Kraft H, Colon-Sanchez K and Ellsworth P: Neonatal circumcision trends from a pediatric urology perspective: results from a survey of members of the Societies for Pediatric Urology. Urol Pract 2021; 8: 589.

Neonatal circumcision remains controversial, with rates varying over the years. Although more commonly performed by nonurological providers, pediatric urologists are often involved with pre-procedural or post-procedural concerns. Currently there is no widely used educational tool and performance assessment for nonurological neonatal circumcision providers. Neonatal circumcision trends and perspectives were evaluated as determined by members of the Societies for Pediatric Urology (SPU) nationwide.

A 20-question survey was distributed electronically via SurveyMonkey® to members of the SPU assessing circumcision practices, preclusions, technique and financial aspects. Four questions evaluated perceptions, and the remaining 16 formed the basis of the study.¹

A total of 223 surveys (37.2%) were returned. The responders self-identified with one of 4 geographic regions, including 32.7% (73) from the South, 24.2% (54) from the Northeast, 23.3% (52) from the Midwest and 18.8% (42) from the West. Median test analysis revealed a greater number of responders from the South with 20 or more years of post-fellowship experience (46.6%) as compared to the Midwest, which had the largest number of responders with less than 5 years of post-fellowship experience (36.5%) and only 19.2% of responders denoting 20 or more years of experience (test statistic=11.126, df=3, p=0.011).¹

Eighty percent of responders (177) perform neonatal circumcision. Of those who reported not performing neonatal circumcision, 38.6% (17) cite other practitioners in the practice performing, whereas 13.6% (6) noted office limitations and 9.1% (4) time constraints.¹

A statistically significant difference exists between responders performing neonatal circumcision in the Northeast (87.0%) and the West (66.7%, p <0.05). Most individuals reported performing fewer than 5 neonatal circumcisions weekly (167, 79.5%). A total of 120 individuals (54.3%) see neonatal circumcisions for routine followup. Although overall an increase in circumcisions performed in the last 2-3 years was reported by 49.8%, prominent differences exist overall between geographic regions (chi-square=8.715, df=3, p=0.033). Fewer responders in the West reported neonatal circumcisions had increased (13, 33.33%) compared to the Northeast (32, 62.7%) and to the South (38, 53.3%; p <0.05).¹

Most individuals surveyed use more than 1 circumcision method, with the Gomco® clamp being most common across all geographic regions. However, the Gomco clamp was found to be used by more respondents from the Midwest (40, 76%) than the West (23, 54.8%; p <0.05). The West has a greater prevalence of Plastibell® device use (15, 35%) than the Northeast (9, 16.7%; p <0.05). The largest proportion of responders using the Mogen clamp (Sklar®) were from the Northeast (12, 22.2%), significantly greater than responders from the South (3, 4.1%) and the West (1, 2.4%; p <0.05). Most of the responders indicated that circumcision technique did not vary due to penile size (168, 76%), age (172, 77.8%) or weight (180, 81.4%). Age limit for neonatal circumcision differed across regions (chi-square=34.712, df=21, p=0.30). Overall, 156 of the responders (70.6%) utilize an age limit that is 12 weeks or younger. Similarly, differences in weight limit for neonatal circumcisions were also found to be statistically significant by region (chi-square=31.443, df=18, p=0.026). Most commonly, weight was limited to less than 4.54 kg (56, 25.3%). Overall, a weight limit defined as 12 lbs (5.44kg) or lighter was identified by 108 responders (48.9%). Of those individuals surveyed, most determined congenital buried penis to preclude neonatal circumcision (155, 70.8%), with 19.6% (43) reporting that this does not preclude neonatal circumcision. Medicaid coverage of neonatal circumcision was significantly different between regions (chi-square=22.214, df=6, p=0.001). Medicaid coverage for circumcision in labor and delivery as well as the neonatal unit was reported by 138 responders (82.1%). However, others reported Medicaid covered only neonatal unit circumcisions (20, 11.9%) or labor and delivery circumcisions (10, 6.0%). Most responders (90, 52%) reported charging greater than $300 for a noncovered neonatal circumcision.¹

This study suggests that various statistically significant differences exist in circumcision practice across geographic regions, including patient demographic qualifiers and procedure technique.¹ Presently, there is not a single, uniform education and training program for best neonatal circumcision practices implemented nationally. However, our study provides valuable information on age and weight criteria among pediatric urologists nationwide that can be used in the education of nonurology providers. Similarly, the widespread use of the Gomco device and Plastibell, with limited use of the Mogen clamp, would support education of nonurological providers with use of Gomco and Plastibell. Furthermore, as most respondents (70.8%) reported that congenital buried penis is a contraindication to circumcision, we believe that nonurological providers of neonatal circumcision should be trained to assess for congenital buried penis. As leaders in the field, it would be ideal for pediatric urologists to establish guidelines for evaluation of neonatal circumcision in infants, and to develop educational tools and performance assessments for nonurological providers performing this procedure. Studies have evaluated the impact of formalized training modules on physicians performing circumcisions, demonstrating a beneficial impact on clinical outcomes and improved circumcision care.^2–4 Our results demonstrate that most of the responding pediatric urologists are comfortable performing circumcisions in male infants less than 12 weeks of age and less than 12 lbs (5.44 kg) in weight in the absence of a congenital buried penis. We believe this information is useful in the education of neonatal circumcision providers, and may warrant establishment of formalized criteria for best practice of neonatal circumcision.