1, and that over the lifetime half of uncircumcised boys suffer a medical condition related to their foreskin. Many of them and their sexual partners will die from diseases such as genital cancers and those caused by HIV infection that can be attributed to lack of circumcision. Deaths from medical circumcision are extremely rare in western settings. See scientific publications: http://www.ncbi.nlm.nih.gov/pubmed/?term=morris+bj+2012+'snip'
and http://www.scirp.org/journal/PaperInformation.aspx?paperID=17415

Ethically, given the enormous health benefits and very low, immediately and easily-treatable risks, failure to circumcise a boy contravenes the United Nations Convention on the Rights of the Child.
Complication rate after circumcision in a paediatric surgical setting should not be neglectedReport
Catherine Schau | 16. August 2013
I don't understand this: "16 were registered with phimosis before circumcision". It can take until 18 years of age for the foreskin to be retractable and it is impossible and medically false to diagnose phimosis before this age so there should have been no patients with phimosis in the original group. Please see here: http://www.cirp.org/library/normal/

"A narrow non-retractable prepuce in boys is within the normal range of development and usually causes no problems. The prepuce usually will spontaneously widen until complete retractability is obtained. About 50-60 percent of boys at age ten do not have fully retractable foreskins."

And here: http://www.doctorsopposingcircumcision.org/pdf/2008-03retractileforeskinleaflet.pdf

Otherwise this is a very useful publication. The bigger question is shouldn't doctors refuse to perform circumcision for religious and cultural reasons, since it clearly violates human rights and medical ethics?


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