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CIRCUMCISIONS IN DOCTORS' OFFICES AS SAFE AS THOSE IN HOSPITALS

COLUMBUS, Ohio -- New research shows that boys circumcised in a doctor's office fare just as well after the procedure as those who were circumcised in a hospital operating room.

Researchers compared the medical and economic outcomes of 532 circumcisions performed either in a doctor's office or an operating room. Only four patients in each group experienced complications. The cost savings in having the circumcisions done in the doctor's office were estimated at $1,609 per procedure, for an overall savings of $184,713 annually in this group of patients.

"There are tremendous savings by doing circumcisions under local anesthesia and avoiding a trip to the operating room," said Venkata Jayanthi, a clinical assistant professor of surgery at Ohio State University and Children's Hospital in Columbus.

Jayanthi co-authored the study with Joanna Burns, a registered nurse at Children's Hospital, and Stephen Koff, a professor of surgery at Ohio State. The research appears in a recent issue of the Journal of Urology.

The researchers divided the boys into two groups -- 287 infants aged 3 days to 9 months were circumcised in the doctor's office under local anesthesia, while 245 boys aged 6 months to 15 years were circumcised in an operating room under general anesthesia. The circumcisions took place at Children's Hospital within a 30-month period.

Boys in the United States are usually circumcised within the first few days of life. There were several reasons given for those in the office group for not having undergone circumcision immediately after birth. These included being born prematurely (105); penile abnormalities (40); the child was an adopted baby (14); and a short postnatal hospital stay (7). Why those in the operating room group had not been circumcised wasn't known since patient charts often lacked such details. Jayanthi said the main reason he and his colleagues started doing in-office circumcisions was "to keep our operating room time free."

Four patients from each group had complications. After the office circumcision, one boy developed an infection, one had some bleeding and two had recessed penises, which required an operation under general anesthesia. Four patients in the operating room group had bleeding, which was managed by a temporary pressure bandage.

He and his colleagues also looked at the price difference between the office and operating room procedures. They excluded the surgeon's fee of $425 in their analysis because this fee is the same regardless of where the procedure took place. The average office cost of $196 covered the fees for use of the office and the equipment. The $1,805 average operating-room fee covered general anesthesia and "global hospital fees," which included facilities, equipment and the salaries of the attending nurses and technicians.

"In the hospital, it's an operation -- not just a circumcision," Jayanthi said. "There are tremendous amounts of hidden costs at that level. The smaller charge for an office procedure helps defray the cost of the attendants and the equipment required for a circumcision."

For the office procedures, doctors injected each boy with a local anesthetic of 1 percent lidocaine. Each baby was placed on a standard circumcision restraining board. A Plastibell device was placed over the penis. This bell- shaped device allowed the foreskin to be pulled back and tied with a ligature. This essentially crushed the skin and controlled the bleeding. The bell fell off once the wound healed.

Although it may sound painful, about "half of all boys will be relatively comfortable during the office procedure," Jayanthi said, adding that some babies cried during the entire office procedure. However, these complaints could have been due to being restrained on the circumcision restraining board.

In the United States, many infants circumcised at birth do not receive anesthesia. A study in the Dec. 24, 1997 issue of the Journal of the American Medical Association showed that infants receiving local anesthesia cried less and had lower heart rates during and after the procedure when compared with those who did not receive anesthesia.

About 60 to 80 percent of all boys born each year in the United States are circumcised. It's the "cultural norm" in this country, Jayanthi said, citing that studies in some countries have shown an increased risk of urinary tract infections and HIV transmission in men who have not been circumcised.

However, the American Academy of Pediatrics recently issued a statement indicating that the mild increase in risk of infections does not warrant routine circumcision of all boys and that there is no medical reason for newborn circumcision. The AAP also suggests that local anesthesia be used to decrease a boy's pain should the parent elect to have their son circumcised.

"Most parents in the U.S. don't get their boys circumcised because they are afraid that their child will develop an infection; rather, they get the babies circumcised because their fathers usually are," Jayanthi said. "There is also the false perception that a circumcised boy will be easier to care for."

Jayanthi said that this study suggests that if parents want their son to be circumcised, yet the circumcision cannot be performed immediately after birth, the procedure should be done in an office setting as soon as it is medically safe.

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