Elsevier

Urology

Volume 152, June 2021, Pages 25-34
Urology

Penile Surgery
Male Circumcision Complications – A Systematic Review, Meta-Analysis and Meta-Regression

https://doi.org/10.1016/j.urology.2021.01.041Get rights and content

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.

Section snippets

BACKGROUND

Male circumcision is one of the oldest and most common surgical procedures with an estimated global prevalence of 30% among adult males. It is performed due to medical, health preventive, cultural, social, and religious reasons.1 Like all surgery, circumcision is a procedure with risks of complications. There is no consensus regarding the magnitude of circumcision complications, but a number of risk factors such as higher age at circumcision have been suggested.2,3 Due to multiple reasons for

METHODS

We registered a protocol including outcomes, explorative variables and methods before performing searches and analyses (www.crd.york.ac.uk/prospero, ID CRD42020116770). We performed systematic searches in online databases MEDLINE, EMBASE and CENTRAL using index terms (MeSH) and keywords. The search string was “(Circumcision, Male"[Mesh] OR circumcision) AND ("Postoperative Complications"[Mesh] OR complication* OR adverse) AND (boy* or male* or men or infant* or neonat* or newborn* or routine)”.

RESULTS

Electronic database searches yielded 4138 records after duplicates were removed. We included 331 studies according to eligibility criteria and identified 20 additional studies through hand searches. A total of 351 studies were included (Fig. 1) which contributed 469 unique study entries. Non full-text publications contributed 43 entries. Zero outcome events were reported in 76 entries. For characteristics of included studies and references see Supplementary Table 2. Studies reporting primary

DISCUSSION

We performed random-effects meta-analysis to determine risks of post-surgery complications and found about four complications per hundred circumcisions. We also performed mixed-effects metaregression analyses and found circumcision complications to be determined by therapeutic indication, age “child” at circumcision, and South American continent in both complete data and sensitivity analyses. General anesthesia, a study population consisting of private clinic, and European continent also

CONCLUSIONS

Studies of circumcision complications are heterogeneous regarding to the participant, type of circumcision, and study design. Risk of complications was about four per hundred circumcisions across studies and was mainly determined by the participant and the study design. Higher risk of complications was determined by therapeutic circumcisions and age 2-18 years at circumcision as compared to infants. Few of the explored type of circumcision variables seemed associated with complications such as

Acknowledgments

We would like to thank Igor Petrov, MD and Karin Mønsted Shabanzadeh for language assistance.

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      Circumcision age has an influence on the chance of complications; for example, circumcision complications are infrequent in neonates and infants attributable of the procedure's simplicity and the newborn's potential to recover [26]. Complications are also low when administered by medical personnel at a public (University Teaching) hospital [27,28]. Complications emerge when caregivers are unable to deliver proper sterile equipment and conditions [27].

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    Declarations of Interest: None to report.

    Financial disclosures: None to report.

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