Neonatal circumcision is the most common neonatal surgical procedure in the world; however, it remains controversial.1 In the United States, the prevalence of circumcision varies markedly with race, ethnicity, and geographic regions.2 Neonatal circumcision complication rates in the United States range from 0.2% to 3%.3 However, rates as high as 26% have been reported.4 Reported complications may be minor or severe. Minor complications include poor cosmetic appearance, infection, bleeding, postprocedural adhesions, skin bridges, and buried or concealed penis. More serious complications include complete or partial degloving of the penile skin, iatrogenic urethrocutaneous fistula, amputations of the penis, and death.4-6 Despite the risk of complications, neonatal circumcision remains commonly performed by clinicians not in urology and with variable training in performing the procedure, such as pediatricians, obstetricians, and family practice physicians.7,8 Financial constraints as well as limited access to clinicians may create a burden for caregivers who desire neonatal circumcision for their infant.9-12
The role of PAs and NPs in adult urology continues to evolve. Historically, PAs in surgical specialties often were surgical first assistants and provided postoperative patient management. More recently, PAs and NPs in urology have performed office-based procedures, including transrectal ultrasound-guided prostate biopsy and cystoscopy.13,14 The role of the PA in pediatric urology is not well defined in the scientific literature. In fact, the American Urological Association consensus statement on advanced practice providers does not discuss roles specific to pediatric urology, nor does the report identify training modules to assist PA and NP training and integration in the field of pediatric urology.15 Neonatal circumcision is an office-based procedure for which PAs in pediatric urology would be ideally suited, given their surgical experience, clinical acumen, and awareness of postoperative management and care. PAs possess the procedural skills because they often are surgical assistants and are aware of postoperative complications, based on their role as postoperative care providers. However, with appropriate training, PAs in nonsurgical subspecialties also can be appropriate candidates to perform urologic procedures such as circumcision.
This study evaluated neonatal circumcision outcomes of a single PA and compared them with those reported in the literature. The authors did not intend to evaluate the indications for or against routine circumcision, a topic that continues to be very controversial. We believe that, similar to the expanding role of PAs and NPs in adult urology, the role of PAs in pediatric urology is evolving and can encompass office-based procedures. This study sought to demonstrate that PAs in pediatric urology are well suited to performing neonatal circumcisions with minimal complications.
The study was approved by the institutional review board at Nemours Children's Hospital in Orlando, Fla. A retrospective review was performed of all male infants evaluated for neonatal circumcision by a single PA in pediatric urology at a single institution between August 2015 and February 2018. The PA performing the neonatal circumcisions had 6 years of surgical experience before being trained in neonatal circumcisions. The training consisted of watching five neonatal circumcisions and performing five procedures under direct supervision. The PA also shadowed urologists to learn a focused genital examination. The PA always had an attending physician readily available for questions, concerns, or to address any acute intraprocedural complications that arose. Circumcision technique, patient age and weight at time of circumcision, presence or absence of genital anomalies, complications, and returns to ED were gathered.
At the time of scheduling the neonatal circumcision, all caregivers were informed that the procedure would be performed by the PA. All infants underwent a detailed genital examination the day of the procedure to determine suitability for the procedure. Detailed medical and family history was obtained to ensure the infant had received vitamin K postnatally as well as to rule out a family history of bleeding disorders. Extensive unbiased counseling on the risks and benefits of circumcision as per CDC and American Academy of Pediatrics recommendations was discussed with caregivers before obtaining informed consent. Caregivers were given time to ask questions and rescheduling offered if they wished to have more time to consider the risks and benefits of neonatal circumcision. Detailed discussion on type of circumcision, use of local regional anesthetic, postcircumcision care, expectations of normal healing, and acute complications was reviewed with each caregiver before discharge. All caregivers were provided with an aftervisit summary with details on postprocedure care and clinic and on-call provider contact information.
No formal follow-up visit was scheduled after the neonatal circumcision. However, every caregiver was clearly informed to contact the urology clinic or come to the clinic with any questions or concerns. A comprehensive review of the EPIC medical record was performed to identify visits to the ED, urology clinic, primary care provider, phone calls, and portal correspondence pertaining to the neonatal circumcision and outcomes.
