One stop shopping: same day office circumcision evaluation and management
Venkata R. Jayanthi, MD, Christina Ching, MD, Seth Alpert, MD, Molly Fuchs, MD, Daniel DaJusta, MD, Daryl McLeod, MD, Lauren Nicassio, BS.
Nationwide Children's Hospital, Columbus, OH, USA.
BACKGROUND: Many children are referred to pediatric urologists for elective circumcision when this could not be performed in the immediate post-natal period. In an attempt to reduce health care burden and improve efficiency for those requesting circumcision, we developed a protocol so that babies undergo initial evaluation followed by immediate office circumcision under local anesthesia, if deemed an appropriate candidate.
METHODS: Our hospital-based practice uses a centralized scheduling system with flowcharts and templates to schedule patients. We modified clinic templates to allow for 2-3 circumcision slots during the first hour of each clinic day and central scheduling was given a protocol to follow to fill these time slots. Briefly, otherwise healthy children less than 14 lbs and less than 4 months of age were automatically scheduled for an evaluation followed by circumcision at the same visit, if anatomically feasible and without medical contraindication. The family was asked to have the child fast for one hour prior to the clinic visit. Children greater than 14 lbs or 4 months of age were not scheduled for same day circumcision but could still have this done the same day at the discretion of the urologist. Circumcisions were performed using either a Plastibell or Gomco device after a dorsal penile block injection using 1% lidocaine. We reviewed 12 months of using this protocol.
RESULTS: During 2018, 284 boys were evaluated using our same day office circumcision concept. Mean age at evaluation was 11 weeks (0.1 - 40.1). The mean weight at the time of circumcision was 5624 gms (2550 - 8060). Reasons given for not performing newborn circumcision at birth hospital included a concern of a possible genital abnormality in 142 (50%), medical condition in 49 (17%), prematurity in 53 (19%), parental choice in 19 (7%), logistical factors in 7 (2%) and unknown factors in 14 (5%). Overall, 209 boys (73.6%) were able to have the circumcision done during the same visit as the initial evaluation. Of the remaining seventy-five boys who were not able to be circumcised: 48 (64%) could not be circumcised because of a genital abnormality requiring formal operative intervention, 16 (21%) due to logistical factors, 8 (10%) due to a lack of medical clearance and 3 (4%) because of parental choice. The Plastibell device was used in 121 (58%) and the Gomco clamp in 88 (42%).
CONCLUSIONS: A same day office circumcision clinic is feasible and simplifies management for children not circumcised in the neonatal period. This not only has the potential to decrease costs but also to free up surgical blocks for more complex cases that truly require the use an operating room.
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