Preferencias del usuario a considerar

xlvii

upper Egypt had circumcision done for cultural reasons by an inexpert surgeon who removed excess penile skin causing long lasting infection. This healed with hypertrophic scar that spread to involve the dorsal penile skin leaving a huge mass. When all conservative measures (pressure dressing, irradiation) failed, complete exisional biopsy, reconstruction of the supra pubic region and coverage with split thickness skin grafting were performed with good result.

xlviii

From the above, one can infer that the economic cost of a medical procedure consists of:

(1) Direct cost: which is the monetary expenditure attributable to the procedure, the time spent to perform the procedure and how long it takes to achieve the desired results (with regards to newborn circumcision, this implies days of healing or duration in days for the ring to drop or slough off)

(2) Indirect cost which is associated with loss of output attributable to the complications arising from the procedure.

In the assessment of (2) above, it would be incomplete to ignore the benefit of a medical procedure when discussing the cost. The type of benefit the individual receives from health care could be psychic or monetary, relief from pain, suffering, anxiety ⁹⁵ etc.

With regards to circumcision in the newborn, this can be related to the future benefits in preventing invasive penile carcinoma, reduction of risk of cervical cancer in female partners and decreased risk of UTI STDS and AIDS. 5, 7, 8,14,9697

Benefit in the form of capital good being monetary ‘pay off’ measured by increased production: In case of circumcision this had been related to the amount that will be saved in terms of expenditure for circumcision of Adults/Pubertal boys in USA^.98 a decision analysis model in which they evaluated the cost of the circumcision in the newborn compared to the cost of adult circumcision. With the average annual cost of circumcision in the US being $250 million from various sources^. It has been estimated that 10 to 15% of uncircumcised male subjects will eventually need the procedure later in life. As adults, they will miss work, have to pay for hospitalization, anaesthesia etc. A conclusive estimate for the cost of an adult circumcision is $2000 to $4000. Thus, if no boy was circumcised in the USA and 10% later required the procedure, the annual cost would be $400 to $800 million, far greater than the cost of neonatal circumcision⁹⁸

PROCEDURE TIME

The duration of time spent to perform circumcision using a particular technique can be used to indirectly determine the ease of use of the technique and directly determine the convenience experienced by the service provider and the degree of discomfort imposed on the patient.

xlix

Most statements on circumcision procedure time were mere commentaries without specifications. Moskovich²¹ asserted that the use of special circumcision forceps (with seven indentations) hastened the procedure time. Yellen²² who designed a template for Gomco clamp reported 500 cases of circumcision and claimed that the time spent in performing each was less than that by other methods. In the two studies above, the authors neither stated the range of procedure time nor that of the methods of comparison.

Melges and Stadles²⁶ used the Glansguard for circumcision of thousands of infants for over 35 years. The authors stated that the procedure of circumcision using the instrument could be completed within 3 minutes. Kariher and Smith²⁷, the originators of the plastibell circumcised 600 of the 800 newborn males in their series with the instruments. The authors concluded that none of the procedures lasted more than 3 minutes.

They recommended the use of plastibell for circumcision as an office procedure.

Marshall et al ⁹⁹ in 1980 found that Gomco clamp circumcision lasted 7.6 ± 1.8 minutes. Schoen⁶ remarked on Marshall’s study that the results were comparable to that of the plastibell in convenience and speed of procedure.

Currently, the use of Mogen clamp for circumcision has been reported to be swifter than them all; lasting about 30 seconds²⁴. However, it is uncertain whether the time spent for the initial separation of the adhesions between the glans and inner preputial membrane, making of dorsal slit and clearing of the smegma was actually taken into consideration in the timing reported by various authors.

DURATION OF DAYS FOR THE RING TO DROP

After the ischaemic necrosis of the ligated foreskin, the ring will drop off leaving a circumcised appearance. The number of days it takes for the ligated foreskin to slough off is an objective way of assessing the time of healing of circumcision wounds. There have been conflicting reports about this. Robenstein and Bason⁷⁷ allowed the plastibell ring to remain till 10 to 12 days but Frazer et al⁶³ expected that all rings would drop off within 9 days after circumcision. In the series studied by Kariher and Smith²⁷, healing occurred within 6 days. The current manufacturers of Plastibells( PlastiBell Hollister Libertyville ILL. USA) recommended that the Plastibell ring should slough off within the first week of the surgery. This is quite reasonable and acceptable because carrying a foreign body about

l

in the external genitalia beyond a week can be culturally embarrassing especially where the people are not used to the technique in trial.

CHARGING PATIENTS FOR CIRCUMCISION

Since 1950, British National Health Service (NHS) had deleted non-therapeutic neonatal circumcision from the schedule of covered procedures.^12,34 Circumcision is provided under the NHS only for medical reasons not on religious grounds¹⁰⁰. While there is no duty upon doctors or hospitals to do so, some will do this procedure without charge rather than risk the procedure being carried out in unhygienic conditions. The cost to the patient for the expenses incurred in providing plastibell circumcision service in Bradford Royal Infirmary in 1998 was 60 pound sterling per procedure.¹⁰⁰

In the United States of America fees paid to physician(s) for circumcision generally range between $75 and $125. Most hospitals do not charge separately for circumcision.^,98

In the states that use the medicaids prospective payment system, the facility charges for circumcision are part of a single payment to the hospital for the care of normal newborn infant. Some private insurance, plan to reimburse physician for the procedure and others do not^.98

In Pennsylvania and Michigan, reimbursement range from $20 to$28 and each state has its’ own payment structure.

In1998, approximately 30% of all newborn were insured through medicaid program. According to state report, the cost of universal circumcision in the USA would therefore be $140 million a year.^97,

It is not possible to estimate what the cost of universal circumcision may be in Nigeria because:

(1) The proposed National Health Insurance Scheme is yet to take off and even when it eventually does it cannot cover all patients and all procedures.