Between August 2015 and February 2018, a total of 371 male infants were evaluated for neonatal circumcision by a single PA at a single institution. Infant ages ranged from 1 week to 13 weeks; average 7.8 weeks. Infant weight at the time of presentation ranged from 3.2 kg to 7.5 kg; average 5.2 kg. Ninety-five of the 371 patients evaluated did not undergo neonatal circumcision, most commonly due to an abnormal genital examination (buried penis [n = 80], hypospadias [n = 1], large hydrocele(s) [n = 3], chordee [n = 2], penile torsion [n = 2], penis too small for Plastibell [n = 1], but not a micropenis). Other reasons for infants not undergoing neonatal circumcision was parental choice (n = 3), infant being too large to be properly restrained on circumcision board (n = 2), and family history of a bleeding disorder without appropriate patient workup (n = 1). Every caregiver was informed at the time of scheduling the procedure that a PA would be performing the circumcision. None expressed discontent with a PA performing the procedure at the time of the procedure or after the procedure. No insurance denials were related to the PA as the clinician performing the procedure. The Plastibell circumcision device was used in 272 infants and the Gomco device in four. All infants underwent a penile ring block with 4 mg/kg of 1% lidocaine without epinephrine. The small number of Gomco procedures limits separate evaluation of the devices used for neonatal circumcision. No acute procedural complications occurred. No patients experienced significant bleeding at the time of the procedure or required acute surgical intervention.
Complications occurred in 16 patients (5.8%): retained Plastibell (2.1%), penile swelling (1.8%), penile adhesions (1.1%), and cosmesis (0.73%). A total of 18 unanticipated visits occurred, four of which were in the ED and 14 in the urology clinic, two of whom were previously seen in the ED. Four patients (1.4%) were seen in the ED: two for swelling, one for a possible infection, and one for a retained Plastibell, which was removed at the time of the ED visit. Twelve patients (4.4%) were initially seen for follow-up in the urology clinic, five for retained Plastibell, four for penile swelling, three for penile adhesions, and two for concerns regarding appearance.
The role of PAs in pediatric urology is poorly defined by national criteria or scientific literature. The limited available data support expanding the role of PAs and NPs in the ambulatory setting. With growing demand, PAs and NPs are appropriately trained and sufficiently knowledgeable to evaluate and treat patients and perform office-based procedures. More research is necessary to elucidate and define the roles best suited for these clinicians to optimize clinic efficiency without compromising patient care or safety. However, the limited available data support expanding the role of PAs and NPs in the clinic.13,14 Neonatal circumcisions are a safe office-based procedure; however, nonsurgeons are more uncomfortable and less prepared to deal with acute complications such as bleeding or wound dehiscence and may not be adequately trained to assess and manage potential long-term complications such as a trapped penis or meatal stenosis.7 PAs in urology possess the procedural skills because they often are surgical assistants and are aware of postoperative complications based on their role as postoperative care providers. This role may improve access to neonatal circumcisions where there are insufficient clinicians, as well as increase clinical revenue.
A recent study by Gerber and colleagues evaluated the outcomes of a PA- or NP-led newborn circumcision.16 In this study, 314 infants with an average weight of 3.8 kg and average age of 20.3 days underwent neonatal circumcision by trained advanced practice registered nurses (APRNs) and PAs using the Gomco device. Acute procedural complications included bleeding requiring some form of intervention occurred in 11 infants (3.5%). An additional two infants presented to the ED within 30 days for postprocedural bleeding. Two infants (0.6%) had late complications requiring intervention, including penile adhesions/skin bridges in one and need for revision of circumcision in one.16 When we compare our study with that of Gerber and colleagues, our infants on average were heavier and older. Unlike the Gerber study, we did not have any acute or late occurrences of bleeding requiring intervention, which may reflect the use of the Plastibell device instead of the Gomco device. In our study, only one infant (0.3%) underwent postcircumcision lysis of adhesions in the OR. Both studies demonstrate, when compared with the literature on neonatal circumcisions and low complication rates, supporting the role of PAs and NPs in neonatal circumcision clinics. As with our study, limitations exist with postprocedural follow-up.
