包皮环切获有力证据支持 AAP发布相关声明

美国儿科学会(APP)最新发布的政策声明可能会改变临床医生对于男婴是否应接受包皮环切术的判断。APP在新的包皮环切政策声明中陈述了该手术利大于弊的有力证据(Pediatrics 2012 Aug. 27;130:585-86)。针对相关医学文献的系统综述表明，包皮环切的确有助于预防尿路感染、阴茎癌以及包括HIV感染在内的部分性传播疾病。

APP称，当然最终的决定权还是在家长手中。不过，现有证据已足以证明包皮环切的必要性，并要求第三方保险机构为选择做这项手术的所有家庭支付这笔费用。

APP包皮环切工作组成员之一、美国洛杉矶Cedars-Sinai 医疗中心小儿外科部副主任兼小儿泌尿科主任Andrew Freedman博士在接受采访时说：“在对相关文献进行综述尤其是考虑到有关HIV传播的最新数据之后，我们认为包皮环切的确具有多方面的优势，而且风险很小。总的来看，该手术很可能利大于弊，或者至少对于有意愿做包皮环切的家庭，我们有足够的理由同意这一决定。”

Freedman博士补充道：“但这种优势还不足以让我们给出普遍适用的建议。我们不能说每个人都应该接受包皮环切。”医学方面的考虑仅仅是决策制定过程中的一部分，“对于不同的家庭而言，这还取决于其他方面的因素，比如种族、宗教和美学。”

儿科医生在家长咨询中起着很关键的作用，Freedman博士建议医生们阅读这份政策声明附带的一份技术报告(Pediatrics 2012 Aug. 27;130:e756-85)，报告中“非常详细地讨论了相关的科学数据，这对于儿科医生与家长商讨包皮环切问题时会非常有用”。

David M. Jaspan博士

包皮环切的健康效益包括降低婴儿2岁前出现尿路感染的风险(Pediatr. Infect. Dis. J. 2008;27:302-8)。文献综述还提示，该手术可以降低HIV (PLoS One 2010;5:e8723)、生殖器疱疹(CDC fact sheet, Jan. 31, 2012)以及人乳头状瘤病毒(Lancet 2011;377:209-18)的感染风险。此外，证据还显示包皮环切术对于梅毒也有一定的预防作用(Lancet Infect Dis. 2009;9:669-77)。工作小组还指出，有证据表明包皮环切术能降低男性终身患阴茎癌的风险(Int. J. Cancer. 2005;116:606-116)以及其配偶患宫颈癌的风险(N. Engl. J. Med. 2002;346:1105-12)。

Freedman博士说，目前关于包皮环切呈现出了两种完全对立的态度。“有的人坚决支持，有的人坚决反对。APP并不是要参与这样的争论，只是试图对相关数据进行公平、科学的总结，提供相关的医学建议。”“因为这是一项很微妙的政策，所以我们只是希望把问题阐述得更清楚。过去的声明也是出于同样的目的，请大家不要逼迫我们给出‘是’或‘否’的明确答案。”

这份政策声明是对APP 1999年发布并于2005年修订的包皮环切术政策的更新。美国妇产科医师协会(ACOG)对这份APP政策声明和技术报告表示支持。ACOG、美国家庭医师协会和疾病预防控制中心都向工作小组派出了联络员。

美国医疗保健研究与质量局1988~2008年的全国住院患者样本数据显示，1988~1991年男性新生儿出生后即接受包皮环切术的比例为48%，在1997~2000年上升至61%，随后在2000~2008年又回落至56%。由于这些数据并不包括那些在出院后接受包皮环切术的男婴，因此很可能低估了男婴在出生后1个月内接受包皮环切术的实际发生率。

Freedman博士声明无相关经济利益冲突。

相关评论：妇产科医生表示支持 费用问题尚未解决

美国纽约爱因斯坦医疗中心妇产科副主席兼妇科主任David M. Jaspan博士在应邀发表评论时说：“产科医生有责任向产妇提供有关孕产健康方面的教育咨询。对于像我这样的可以做包皮环切术的产科医生，这份新文件使我们在患者考虑是否做包皮环切术时可以向其提供循证医学证据。”

Jaspan博士说：“我们经常会听到这样的问题，‘有必要做包皮环切术吗？’现在我们可以列举这项手术的具体好处了，包括‘预防尿路感染、阴茎癌以及部分性传播疾病，如HIV感染’。”

美国马里兰大学妇产科学与生殖医学教授/马里兰大学医学中心产科主任Lindsay S. Alger博士说：“我完全同意这项新政策，我认为有必要确保有这方面需求的家庭不会遭遇任何障碍，包括经济方面的障碍。”

Alger博士评论道：“ACOG同意APP的观点，即包皮环切术的益处足以让决定做这项手术的家庭顺利完成这一手术，也足以说服第三方保险机构支付新生男婴的包皮环切术费用，尽管部分家长出于文化、种族或者宗教等方面的考虑也可能决定不做这项手术。”她还提到了包皮环切在技术方面的进步，包括使用局部麻醉使手术更加安全，也更容易耐受。“在我35年的行医生涯中，我还从未见过因包皮环切引发任何严重并发症。”

