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    Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention-15 African Countries, 2015-2019. Lucas Todd,Hines Jonas Z,Samuelson Julia,Hargreave Timothy,Davis Stephanie M,Fellows Ian,Prainito Amber,Watts D Heather,Kiggundu Valerian,Thomas Anne G,Ntsuape Onkemetse Conrad,Dare Kunle,Odoyo-June Elijah,Soo Leonard,Toti-Mokoteli Likabelo,Manda Robert,Kapito Martin,Msungama Wezi,Odek James,Come Jotamo,Canda Marcos,Gaspar Nuno,Mekondjo Aupokolo,Zemburuka Brigitte,Bonnecwe Collen,Vranken Peter,Mmbando Susan,Simbeye Daimon,Rwegerera Fredrick,Wamai Nafuna,Kyobutungi Shelia,Zulu James Exnobert,Chituwo Omega,Xaba Sinokuthemba,Mandisarisa John,Toledo Carlos BMC urology BACKGROUND:Voluntary medical male circumcision (VMMC) is an HIV prevention strategy recommended to partially protect men from heterosexually acquired HIV. From 2015 to 2019, the President's Emergency Plan for AIDS Relief (PEPFAR) has supported approximately 14.9 million VMMCs in 15 African countries. Urethrocutaneous fistulas, abnormal openings between the urethra and penile skin through which urine can escape, are rare, severe adverse events (AEs) that can occur with VMMC. This analysis describes fistula cases, identifies possible risks and mechanisms of injury, and offers mitigation actions. METHODS:Demographic and clinical program data were reviewed from all reported fistula cases during 2015 to 2019, descriptive analyses were performed, and an odds ratio was calculated by patient age group. RESULTS:In total, 41 fistula cases were reported. Median patient age for fistula cases was 11 years and 40/41 (98%) occurred in patients aged < 15 years. Fistulas were more often reported among patients < 15 compared to ≥ 15 years old (0.61 vs. 0.01 fistulas per 100,000 VMMCs, odds ratio 50.9 (95% confidence interval [CI] = 8.6-2060.0)). Median time from VMMC surgery to appearance of fistula was 20 days (interquartile range (IQR) 14-27). CONCLUSIONS:Urethral fistulas were significantly more common in patients under age 15 years. Thinner tissue overlying the urethra in immature genitalia may predispose boys to injury. The delay between procedure and symptom onset of 2-3 weeks indicates partial thickness injury or suture violation of the urethral wall as more likely mechanisms of injury than intra-operative urethral transection. This analysis helped to inform PEPFAR's recent decision to change VMMC eligibility policy in 2020, raising the minimum age to 15 years. 10.1186/s12894-021-00790-y
    Determinants of morbidity associated with infant male circumcision: community-level population-based study in rural Ghana. Gyan Thomas,McAuley Kimberley,Strobel Natalie A,Shannon Caitlin,Newton Sam,Tawiah-Agyemang Charlotte,Amenga-Etego Seeba,Owusu-Agyei Seth,Kirkwood Betty,Edmond Karen M Tropical medicine & international health : TM & IH OBJECTIVE:Male circumcision services have expanded throughout Africa as part of a long-term HIV prevention strategy. We assessed the effect of type of service provider (formal and informal) and hygiene practices on circumcision-related morbidities in rural Ghana. METHODS:Population-based, cross-sectional study conducted between May and December 2012 involving 2850 circumcised infant males aged under 12 weeks. Multivariable logistic regression models were adjusted for maternal age, maternal education, income, birthweight and site of circumcision. RESULTS:A total of 2850 (90.7%) infant males were circumcised. Overall, the risk of experiencing a morbidity (defined as complications occurring during or after the circumcision procedure as reported by the primary caregiver) was 8.1% (230). Risk was not significantly increased if the circumcision was performed by informal providers (121, 7.2%) vs. formal health service providers (109, 9.8%) [adjusted odds ratio (aOR) 1.11, 95% CI 0.80-1.47, P = 0.456]. Poor hygiene practices were associated with significantly increased risk of morbidity: no handwashing [148 (11.7%)] (aOR 1.78, 95% CI 1.27-2.52, P = 0.001); not cleaning circumcision instruments [174 (10.6%)] (aOR 1.80, 95% CI 1.27-2.54, P = 0.001); and uncleaned penile area [190 (10.0%)] (aOR 1.84, 95% CI 1.25-2.70, P = 0.002). CONCLUSION:The risk of morbidity after infant male circumcision in rural Ghana is high, chiefly due to poor hygiene practices. Governmental and non-governmental organisations need to improve training of circumcision providers in hygiene practices in sub-Saharan Africa. 10.1111/tmi.12829
    Pain control in neonatal male circumcision: A best evidence review. Journal of pediatric urology OBJECTIVE:Routine male infant circumcision (RMIC) is a common procedure that inadvertently causes significant but preventable pain. In this best evidence review, we examine the available pain management options and their effectiveness for RMIC. MATERIAL AND METHODS:The Medline (OVID) and Cochrane library were searched for randomized controlled trials investigating pain control for RMIC. Only trials that included newborns younger than 45 days of age were included. The articles generated in the initial search were screened independently by two of the authors. A third reviewer settled any discrepancies about the inclusion. Then, trials were categorized based on the type of intervention: topical anesthetics, oral sucrose, oral acetaminophen, nerve blocks, caudal blocks, circumcision device, non-pharmacological adjuncts, and multiple combinations. RESULTS:Twenty-nine