The number of procedures required to achieve optimal competency with male circumcision: findings from a randomized trial in Rakai, Uganda

Abstract

OBJECTIVE To assess the number of procedures required to achieve optimal competency (time required for surgery with minimal adverse events) in Rakai, Uganda, and thus facilitate the development of guidelines for training providers, as male circumcision reduces the acquisition of human immunodeficiency virus (HIV) in men and is recommended for HIV prevention. PATIENTS AND METHODS In a randomized trial, 3011 men were circumcised, using the sleeve method, by six physicians who had completed training, which included 15–20 supervised procedures. The duration of surgery from local anaesthesia to wound closure, moderate or severe surgery‐related adverse events (AEs), and wound healing were assessed in relation to the number of procedures done by each physician. RESULTS The median age of the patients was 24 years. The number of procedures per surgeon was 20–981. The mean time required to complete surgery was ≈40 min for the first 100 procedures and declined to 25 min for the subsequent 100 circumcisions. After controlling for the number of procedures there was no significant difference in duration of the surgery by patient HIV status or age. The rate of moderate and severe AEs was 8.8% (10/114) for the first 19 unsupervised procedures after training, 4.0% for the next 20–99 (13/328) and 2.0% for the last 100 (P for trend, 0.003). All AEs resolved with management. CONCLUSION The completion of more than 100 circumcisions was required before newly trained physicians achieved the optimum duration of surgery. AEs were higher immediately after training and additional supervision is needed for at least the first 20 procedures after completing training.

Factors associated with the safety of voluntary medical male circumcision in Nyanza province, Kenya

“…RCTs have shown that more experienced providers perform faster and safer circumcisions, 8,22 and our results confirm these findings. In our study, the providers who had performed only 20 male circumcisions under supervision took an average of 21.0 minutes to perform their first 20 procedures; however, providers who had performed more than 100 circumcisions and those who had performed over 200 procedures took an average of 17.6 and 15.5 minutes, respectively.…”

“…This study lends support to recommendations that providers must perform a minimum of 20 male circumcision procedures to qualify as a VMMC provider, and ideally over 100 procedures to reach and maintain a desired level of clinical expertise. 8,22 In Kenya, legislation was passed in 2009 to allow nurses to provide VMMC services as part of the national VMMC programme. While adjusting for provider experience reduced the magnitude of the protective effect conferred by having a clinician rather than a nurse perform the circumcision, in the clinic system a procedure performed by a clinician was still 40.0% less likely to result in an adverse event than one performed by a nurse.…”

Evaluation of neonatal circumcision training for resident doctors in a developing country

“…It would be instructive to look at the nature of training obtained, total number of cases performed and the complication rates among the trainees, as this may give objective insight into the actual level of competence in the NC procedure. Although a study has suggested that performing at least 100 circumcisions is required before some Evaluation of neonatal circumcision training 1.e3 + MODEL measure of competence is assured for male circumcision [16], this alone is insufficient. Concerning training in surgical procedures, several studies have shown that well-structured training, which encompasses a good theoretical knowledge base and practical exposure to a specific surgical procedure, is imperative to perform the procedure well and to diminish complications [15e18].…”

CUA guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants

“…When presented with contraindications to circumcision like hypospadias, buried penis and micropenis, the average rate of correctly identified contraindications was a dismal 42%. Evidence from the Ugandan trial data showed that approximately 100 procedures are needed to gain competence in sleeve circumcision technique [231]. The rate of moderate or severe adverse events showed a statistically significant trend decreasing from 8.8% for the first 20 procedures to around 2% beyond 100.…”