Jaspan博士和Alger博士均声明无相关经济利益冲突。

AAP工作小组对一系列复杂的问题进行了总结：包皮环切手术的择期性质，无偏倚咨询的重要性，统一使用镇痛剂以减轻手术疼痛，强调无论是否决定做包皮环切术都应重视新生儿的阴茎健康及护理。新的推荐意见补充并完善了1999年发布的AAP包皮环切术政策声明和推荐意见(Pediatrics 1999;103:686-93)，此外也指出了旧版推荐意见的不足，并对这项手术作出了合理的评价。

包皮环切的反对者声称这种手术是对“男性生殖器的摧残”，认为包皮被切除后会影响阴茎感觉和性生活质量，质疑“知情同意程序”的伦理性，包括同意书是由家长而非男婴本人签署、没有讨论其他非手术方案以及忽视了手术可能对生理、心理和性生活等方面的不良影响。美国印第安纳州玛丽安骨科学院的PATRICK J. WOODMAN博士认为，工作组公布的这份报告最重要的意义在于对上述问题作出了逐一解答，其文献检索工作非常全面，并且对现有的同行评审文献进行了很好的总结。

他表示还将继续密切关注Medicare计划以及其他第三方支付机构对于这些推荐意见会作出怎样的回应，是否会“减少甚至清除”影响家长为新生儿做出包皮环切术决定的经济障碍。这份报告指出，没有保险者决定做包皮环切术的几率比可以报销这笔费用者低20%左右。截止2009年，美国有15个州的Medicare计划都没有覆盖新生男婴包皮环切术，还有2个州只有不同程度的覆盖。不予报销对于感染HIV和其他性传播疾病风险较高人群的影响更大。鉴于美国疾病预防控制中心近期公布的一份报告显示：新生儿包皮环切术是一项具有社会意义且成本效益较高的HIV预防计划(PLoS ONE 2010;5:e8723)，因此各州的Medicare计划对包皮环切术费用报销的限制对于那些可能受益最大的人群造成了很大的影响。

PATRICK J. WOODMAN声称无相关经济利益冲突。

爱思唯尔版权所有  未经授权请勿转载

By: DAMIAN MCNAMARA, Ob.Gyn. News Digital Network

How you counsel parents regarding their ultimate decision about male infant circumcision could change based on a new policy statement from the American Academy of Pediatrics.

The academy points to stronger evidence of health benefits that outweigh the risks of the procedure in an updated circumcision policy statement (Pediatrics 2012 Aug. 27;130:585-86). Data support the prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV, for example, based on a systematic review of the medical literature.

The AAP Task Force summarized a complicated issue: the elective nature of circumcision, the importance of nonbiased counseling, the uniform use of analgesics to reduce procedural pain, and stressing the health and care of the newborn penis, whether circumcision is chosen or not, said Dr. Patrick J. Woodman.

The final decision lies with parents. However, the evidence is now strong enough to justify access to circumcision and third-party insurance payment for all families who choose the procedure, the American Academy of Pediatrics stated.

"What we suggest is that, having reviewed the literature, especially incorporating the new data on HIV acquisition, we feel that circumcision does have a lot of benefit and some very modest risk," Dr. Andrew Freedman, a member of the AAP Task Force on Circumcision, said in an interview. "Overall, the benefits are probably greater than the risks, or at least great enough that for a family that wishes to have a circumcision, we feel they should be allowed to have a circumcision."
   
"However, the benefits are not so great that we are advocating a universal recommendation. We’re not suggesting everyone should have a circumcision," added Dr. Freedman, who is vice chair of pediatric surgical services and director of pediatric urology at Cedars-Sinai Medical Center in Los Angeles.

The task force recognized that the medical considerations are just one part of the decision making process, Dr. Freedman said. "For families, this cuts across other paradigms: the ethnic, the religious, and the aesthetic."

Pediatricians play a vital role in counseling families. Dr. Freedman suggested physicians read the technical report that accompanies the policy statement (Pediatrics 2012 Aug. 27;130:e756-85) for "a very robust discussion of the scientific data that I think will be very helpful to pediatricians counseling [families] about circumcision, to provide them with the most relevant data from the literature review."

The health benefits of circumcision include lowering the risk of urinary tract infections in the first 2 years of life (Pediatr. Infect. Dis. J. 2008;27:302-8).The literature review also indicates the procedure lowers the risk of acquiring HIV (PLoS One 2010;5:e8723); genital herpes (CDC fact sheet, Jan. 31, 2012); and human papillomavirus virus (Lancet 2011;377:209-18). To a lesser extent, the evidence also suggests a protective effect against syphilis (Lancet Infect Dis. 2009;9:669-77).

