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Having described the benefits, let's look at the risks. Surgical complications for large published series range from 0.2% to 0.6% [65, 66, 396]. Higher rates of 2-10% have been reported in much older and smaller studies [114, 138, 177]. One, conducted in US Army hospitals from 1980 to 1985, found that for 100,157 boys who were circumcised in the first month of life, there were 193 complications (0.19%) [396]. These included 62 local infections, 83 of hemorrhage (31 requiring ligature and 3 requiring transfusion), 25 instances of surgical trauma, 20 urinary tract infections (cf. 88 UTIs in the 35,929 boys in this study who had not been circumcised), and 8 cases of bacteremia (cf. 32 in the uncircumcised). There were no deaths or reported losses of the glans or entire penis. However, in the uncircumcised boys, 3 developed meningitis, 2 got renal failure and 2 died. The largest study, of 354,297 male infants born in Washington State from 1987-1996, noted a complication rate in the 130,475 who were circumcised during their newborn hospital stay of only 0.21% (1 in 476) [65]. It was then calculated that 6 UTIs could be prevented for every circumcision complication and 1 penile cancer prevented for every 2 complications. In a small study of 500 New Zealand boys over a longer period, namely from birth to 8 years of age, the rate of penile problems was 2-fold higher in those who were not circumcised (19% vs 11%), the inclusion of both minor and more serious problems leading to an overall higher rate than would otherwise have been the case [116]. Preliminary data such as in this study needs to be extended to very large studies, such as those conducted in the USA for infants, before a conclusion can be reached. A study in 2005 of 19,478 circumcisions in Israel (on day 8, made up of 83% ritual and 17% involving a physician) found a complication rate of 0.34% [41]. The breakdown is shown below, to which I have added comments by Dr Sam Kunin from Los Angeles , who is very experienced in the field of circumcision.

- Excess skin left 0.19%. This can be illusory. Dr Kunin says that if a baby is chubby, has an abundant prepubic fat pad or scrotal swellings from hydrocele or hernia it may look like not enough skin has been removed, when in reality the circumcision has been a good one. One can test this by seeing whether the glans penis is apparent in the erect state. To do this one can depress the fat surrounding the penis at the 3.00 and 9.00 o'clock positions to the pubic symphysis. If the glans is seen the circumcision is satisfactory. If the inner layer of foreskin is not completely freed up before circumcision there may be uneven inner skin left. This can lead to `buried penis' which is when the penis retracts into the fat pad. It can occur with the Mogen method and is avoided by Gomco. Adhesions can develop between the glans penis and the remnant of the foreskin. To avoid this, parents must be instructed to routinely push the skin off the glans.

- Acute bleeding 0.08%. Although rare, this is more prone to occur with a ritual shield. It cannot occur with the Plastibell.

- Penile torsion 0.03%. This is congenital, but can be revealed by circumcision. It does not affect function.

- Skin shortage 0.02%. This is unlikely to occur if the circumciser is experienced.

- Wound infection 0.01%. Although rare, this can be more common with Plastibell, if instruments are not sterilized adequately, or if in a ritual Jewish ceremony the mohel performs metzitza b' pe (the sucking of blood from the would by mouth - which can also lead to herpes simplex type 1 infection).

- Partial amputation 0.005% (n = 1). Partial amputation cannot occur with the Plastibell or Gomco clamp, but is a remote possibility for Mogen clamps or, in Jewish ritual circumcisions, shields.

- Inclusion cysts can occur, most often with the Mogen procedure, since freeing up the foreskin from the glans is blind and does not include cleaning out smegma, which becomes trapped in the line of the clamp to form a cyst. In Gomco and Plastibell a dorsal slit in the foreskin is made after clamping and at this time all inner connections can be released and smegma removed.

Thanks to Dr Kunin for the clinical explanations and advice. He says that it is important to equate a given complication with what tool is used, but overall complications should approach zero for an experienced operator.

Thus, in this study, complications were rare, mild and virtually all easily correctable, with little difference in rate between ritual and medical circumcisions.

An overall summary of the various complications of circumcision in infancy and the rates of each appears below. References: [8, 390-392, 396].

· Excessive bleeding: Occurs in 1 in 1000. This is treated with pressure or locally-acting agents, but 1 in 4000 may require a ligature and 1 in 20,000 need a blood transfusion because they have a previously unrecognized bleeding disorder. Hemophilia in the family is of course a contra-indication for circumcision.

· Infection: Local infections occur in 1 in 100-1000 and are easily treated with local antibiotics. Systemic infections may appear in 1 in 4,000 and require intravenous or intramuscular injection of antibiotics.

· Subsequent surgery: Needed for 1 in 1000 because of skin bridges, or removal of too much or too little foreskin. Repair of injury to penis or glans required for 1 in 15,000. Loss of entire penis: 1 in 1,000,0000, and is avoidable by ensuring the practitioner performing the procedure is competent. Injuries (rare) can be repaired and in the extraordinarily remote instance of loss of the penis it can be reattached surgically [262]. (Successful reattachment can also follow adult self-inflicted penile amputation [203].)

· Local anesthetic: The only risk is when the type of anesthetic used is a dorsal penile nerve block, with 1 in 4 having a small bruise at the injection site. This will disappear.

· Death: Data in the records show that between 1954 and 1989, during which time 50,000,000 circumcisions were performed in the USA there were only 3 deaths, but during this period there were 11,000 from penile cancer, a disease essentially confined to the uncircumcised [392]. In the study by Wiswell referred to above there were 2 deaths in those NOT circumcised, but none in the 3 times as many who were circumcised [396]. In Jewish ritual circumcision tightly wrapped gauze is used to stop minor bleeding (as compared to use of local pressure in hospitals), and it is thought that this can cause urinary retention and hence UTI [149]. Not surprisingly, complication rates are higher when circumcision is carried out by individuals who are not medically trained [260].

Although very rare, complications from use of the Plastibell have been reported and include a higher rate of infection [124], proximal migration and tissue strangulation if the none chosen is too large [66], pressure necrosis of the glans if one is used that is too small [66], urinary retention [231], distended bladder [215] and sepsis [186]. To illustrate the rarity of these, in a study of 2000 neonates there were no serious sequelae at all [7]. In the case of the Gomco clamp excessive removal of foreskin tissue can occur [124].

It should be stressed that there are contraindications to circumcision in the case of prematurity, family history of bleeding disorders (hemophilia), penile abnormalities (hypospadias, epispadias, micropenis, ambiguous genitalia, megalourethra, webbed penis) in which the foreskin may be required to reconstruct the penis at a later date [8]. Not surprisingly, nonmedical, co-called "community circumcision" is associated with higher risk of complications [76].