randomized clinical trials (RCTs) were found to address pain preventative measures in RMIC. As single agent, nerve blocks outperformed topical anesthetics and oral sucrose, as the latter two proved to be insufficient for proper pain control. Additionally, dorsal penile nerve block and ring blocks have a reasonable safety profile. The use of caudal blocks in RMIC was uncommon. Oral sucrose in association with swaddling or music are helpful and can be easily combined with other methods of pain management. Moreover, oral acetaminophen given perioperatively helps the patient recover. Ultimately, pain control should rely on a combination of anesthetics, analgesics, and kinesthetic methods to be administered before, during, and after the procedure for optimal outcome. CONCLUSION:RMIC is a painful procedure in need of proper pain control. Different interventions and agents have various abilities in controlling pain; however, developing a protocol centered around multimodal pain control proves to be the most effective. 10.1016/j.jpurol.2020.09.017
    Opinions and Perceptions Regarding Traditional Male Circumcision With Related Deaths and Complications. Douglas Mbuyiselo,Maluleke Thelmah Xavela,Manyaapelo Thabang,Pinkney-Atkinson Vicki American journal of men's health The notion of manhood values is highly treasured and respected by various cultural groups practicing traditional male circumcision (TMC) in South Africa. This study was conducted at Libode, Eastern Cape, South Africa. The goals of this study were to (a) explore opinions and perceptions related to TMC among boys from 12 to 18 years of age, and (b) determine the actions to be taken to prevent high mortality and morbidity rates related to TMC. A simple random sampling was used to select three focus group discussions with 36 circumcised boys, and purposive sampling was used to select 10 key informants. The overarching themes collated included the following: (a) accepted age for circumcision, (b) causes attributed to deaths and complications, (c) TMC is preferred to medical male circumcision, and (d) acceptable community actions to prevent the problem. The study concludes with discussion and recommendation of a comprehensive health promotion program that is considerate of community opinions and perceptions in the prevention of deaths and complications affecting the circumcision initiates and at the same time respecting the culture. 10.1177/1557988317736991
    Is the PrePex device an alternative for surgical male circumcision in adolescents ages 13-17 years? Findings from routine service delivery during active surveillance in Zimbabwe. Mavhu Webster,Hatzold Karin,Madidi Ngonidzashe,Maponga Brian,Dhlamini Roy,Munjoma Malvern,Xaba Sinokuthemba,Ncube Getrude,Mugurungi Owen,Cowan Frances M PloS one BACKGROUND:Male circumcision devices have the potential to accelerate adolescent voluntary medical male circumcision roll-out. Here, we present findings on safety, acceptability and satisfaction from active surveillance of PrePex implementation among 618 adolescent males (13-17 years) circumcised in Zimbabwe. METHODS:The first 618 adolescents consecutively circumcised from October 2015 to October 2016 using PrePex during routine service delivery were actively followed up. Outcome measures included PrePex uptake, attendance for post-circumcision visits and adverse events (AEs). A survey was conducted amongst 500 consecutive active surveillance clients to assess acceptability and satisfaction with PrePex. RESULTS:A total of 1,811 adolescent males were circumcised across the three PrePex active surveillance sites. Of these, 870 (48%) opted for PrePex but only 618/870 (71%) were eligible. Among the 618, two (0.3%) self-removals requiring surgery (severe AEs), were observed. Four (0.6%) removals by providers (moderate AEs) did not require surgery. Another 6 (1%) mild AEs were due to: bleeding (n = 2), swelling (n = 2), and infection (n = 2). All AEs resolved without sequelae. Adherence to follow-up appointments was high (97.7% attended 7 day visit). A high proportion (71.6%) of survey respondents said they heard about PrePex from a mobilizer; 49.8% said they chose PrePex because they wanted to avoid the pain associated with the surgical procedure/surgery on their penis. Acceptability and satisfaction with PrePex was high; 95.4% indicated willingness to recommend PrePex to peers. A majority (92%) reported experiencing pain when PrePex was being removed. CONCLUSIONS:Active surveillance of the first 618 adolescent males circumcised using PrePex suggests that the device is both safe and acceptable when used in routine service delivery among 13-17 year-olds. There is need to intensify specific demand generation activities for PrePex male circumcision among this group of males. 10.1371/journal.pone.0213399
