Notat om omskæring af drenge - Sundhedsstyrelsen

was reported in 2.2% of cases andinfection in 1.3% of boys circumcisedin a hospital, versus a bleeding rate of3.6% and an infection rate of 2.7% inboys undergoing a nonhospital-basedmass religious procedure, despitethe latter procedure being performedby trained personnel. 196There are no adequate analytic studiesof late complications in boys undergoingcircumcision in the post-newborn period.An Iranian cross-sectional studywith good evidence reported a latecomplication rate of 7.4%, includingredundant skin in 3.6%, excessive skinremoval in 1.3%, and meatal stenosisin 0.9%. 197Major ComplicationsThe majority of severe or even catastrophicinjuries are so infrequent asto be reported as case reports (andwere therefore excluded from thisliterature review). These rare complicationsinclude glans or penile amputation,198–206 transmission of herpessimplex after mouth-to-penis contactby a mohel (Jewish ritual circumcisers)after circumcision, 207–209 methicillinresistantStaphylococcus aureus infection,210 urethral cutaneous fistula, 211glans ischemia, 212 and death. 213Medical Versus Traditional ProvidersIn general, untrained providers createmore complications when performingmale circumcision than dowell-trained providers, regardless ofwhether they are physicians, nurses, ortraditional religious providers. Physiciansin a hospital setting generallyhave fewer complications than traditionalproviders in the communitysetting.A prospective study in Kenya with goodevidence found an overall complicationrate of 35% in 443 children and youngmen aged 5 to 21 years who hadtraditional circumcision performed ina village or household setting, comparedwith an overall complicationrate of 17% in those whose circumcisionwas performed by trained providersin a medical setting such asa hospital, health center, or physician’soffice. 214 The most common complicationswere bleeding and infection;excessive pain, lacerations, torsion,and erectile dysfunction were alsoobserved. A study in Turkey with fairevidence studied a historical cohortand found a significantly higher rate ofcomplications when male circumcisionwas performed by traditional circumcisers,compared with those performedby physicians; complicationrates were 85% for traditional providersversus 2.6% for physicians. 215A study in Israel with fair evidencefound there was no difference in therate of complications in newborncircumcision between hospital-basedphysicians and well-trained, homebasedritual circumcisers (mohels). 183Complications With Different Methodsof Male CircumcisionThere have been few studies comparingthe 3 most commonly usedtechniques for male circumcision inthe United States (the Gomco clamp,the Plastibell device, and the Mogenclamp). Steps common to all 3 includeestimation of the amount of externalskin to be removed; dilation of thepreputial orifice so the glans can bevisualized to ensure that the glans itselfis normal; bluntly freeing the innerpreputial epithelium from the epitheliumof the glans; placing the device;leaving the device in place long enoughto produce hemostasis; and surgicallyremoving the foreskin.Gomco ClampThe Gomco clamp was specificallydesigned for performing circumcisions.In this procedure, “the foreskinis cut lengthwise through thestretched tissue (dorsal slit) to allowspace to insert the circumcision device.The bell of the Gomco clamp isplaced over the glans, and the foreskinis pulled over the bell. The baseof the Gomco clamp is placed over thebell, and the Gomco clamp’s arm isfitted. After the surgeon confirmscorrect fitting and placement (and theamount of foreskin to be excised), thenut on the Gomco clamp is tightenedand left in place for 3 to 5 minutes toallow hemostasis to occur, then theforeskin is removed using a scalpel.The Gomco’s base and bell are thenremoved.” 216One study of the Gomco clamp with fairevidence reviewed 1000 newborn circumcisionsin a hospital setting inSaudi Arabia and found an overallcomplication rate of 1.9%. 185 Bleedingoccurred in 0.6% of cases, infection in0.4%, and redundant prepuce in 0.3%.Another study of 521 newborn malecircumcisions performed at a Houstonoutpatient clinic with fair evidencereported a 2.9% incidence of phimosis(trapped penis) after newborn circumcisionusing the Gomco clamp. 217Plastibell DevicePlastibell circumcision involves a surgicalprocedure in which a plastic ringis inserted under the foreskin, anda tie is placed over the ring to providehemostasis. The ring remains on thepenis for several days until the tissuenecroses and the ring falls off spontaneously.Bleeding ranged from 0.8% to3% of cases; infection occurred in 2.1%of cases. 218 Urinary retention 219,220 andproblems with the Plastibell ring havebeen reported in 3.6% of cases. 221Studies of the Plastibell device with fairand good evidence found, overall, thatcomplications range from 2.4% to5%. 218,221–223Mogen ClampThe Mogen clamp is a device consistingof 2 flat blades that have a limitede774FROM THE AMERICAN ACADEMY OF PEDIATRICSDownloaded from pediatrics.aappublications.org by guest on June 19, 2013