Benefits

• ↓ risk of UTI (circumcise infants with VUR; males have higher incidence of UTI because they have sphincter dysynergy until 1 year of age)
• NNT ~ 100 for normal infants, 5-10 for VUR/recurrent UTI
• ↓ risk of STI (HPV), HIV (RR 0.6), balanitis
• ↓ risk of phimosis
• ↓ risk of penile cancer (on the glans)

Always look for hypospadias before performing circumcision - foreskin may be need to be used in hypospadias repair (Byar's flaps = dorsal slit and bringing foreskin ventrally as skin flaps)

Newborn/< 1 mo (no sedation)

• Pain management with Sweetease (sugar water) = efficacy of penile block
• Plastibell - Clamp and divide prepuce dorsally, retract and place Plastibell over glans, draw prepuce over bell/glans and tie suture around bell - falls off in a few days
• Gomco clamp - similar setup to Plastibell, except prepuce is clamped x 5 min for hemostasis and then cut with scalpel
• Mogen - fastest, but blind/does not protect glans
• 

> 1 mo (general anesthesia)

• Pre-op: caudal or penile bupivacaine nerve block
• Sleeve incision
• Retract foreskin, clean, examine glans and meatus
• Replace foreskin and mark at level of coronal sulcus
• Retract foreskin and mark inner incision 5 mm from edge of glans
• Incise the two lines
• 4 mosquito snaps on dorsal side of skin to be removed, divide skin
• Sheth - hold all 4 mosquitos up, use Littlers to make tract underneath skin
• Kan - 
• Dissect off of dartos
• Sew shaft skin to new preputial collar
• Sheth - deep dermals, Dermabond (if older/will have erections, do running plain gut and Coban dressing)
• If foreskin is phimotic/not easily retracted,
• Make dorsal slit down to coronal sulcus
• Divide both layers of prepuce circumferentially with sharp scissors
• Reapproximate edges