How do we do less circumcisions in the operating room and more in the clinic?

The case for clinic circumcisions

In my practice, the majority of cases done in the operating room (OR) under general anesthesia are circumcisions. Doing all these circumcisions in the clinic instead of the OR would result in significant money and time savings:

  1. A circumcision in the office can be done for around $400, whereas the costs in the operating room are closer to $5,000-$10,000.
  2. I can book circumcisions in the office every 20 minutes, whereas I need to book 1 hr for a circumcision in the OR — due to the time it takes to put a patient under anesthesia, wake him up and clean the room.

 

Key elements for successful clinic circumcisions

In order to switch circumcisions from the OR to the clinic, certain things need to be optimized:

  1. Penile block: perfecting the penile block technique is key to a successful clinic circumcision for obvious reasons.
  2. Sedation: for small babies under 3-6 months of age — who don’t seem to care much when they are strapped to a circumcision board– as well as older children able to cooperate, sedation is not necessary. However, most other boys would need some sort of sedative to allow them to lay still.
  3. Devices: for babies younger than 3 months, the Gomco clamp works great. However, Gomco circumcisions are associated with more bleeding in babies older than 3 months. A freehand circumcision can be done in 15 minutes in a child under anesthesia who is not moving or crying. However, trying to do a freehand circumcision under not ideal circumstances can take longer. That is why using devices like the Shang ring could be key for a successful and quick office circumcision in older boys.

 

 

Penile block

The penile block is the foundation of a clinic circumcision. The faster one can be delivered and the more effective one is, will be critical at determining the success of this endeavor.

Up to recently, I was using 1% Lidocaine with mixed results. I don’t know if my results were mixed because of the medication itself, not waiting enough to allow the block to work, or due to the injection technique. This is why I sought to find out the best medication and injection technique for penile blocks.

There are many variables with regards to the penile block:

  • Type of block.
  • Type of drug.
  • Lenght and caliber of the needle.
  • Speed of the injection
  • Wait time in between the block and the procedure.
  • The temperature of the medication.
  • Adjuncts (sucrose, swaddling, room temperature, etc.)

Type of block

One approach is to block the dorsal nerve of the penis –which is a terminal branch of the pudendal nerve — in the subpubic space under Scarpa’s fascia. This block is done at 10 and 2 o’clock by placing the penis on mild downward traction and getting the needle caudal to the pubic bone. One can try to touch the pubic bone first and then move inferior to get into the subpubic space. In the OR I have found that needles shorter than 1 inch cannot even touch the pubic bone in the normal chubby 1-year-old, and thus I believe longer needles are necessary for a good dorsal nerve block.

The dorsal nerve block is often combined with a ring block around the base of the penis. The question is how close to Buck’s fascia should the ring block be done: closer to Bucks or closer to the skin? Since the nerves come off the inside of Bucks fascia, it would be preferable to stay close to the penis. Also, injecting into the dermis is more painful than injecting into the subcutaneous space.

Local Anesthetic

Most penile blocks are either done with 1% Lidocaine or with 0.25-0.5% Bupivacaine. But which is better? Also, should everyone get EMLA before the procedure or the block is enough?

Bupivacaine allows for the administration of more volume in the neonatal period, which sometimes facilitates the block. This study compared lidocaine versus bupivacaine in 38 neonates undergoing circumcision. The study outcome was the administration of Tylenol after the procedure. 59% of the boys that received lidocaine were given Tylenol compared to 16% of those that received Bupivacaine. Although the study had many flaws –the biggest of which was its retrospective design– I was not able to find a better study of this kind.

The administration of EMLA cream 1 hour before the circumcision has also been extensively studied. The study just mentioned above used EMLA administered by the parents 1 hrs before the injection of either lidocaine or bupivacaine. In addition, in the same study, the patients were given high doses of Tylenol before the procedure (25-30 mg/kg). EMLA by itself is, however, inferior to a penile block alone but superior to no anesthesia, with NIPS pain scores of 2.3 in the penile block group and 4.8 in the EMLA group — and higher in the no anesthesia group. Heart rate was increased by 49  with EMLA compared to 9 with the Dorsal penile block. A Cochrane review concluded DPNB was substantially better than EMLA. One downside of EMLA is the discoloration of the skin and edema sometimes seen which could potentially blur some of the landmarks necessary for a well-done circumcision.

A more recent study from Beirut compared EMLA  + sugar, EMLA + sugar +DBNV or EMLA +sugar + Ring block, with just EMLA (4 groups). They used 1% lidocaine at a dose of 2 mg/kg –0.6 ml for a 3 kg boy and 0.8 ml for a 4 kg boy. They allowed 5 minutes in between the injection and the procedure. The main outcome was pain assessed with a modified NIPS score. The NIPS scores were almost identical in between EMLA + sugar and EMLA + sugar + DPNB, which I think is due to the fact that so little Lidocaine (0.6-0.8ml) was administered — the very small volume of anesthetic likely insufficiently blocks the nerves. The NIPS scores went up by 2-3 points during the lysis of adhesions in all the groups, suggesting an incomplete block (again I think due to insufficient volume of anesthetic injected). Patients that had a ring block had less pain during the tying of the clamp. Patients that just received EMLA, exhibited very high pain scores throughout the procedure, suggesting that only using EMLA is not enough for newborn circumcisions.