The task force also considered evidence that circumcision can lower the risk of penile cancer over a lifetime (Int. J. Cancer. 2005;116:606-116); and the risk of cervical cancer in sexual partners (N. Engl. J. Med. 2002;346:1105-12).

There is a lot of partisanship regarding circumcision, Dr. Freedman said. "People are for it or against it, and they don’t recognize the AAP is not in that game. We are just trying to do a fair, scientific review of the data and put the medical aspect into context."

"What we’ve tried to do is add clarification because it’s a nuanced policy. The old policy was as well, but people did not appreciate that," he said. "People tended to want to see the policy as a ‘yes or no’ vote on circumcision."

"Everyone [on the task force] approached it from the standpoint that we should start without any preconceived bias. Let the data drive where it goes." Once task force members identified the relevant issues, accumulated the research, presented it to each other, and discussed the findings, "we reached consensus pretty easily," he said.

The policy statement updates the previous policy on circumcision that the AAP published in 1999 and reaffirmed in 2005.

The American College of Obstetricians and Gynecologists endorsed the AAP policy statement and the technical report. ACOG provided a liaison member to the task force, as did the American Academy of Family Physicians and the Centers for Disease Control and Prevention.

The Agency for Healthcare Research and Quality’s National Inpatient Sample data from 1988 to 2008 reveal that the rate of circumcision performed during newborn male delivery hospitalizations rose from 48% in 1988-1991, to 61% in 1997-2000, then fell to 56% in 2000-2008. This does not include out-of hospital circumcisions and thus underestimates the rate of male circumcisions in the first month of life.

Dr. Freedman said that he had no relevant financial disclosures.

View on The News
Ob. Gyns. Support AAP Statement

Changes to Financial Barriers Still Pending

"As obstetricians, we are charged with providing education to mothers about the health and welfare of their pregnancy. For those obstetricians like me who perform circumcisions, this new document provides evidenced-based information to our patients as they contemplate the circumcision procedure," Dr. David M. Jaspan said when asked to comment.

"Many times we are asked, ‘Is the procedure necessary?’ We can now answer that there are specific benefits including ‘prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV,’ " Dr. Jaspan said.

"I am in complete agreement with the new policy and believe that it is important that there are no impediments, financial or otherwise, to access to this procedure for families that request it," said Dr. Lindsay S. Alger.

"ACOG agrees with the AAP that the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns, although for cultural, ethical or religious considerations parents may choose not to have this procedure done," Dr. Alger said when asked to comment.

She also pointed to improvements in technique, including the use of local anesthesia, which makes circumcision safer and well-tolerated. "I have never seen a serious complication in over 35 years."

DR. JASPAN is vice chairman and chief of gynecology in the department of obstetrics and gynecology at the Albert Einstein Medical Center in New York. He said he had no relevant financial disclosures.

DR. ALGER is professor of obstetrics, gynecology, and reproductive services at the University of Maryland and medical director of labor and delivery at the University of Maryland Medical Center, both in Baltimore. She said she had no relevant financial disclosures.

The AAP Task Force summarized a complicated issue: the elective nature of circumcision, the importance of nonbiased counseling, the uniform use of analgesics to reduce procedural pain, and stressing the health and care of the newborn penis, whether circumcision is chosen or not. The recommendations reinforce and strengthen the 1999 AAP Circumcision Policy Statement and recommendation (Pediatrics 1999;103:686-93), but they went much further than that. They examined the areas of weakness in the previous recommendations and give credence to the rightful critics of the procedure.

Circumcision detractors have touted the procedure as "male genital mutilation," citing a decrease in penile sensation and sexual satisfaction upon removal of the prepuce, and questioned the ethics of an "informed consent process" that does not include "the patient," lacks a discussion of nonsurgical alternatives, and ignores potential adverse physical, sexual, and psychological effects. I believe the big difference in the current Task Force’s reports was that they make a point-by-point case for each of the above disadvantages. From my knowledge of the circumcision literature, I believe the Task Force’s literature search was exhaustive, and they do a fine job of summarizing the existing peer-reviewed literature.

It will be interesting to see how Medicaid programs and third-party payers interpret the recommendation to "reduce or eliminate" financial barriers that prevent parents from having the choice to circumcise their male infants. The report notes that uninsured clients are about 20% less likely to choose circumcision than do those who have coverage. As of 2009, 15 states did not cover newborn male circumcisions in their Medicaid programs, and 2 others had variable coverage, according to the report. Denying coverage disproportionately affects groups that are at greater risk for HIV and other sexually transmitted infections and also are overly represented in the Medicaid population: African American and Hispanic males. Since a recent Centers for Disease Control and Prevention report concluded that newborn circumcision is a societal cost-effective HIV prevention program (PLoS ONE 2010;5:e8723), efforts by state Medicaid programs to limit payment disproportionately affects those that could benefit most from circumcision.

PATRICK J. WOODMAN, D.O., is a urogynecologist, associate professor of obstetrics and gynecology, and is chief of specialty care at Marian University College of Osteopathic Medicine in Indianapolis. He said that he has no disclosures pertinent to the story.