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BACKGROUND: In 2004 the University of Michigan Department of Obstetrics and Gynecology ceased performing neonatal circumcisions. The Pediatric Hospitalist service, with training and support from the Division of Pediatric Urology, took over the bulk of these procedures. The efficacy of this transition offers insights into the practicality of having personnel from a non-surgical background perform circumcision.
MATERIALS & METHODS: Following IRB approval, billing and medical records from June 2, 2004 to June 7, 2013 identified all neonatal circumcision patients. Three services performed the majority of these cases: Pediatric Hospitalists, Family Medicine physicians, and midlevel providers and surgeons from the Pediatric Surgery service. The few circumcisions performed by other services were excluded. Data points collected included; date of initial circumcision, circumcision method, service performing procedure, complications, date of revision circumcision, service providing revision circumcision, and complications from the secondary procedure. The complication and revision rates of the Gomco and Plastibell were compared as well as the rates of the Pediatric Hospitalists (the novel circumcision service) vs. Pediatric Surgery and Family Medicine providers (the more experienced circumcision services). Statistical analyses were performed using SAS (v. 9.3) employing chi-square, p-test, and Fisher’s Exact Test methods.
RESULTS: After exclusions, 11,900 infants underwent neonatal circumcision by Pediatric Surgery (n= 1,371), Family Medicine (n= 1,953), or Pediatric Hospitalists (n= 8,576) using either the Gomco clamp or the Plastibell device during the study period. Complications included bleeding, retained device, and urethral/penile injury. The overall complication rate was 0.34% with a revision circumcision rate of 0.66%. There were 3 outcome categories: complications (n=22), need for revision (n=60), and complication in addition to need for revision (n=18). For both complications and revisions the Plastibell device performed significantly worse (Table 1). When compared to the Pediatric Surgery and Family Medicine services together, the Pediatric Hospitalists had significantly better complication and revision rates (Table 2).
CONCLUSION: The overall complication rate in our study was consistent with the approximate 0.5% rate seen in other studies. The Plastibell device performed statistically worse and was associated with a higher rate of revision. The Pediatric Hospitalists had significantly better complication and revision rates compared to the other services grouped together. These data demonstrate that traditionally non-surgical personnel can safely and effectively perform neonatal circumcision and suggest that there are tangible differences between the devices used. These observations may also have implications on current efforts to develop adult circumcision programs with non-surgical personnel.
Table 1:

	Plastibell	Gomco	p value (OR)
Complication Rate	1.31%	0.21%	<0.0001 (OR=6.35 [3.40-11.88])
Revision Rate	2.04%	0.47%	<0.0001 (OR=4.37 [2.74-6.96])

Table 2:

	Pediatric Hospitalists	Family Medicine + Pediatric Surgery	p value (OR)
Complication Rate	0.24%	0.57%	0.0057 (OR=2.34 [1.26-4.36])
Revision Rate	0.50%	1.05%	0.0008 (OR=2.11 [1.35-3.31])