COMMENTARY

Gomco or Mogen for Newborn Circumcision: Is One Better Than the Other?

William T. Basco, Jr., MD, MS

Disclosures

December 17, 2018

Which Instrument Is Safest?

The current position of the American Academy of Pediatrics is that in the United States, the available evidence suggests that the benefits of elective newborn male circumcision outweigh the risks.

Heras and colleagues[1] recently compared outcomes of newborn circumcisions performed at two community hospitals, using two different instruments—the Gomco clamp and the Mogen clamp. Outcomes of interest were postprocedure complications such as bleeding, swelling, infection, urinary retention, insufficient foreskin removal, or the need for a revision procedure. The circumcisions were done between August 2011 and December 2014.

Circumcision complications were classified as minor, intermediate, or major. Minor complications included bleeding that required pressure or topical treatment, local wound infection that required topical antibiotics, or urinary retention lasting longer than 6 hours. Intermediate complications were bleeding that required suturing, wound infection that required systemic antibiotics, insufficient foreskin removal requiring a revision, or urinary retention sufficient to warrant the involvement of an urologist. Major complications involved potential or actual permanent injury that required further treatment.

Circumcision Complications

The investigators reviewed the medical records of 1064 infants who were circumcised in the hospital. All infants were at least 37 weeks' gestation, and severely ill infants were excluded. Circumcisions were performed in the regular nursery (95%) or the neonatal intensive care unit (5%). Most circumcisions were done by obstetric clinicians (45.7% by obstetric residents and 40% by obstetric attending physicians) and less frequently by pediatric providers (13.6% by pediatrician attending physicians, and less than 1% by pediatric residents). The Gomco clamp was used for about 55% of circumcisions and 44% were performed with the Mogen clamp.

Complications were rare, occurring after just 3.8% of all circumcisions. All complications were either minor or intermediate. Bleeding was the only complication, 58.5% of which were controlled with pressure, 26.8% with silver nitrate, 7.3% with topical thrombin, and another 7.3% by suturing.

In comparing circumcisions performed by obstetric attending physicians and obstetric residents, no differences in rates of bleeding were found. Although the Gomco method was used in 55.8% of the procedures, it accounted for 73.1% of the bleeding episodes.

These data suggest that elective newborn circumcision can be safely performed, with tolerable complication rates, in community hospitals. Furthermore, rates of bleeding with the Gomco clamp were higher than with the Mogen clamp.

Viewpoint

I chose this study for review because pediatric providers need periodic updates on what should be expected in terms of circumcision complications. The study authors are careful to acknowledge that they can't support one instrument over the other, even though the bleeding frequency was slightly higher among the circumcisions performed with the Gomco clamp. Another study in the same issue of Hospital Pediatrics[2] reviewed the data from a single hospital to evaluate circumcision complications and the need for revision. In that study of almost 1700 circumcisions, the complication rate of 1.53% was slightly lower. Almost all of the complications were bleeding, but they did find some major complications, and 0.5% required a revision procedure. The revision frequency after Gomco circumcision was 0.41% compared with 0.56% after Mogen circumcision, a nonsignificant difference. In light of both of these studies, pediatricians can expect bleeding after 1.5% - 3% of circumcisions. The need for a revision should be less than 1% among generally healthy newborns. These seem to be reasonable benchmarks for hospitals to use when looking at their own circumcision programs.

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