1. The cumulative risk of requiring surgery for foreskin-related problems in uncircumcised boys in the Capital Region of Denmark was estimated to be at least 1.66%.
2. Subsequent operation was required in 6.6% of foreskin-preserving surgeries.
Evidence Rating Level: 2 (Good)
Study Rundown: Circumcision is performed for both medical and cultural (i.e. nontherapeutic) reasons. Although advocated by the World Health Organization for HIV prevention in regions with widespread infection and by the American Academy of Pediatrics for its potential health benefits, the benefits and harms of circumcision remain a contested topic. To further characterize the morbidity associated with foreskin procedures deemed medically necessary, authors investigated such surgeries in the “foreskin-preserving culture” of the Capital Region of Denmark. In Denmark, the public healthcare system does not perform nontherapeutic neonatal circumcisions and, in general, circumcision is limited to cases for which medical treatment and alternative surgical techniques would not be effective. Based on the birth rates of living boys in the Capital Region of Denmark, the authors determined that the cumulative risk of requiring foreskin surgery with general anesthesia prior to 18 years of age was 1.66%. However, the actual risk of requiring surgery is likely greater as investigators were unable to account for nontherapeutic circumcisions in the birth cohorts. Less than 10% of those who underwent surgical intervention required repeat operating room visits for revision. Limitations of this study included its small sample size and potential lack of coverage due to missing/unattainable data. Despite these features, this study adds an important contribution to the debate on neonatal circumcision, revealing non-negligible foreskin morbidity in an uncircumcised population.
Relevant Reading: Male circumcision: Assessment of health benefits and risks
Study Author, Jørgen Thorup, MD, PhD talks to 2 Minute Medicine: Professor, Department of Pediatric Surgery, Faculty of Health and Medical Sciences, University Hospital of Copenhagen, Copenhagen, Denmark.
“Uncircumcised boys with foreskin problems should have appropriate treatment without delay and with special attention to the diagnosis of BXO. In the latter cases circumcision should be performed. Parents who consider prophylactic neonatal circumcision should also be informed about available data on natural foreskin morbidity in childhood.”
In-Depth [retrospective cohort]: Participants included 181 boys from the Capital Region of Denmark born between the years of 1996 and 2014 who were admitted to the Department of Pediatric Surgery, Rigshospitalet, University of Copenhagen in 2014 and underwent foreskin surgery. The median age at the time of operation was 11 years. Danish Statistics were used to determine the proportion of the birth cohort from each year that underwent foreskin surgery. It was estimated that between 5.2% and 5.7% of the annual birth cohort was admitted to the Department; not all of those admitted received surgery. The vast majority of the 181 boys who met the inclusion criteria for this study (95%) were diagnosed with phimosis, and more than half of them (55.2%; 95% CI 48.0-62.4) had used topical steroids prior to surgery. Balanitis xerotica obliterans (BXO) was histologically verified in 40 of the boys; and, of this subgroup, 15 (37.5%) had developed meatus stenosis. Of the 9 boys who initially had just the fibrotic part of their preputium removed, 2 (22.2%) necessitated redo-surgery. An additional 8 boys also required redo-surgery for a total of 10 boys needing >1 operation (5.5%; 95% CI 2.2-8.8). Complications from foreskin surgery, including recurrent phimosis, were common, with 45 patients (24.8%; 95% CI 18.5-31.1) contacting the surgical department postoperatively.
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