EMLA could potentially reduce the pain of the injection, but none of the studies I read assessed that. My review of the literature suggests that adding EMLA to a good block adds little to nothing, except for the potential for a less painful injection. However, EMLA is unlikely to affect the pain of doing a DNPB since the nerves lie deeper away where it would have any effect. To decrease the pain of the injection, some have suggested that the faster the medicine is injected the more pain, so slowing down during the block might be better.

In conclusion, I would use Bupivacaine 0.25% as it allows for the administration of larger volumes of local anesthetic which would then allow for the performance of both a DPNB and a ring block. Also, bupivacaine seems to provide better postoperative pain control, as its average duration of action is 200 minutes compared to 100 minutes for Lidocaine. I would not recommend using EMLA as it seems to add little in terms of pain control and the edema it causes can make the circumcision more difficult.

 

Sedation

The ideal drug for sedation in the clinic would not cause respiratory or cardiovascular depression and would not require an IV. After talking to one of my anesthesiologist colleagues, he could not think of any drug that could be administered for sedation without some sort of post-procedure monitoring and support in case something goes wrong. He thought that a combination of Versed and Nitrous Oxide could work to do short procedures in the clinic.

Rosen’s Emergency Medicine does not recommend fasting for procedural sedation and analgesia (PSA) but do recommend capnography to detect any decrease in the respiratory rate.

Propofol was used by ED doctors for PSA in 25,000 with adverse effects noted in around 500, with one unplanned intubation, one cardiac arrest and 2 cases of aspiration. They identified weight less than 5 kg, used of multiple meds (ketamine, benzos, etc), primary diagnosis of URI or prematurity, and ASA >2 as risk factors.

Ketamine might seem like an ideal drug to use for PSA, however, it is associated with laryngospasm and apnea in 0.3-0.8% of administrations (Rosen’s Emergency Medicine). Other issues with ketamine are post-emergence agitation, increased salivation (more so in babies) and vomiting.

My conclusion with regards to sedation is that it may be best to try that in an environment with proper monitoring and supervision by someone from the anesthesia team. Unfortunately, clinic circumcision under sedation in urologic clinics ran by urologists and medical assistants might be too risky.

 

Devices

I found one article that has all the different devices that have been used for circumcisions, many of which I had never heard before.

This study compared Gomco circumcision + surgical glue versus freehand circumcision in adults. The authors reported similar cosmetic outcomes at 4 weeks, but 20% of wound separation at 2 weeks in the Gomco group — compared to 0 in the surgical arm — and 10 cases of bleeding in the Gomco group, 6 of which required suturing  –versus 1 case in the surgical group who required suturing. It is clear from this article, the article I referenced above, and my personal experience, that Gomco circumcision beyond the age of 3-6 months carries an increased risk of bleeding and wound separation, not worth the 10 minutes of operating time saved.

The Shang ring might be the ideal instrument for clinic circumcisions, as bleeding is rare when using this device. The experience with this device in the US is limited.

 

Examples from the literature

In this study from New York, 500 circumcisions were done in infants younger than 6 months with only local anesthesia. Some takeaways from that study include:

  • Waiting at least 3 minutes in between the block and the procedure.
  • Infants younger than 3 months settle down quickly, and infants 3-6 months can take 3-5 minutes to settle down.
  • Injecting most of the block as a ring block and less in the dorsal nerves.
  • They used 40 mg/kg of Tylenol in suppository form before the procedure.
  • They always test the effectiveness of the block by clamping the foreskin before they start.
  • One key element according to the authors was to feed the boy 5-10 minutes before the procedure.
  • The room temperature was kept at 72 degrees.

 

Conclusions

One achievable goal for most practitioners doing circumcisions in the clinic will be to do them in boys up to 3 months of age with the aim of inflicting minimal pain by doing a good block with 0.25% Bupivacaine and paying attention to other details highlighted in the last section.

One goal for myself will be to learn more about the Shang ring and gradually introduce it to select cases in the clinic, such as teenagers who do not want to be put under anesthesia.

With regards to boys 3-6 months to 12-13 years old, doing a circumcision in the clinic under sedation may not be worth the risks. To decrease the number of circumcisions done in the OR in this group, better options would include:

  • Improve access to newborn circumcisions in patients that cannot afford to pay the procedure. The 16 states without Medicaid coverage for male circumcision are California, Oregon, North Dakota, Mississippi, Nevada, Washington, Missouri, Arizona, North Carolina, Montana, Utah, Florida, Maine, Louisiana, Idaho, and Minnesota. Having worked in a state with Medicaid coverage and one without, I can tell you that the number of circumcisions done under anesthesia is about 10 fold in the state with no coverage. About 5% of my OR cases were circumcisions in the state with coverage, versus around 50% in the state without coverage.
  • Treat phimosis with steroid creams and gentle foreskin retraction.
  • Wait until puberty if possible.

 

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