    Male Circumcision Complications - A Systematic Review, Meta-Analysis and Meta-Regression. Shabanzadeh Daniel Mønsted,Clausen Signe,Maigaard Katrine,Fode Mikkel Urology OBJECTIVE:To determine the risk of complications requiring treatment following male circumcision by health-care professionals and to explore the impact of participant characteristics, type of circumcision and study design. METHODS:We identified studies through systematic searches in online databases (MEDLINE, EMBASE and CENTRAL) and hand searches. We performed random-effects meta-analysis to determine risk of circumcision complications and mixed-effects metaregression analyses to explore the impact of participant characteristics, type of circumcision and study design. Methods were prespecified in a registered protocol (Prospero CRD42020116770) and according to PRISMA guidelines. RESULTS:We included 351 studies with 4.042.988 participants. Overall complication risk was 3.84% (95% confidence interval 3.35-4.37). Our meta-analysis revealed that therapeutic circumcisions were associated with a 2-fold increase in complications as compared to nontherapeutic (7.47% and 3.34%, respectively). Adhesions, meatal stenosis and infections were the most frequent complication subgroups to therapeutic circumcisions. Bleeding, device removals and infections occurred more frequently in nontherapeutic circumcisions. Additionally, adjusted metaregression analyses revealed that children above 2 years, South American continent, older publication year and smaller study populations increased complication risk. Type of circumcision method, provider and setting were not associated with complication risk. Sensitivity analyses including only better-quality studies reporting indication, age at circumcision, treatment for complications, full-text articles, and adequate follow-up clinically for a minimum of one month or through databases confirmed our main findings while accounting better for heterogeneity. CONCLUSION:Circumcision complications occur in about 4 per hundred circumcisions. Higher risks of complications were determined by therapeutic circumcisions and by childhood age when compared to infant. Future studies should assess therapeutic and childhood circumcisions separately. 10.1016/j.urology.2021.01.041
    Systematic review of complications arising from male circumcision. BJUI compass Background:Neonatal male circumcision is the most common procedure performed on paediatric patients (Simpson et al., 2014) and one of the most common surgical procedures in the world (American Academy of Pediatrics, 2012). Methods:A search was conducted for articles about complications arising from male circumcision surgeries by entering the term 'male circumcision' into PubMed on June 16, 2020. Six thousand six hundred forty-one articles published from 1945 to 2020 were found. Seventy-eight articles were ultimately selected for the systematic review. Results:The 78 articles selected from the literature search were entered into one of three tables. The first table includes 15 articles pertaining to chart reviews and cohort studies and report complication rates. The second table reports specific complications from 51 case reports and case series, and the third table is a summary from 12 articles regarding physician questionnaires and society recommendations. Additionally, the 78 articles were used to compile a list of 47 specific complications arising from male circumcision surgeries. Conclusions:Complications from neonatal male circumcisions are common and healthcare providers need to be better informed of the potential complications of the surgery so that they can more effectively counsel their patients about potential risks, likelihood of complications and what can be done to prevent them. While experienced providers who practice in sterile settings have better outcomes with fewer complications, encouraging parents to take into account who is performing their son's circumcision, what was their training, how clean is their practice and how much experience they have and reminding them they have the option to decline the procedure entirely allow the parents to get a more complete picture and play an essential role in the decision-making process. 10.1002/bco2.123
    Pigmentary complications after non-medical male circumcision. Tirana Radwa,Othman Doa,Gad Dalia,Elsadek Menan,Fahmy Mohamed A Baky BMC urology BACKGROUND:A wide spectrum of complications are reported after male circumcision (MC), the non-aesthetic complications are well known, but the pigmentary complications scale are not reported precisely. METHODS:This is a prospective cohort study of 550 circumcised boys; aged from 6 months to 14 years (62% aged 5 years) who were examined and appropriately investigated for the incidence of pigmentary complications after circumcision. Most diagnoses were clinically, but dermoscopy was done for 17 case and a skin biopsy for 14 cases. Patients with personal or family history of vitiligo, or congenital nevi were excluded. Available hospital records details and parents' statements were revised. The main outcome measures are the incidence of different pigmentary complications and circumcision details; data were analyzed by a non-parametric tests including the Mann-Whitney U test. RESULTS:69 cases had 72 confirmed pigmentary complications discovered at 2-36 months after commencement of circumcision (mean 18). 48 cases had pigmentary complications directly related to MC, 11 cases were probably related and 10 unrelated to MC. The most common lesion is the circular hyperpigmented scar (29 cases); liner hyperpigmented scar in 13, spotted exogenous melanosis in 18 cases, melanocytic nevi (7), hypopigmentation diagnosed in 3 cases, but kissing nevus is the rarest finding (2). Topical corticosteroid was tried in 15 cases, surgical excision of pigmented scar were done for 19 cases, local laser used for 4 resistant cases and reassurance with follow up for the rest. CONCLUSION:Pigmentary complications after male circumcision are not rare and its management is challenging. 10.1186/s12894-022-00999-5