(2) Different private enterprises (banks, factories etc.) quasi-civil service institutions operate different health insurance schemes for their employees and restricted number of dependants with different pay structure.

(3) In most government hospitals, the government pays the staff while the patients buy the drugs and materials needed for special procedures.

li

(4) Majorities of Nigerians who are rural dwellers, and are self employed do not have access to the above services and hence bear the cost of their health care.

In Nigeria, fees paid to circumcisers vary thus:

(i.) About N 200 in the primary health centres in Ogbomoso.

(ii.) N500 to physicians in private hospitals in Ogbomoso.

(iii.) N800 for plastibell circumcision in BMC Ogbomoso.

(iv.) Greater than or equal to N1, 500 in some Teaching Hospitals.

(v.) Greater than or equal to N2, 000 in some private hospitals in Lagos.

In 1998, circumcision cost N1500 in ABUTH Zaria ⁵⁹, which was about 10 times the price charged by the cheapest untrained traditional operator for circumcision without anaesthesia in the region. The sharp decline in the number of circumcision performed in recent years in that Teaching Hospital has been ascribed to the introduction of hospital fees.

The result has been a sharp rise in the incidence of complications following circumcision performed outside.

lii

SUMMARY OF THE LITERATURE REVIEW

Circumcision is one of the oldest surgical procedures. The history dates back to the time of Mohammed. The practice was adopted by Africans from their Arabian trade partners before spreading to other parts of the continent. The procedure is practiced in different cultures for different reasons ranging from religious, cultural and social identification. After its adoption in England in 1865, it became a therapeutic procedure for various ailments. Later, the British National Health Service, The American Academy of Pediatrics began to fault the procedure as being too risky in the same way that Canada and Australia termed the procedure traumatic with violation of human right. However, circumcision is practiced in many parts of Africa except some isolated areas in Western, Eastern and Southern Africa.

Early circumcisions were done free handed till 18^th century when the use of flat shield and probe was introduced. By the beginning of the 20^th century, Sir Fredrick Treves introduced the use of scissors and suture ligation of bleeding frenular vessels only in adults.

To aid haemostasis, Moskovitch designed a circumcision forceps with indentations, but this was poorly accepted because of poor cosmetic result. This led to the development of other clamps like Gomco, Nuteck, Kantor, Sheldon (Bone forceps) and Plastibell each of which has its deficiencies.

The plastibell was initially designed to improve on Ross rings by Kariher and Smith in 1956. Unlike the Ross rings, it was made of special plastic (butyrate). It is cheap simple and disposable and can be used in older children.

Since medical ethics disagree with inflicting pain on the patient by the doctor, the practice of circumcision is considered cruel and unethical. It is recommended that consent be obtained from the parent(s) or equivalent, before the procedure is carried out. Though the Nigerian Medical Council has given no clear practice guidance on circumcision, the British Medical Council recommended that it should always be done by competent doctor with consent or else the circumciser may face the wrath of the Law.

Attempts have been made to minimize the painful distress caused by the procedure of circumcision. Since general anaesthesia is not safe in newborns, local anaesthetic technique have been employed but not without documented complications.

liii

Dorsal penile nerve blocks or penile ring block can cause pain, penile swelling and penile gangrene. EMLA cream takes long time to act and like the nerve blocks, it is associated with the risk of methaemoglobinaemia because of their prilocaine/ lidocaine content.

Since the pain of circumcision is short lived, most doctors do circumcise newborns on the 8^th day of life for various reasons. Circumcision is carried out by local circumcisers, traditional birth attendants, nurse/midwives and doctors using various techniques. In Nigeria, the practice of circumcision is not legally controlled thus allowing unbridled practice despite the varying degree of complications there from, which are often referred to the Teaching Hospital for management. Only competent Nurses are allowed to circumcise if he/she is delegated to or is supervised by a doctor to perform the procedure.

In Nigeria, only very few studies had been carried out on circumcision. Most of them are retrospective review of cases referred to the Teaching Hospital.

Usually surgical complications of circumcision are due to the operators inexperience rather than the method(s) employed. Studies have shown that complication rate may be up to 35% but 2-10% is allowed.

Common operative complications are bleeding, wound infection, urethro-cutaneous fistula, shaft denudation, skin bridge and penile oedema. Other medical complications of circumcision include cardiac arrest, pneumothorax induced by the painful distress of the procedure. Late complications like castration anxiety, dysmorphorbia and psychosexual problems may not be manifested until the child is older. This reaffirmed the AAP recommendation that circumcision should be done only when the parents are well informed, on healthy stable children and/or if analgesia is provided.

Though most parents do not know what a circumcised penis should look like, however, they are satisfied when the penis of their wards looks like that of his father or peers.

Though there is no standardized specifics as to what a cosmetically normal penis should look like, it has been recommended that the glans should be completely exposed leaving about 3mm fringe of preputial membrane around the coronal sulcus without excavating the frenulum. Penis with redundant skin, gross shaft denudation; that is concealed or with keloids is not cosmetically acceptable.

liv

The cost of circumcision has been related to the procedure time, the number of days the ring dropped off, the complications and the monetary cost of the procedure time all of which varies with the method employed. The shortest procedure time being about 30 seconds for circumcision with Mogen clamps. Plastibell circumcision lasts for up to 8-10 minutes on the average. Manufacturers of Plastibell recommend that plastibell ring should have separated in 8 days.

The cost of the procedure varies from as high as N 2,000 in Lagos to as low as N 200 in Ogbomoso. At BMC, plastibell circumcision costs about N 800 only.

lv

CHAPTER THREE