Neonatal circumcisions are a common office-based procedure frequently performed by nonsurgical clinicians.1,7 The level of training and comfort with managing procedural complications among clinicians not in urology is variable. Le and colleagues identified opportunities for improving residency training in both obstetrics-gynecology and urology.17 In a study of ob-gyn and urology residents at their institution, they noted that although ob-gyn residents felt more comfortable than urology residents in performing neonatal circumcisions, the ob-gyn residents felt less comfortable than urology residents evaluating neonates for circumcision. When presented with 10 scenarios for neonatal circumcision, ob-gyn residents underperformed at identifying contraindications, compared with urology residents. Both urology and ob-gyn residents felt that an online training module would be helpful.17
Demaria and colleagues conducted a 19-question cross-sectional survey including visual identification items that was sent to 87 physicians who perform neonatal circumcisions.7 The purpose of the study was not to determine if neonatal circumcision should be performed, but rather to find out who was performing neonatal circumcision, identify their training, and observe their comfort with complications. Fifty-four of 87 (62%) physicians responded and the majority of respondents (85%) were family practice physicians and pediatricians; the remaining 15% were pediatric surgeons or urologists. With respect to neonatal circumcision training background, 19 (43%) of the nonsurgical group of respondents learned the procedure from a colleague pediatrician or family practice physician. Surgeon responders typically learned the procedure as part of their surgical training. None of the respondents noted that they learned through a structured training course. Nonsurgeon clinicians were less comfortable managing early circumcision complications including bleeding (36% of respondents reported being less comfortable), urinary retention (65%), and wound dehiscence (48%). Even fewer nonsurgeons felt comfortable with late circumcision complications such as trapped penis (67%) or meatal stenosis (90%). Of note, 31% of respondents were unable to identify a buried/concealed penis and would have proceeded to perform a neonatal circumcision when it is contraindicated. Despite these numbers, nonsurgeons provide the vast majority of neonatal circumcisions.1,7
Neonatal circumcisions are associated with both immediate and late complications, the latter of which may be preventable. Heras and colleagues performed a retrospective review on all term neonates who were circumcised at two community hospitals, to determine the incidence of immediate complications of elective newborn circumcisions.18 Of 1,064 neonates who met criteria for this study, 3.9% had a complication secondary to hemorrhage. Of these, three patients required sutures and bleeding was controlled with local pressure or the application of hemostatic agents.18 No anatomic complications were noted at discharge, and no deaths, readmissions, or subsequent clinic visits for circumcision complications were reported. Pieretti and colleagues conducted a retrospective study at the Massachussetts General Hospital for Children to review operative and postoperative complications resulting from neonatal circumcisions.1 Nearly 5% of surgeries performed over a 5-year period were for complications resulting from a neonatal circumcision, including release of extensive penile adhesions, skin bridges, meatal stenosis, redundant foreskin, recurrent phimosis, buried penis, or penile rotation. Pieretti and colleagues also reviewed charts of patients referred to the pediatric urology clinic from April 2007 to April 2008 for problems associated with neonatal circumcision.1 More than 7% of all patients seen for chief complaints related to neonatal circumcisions underwent general anesthesia to treat these complications.1 Mayer and colleagues, in a review of 68 children presenting for circumcision revision for possible circumcision complication, confirmed complications in 57 infants.19 The authors noted that patients with a minor circumcision complication had a ninefold higher incidence of prominent suprapubic fat pad, penoscrotal webbing, or prematurity compared with a control group of children seen for other urologic problems during the same 18-month period. The authors recommended thorough examination of the genitalia for these subtle anatomic variations before circumcision to reduce potential complications.19 These studies highlight the importance of proper training in circumcision technique as well as education about the male genital examination for all clinicians performing neonatal circumcision.
This study was a retrospective study and involved a single PA with extensive surgical experience. Studying a single clinician allows for ease of comparison between cases; however, it does not take into consideration the quality or breadth of the PA's training. Extrapolating these data to all APRNs and PAs is difficult and warrants further analysis with more clinicians. Routine postprocedural visits were not required; however, all parents and caregivers were verbally instructed to contact the clinic and/or present to our institution's ED if any issues or concerns arose. In addition, an after-visit summary with detailed postprocedural care as well as an emergency contact number was given to the parent or caregiver on discharge from the clinic at the time of the procedure. Our institution uses EPIC and records of all encounters in our institution as well as correspondence including telephone, outside records, staff messages, and encounters received outside healthcare systems were evaluated for each individual.
Neonatal circumcision is an office-based procedure commonly performed by nonsurgeon clinicians. PAs and NPs have the clinical acumen and some even have extensive surgical experience to be well trained to perform neonatal circumcisions and appropriately deal with both acute and late complications. In our experience, a well-trained PA has performed neonatal circumcisions with relatively low complications compared with the limited data in the literature. Thus, we believe that well-trained NPs or PAs can appropriately recognize congenital anomalies that preclude neonatal circumcision and are able to assess and manage most acute and long-term complications. Although this study is limited to one PA, the growing body of research supports expanding and redefining the role of PAs in surgical specialties. Concerns in the literature arise from lack of consistency in neonatal circumcision training, lack of understanding of contraindications for neonatal circumcision, and comfort of clinicians not in urology with managing neonatal circumcision-related complications. Well-trained PAs can fill the need for clinicians and are well equipped to deal with the risks associated with office-based procedures.
Our experience with a PA neonatal circumcision clinic supports the role of well-trained PA or NP safely and effectively performing neonatal circumcision in areas of need. Further studies are warranted to assess outcomes with a larger number of PAs and NPs with different levels of training and skills. Studies also are needed of clinician education on assessing the male genitalia before circumcision; Maizels and Meade developed a computer-enhanced visual learning interactive on this topic, available at http://cevlforhealthcare.org/cevl/Products/Urology/JournalOfPediatricUrology/Menu/. The financial effect of revenue generated by PAs and NPs performing neonatal circumcision is another area of potential study.
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