title: 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.
  
  
  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 approximately 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Rakai Health Sciences Program, Entebbe, Uganda.
authors.forename: Valerian
authors.initials: V
authors.lastname: Kiggundu
authors.forename: Stephen
authors.initials: S
authors.lastname: Watya
authors.forename: Godfrey
authors.initials: G
authors.lastname: Kigozi
authors.forename: David
authors.initials: D
authors.lastname: Serwadda
authors.forename: Fred
authors.initials: F
authors.lastname: Nalugoda
authors.forename: Denis
authors.initials: D
authors.lastname: Buwembo
authors.forename: Absolom
authors.initials: A
authors.lastname: Settuba
authors.forename: Margaret
authors.initials: M
authors.lastname: Anyokorit
authors.forename: James
authors.initials: J
authors.lastname: Nkale
authors.forename: Nehemiah
authors.initials: N
authors.lastname: Kighoma
authors.forename: Victor
authors.initials: V
authors.lastname: Ssempijja
authors.forename: Maria
authors.initials: M
authors.lastname: Wawer
authors.forename: Ronald H
authors.initials: RH
authors.lastname: Gray
mesh_terms: D000293:Adolescent; D000328:Adult; D002944:Circumcision, Male / Q000009:adverse effects / Q000193:education* / Q000706:statistics & numerical data; D002983:Clinical Competence / Q000592:standards / Q000706:statistics & numerical data*; D018023:HIV Seronegativity; D006679:HIV Seropositivity; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control*; D013997:Time Factors; D016896:Treatment Outcome; D014454:Uganda; D055815:Young Adult