1. WHAT? CIRCUMCISIONS PERFORMED BY NEONATAL NURSE PRACTITIONERS? DT Costakos, LR
Dahlen, SW Dunlap, TJ Heise, RS Muellenberg, JB Richards, JM Walden, Mayo Clinic Health System, La Crosse,
Wisconsin
Abstract
Purpose: Over the last 60 years, the prevalence of United States of America males having a circumcision (penile
foreskin removal) is on the order of about 80%. Our review of the peer review medical literature reveals no articles
regarding Neonatal Nurse Practitioners (NNPs) performing this surgery. Our practice captures the same financial
compensation independent of the provider’s specialty for a neonatal male circumcision. This study examines the
hypothesis that NNPs can safely perform newborn male circumcisions, and includes a health care value analysis to
assess for value to cost.
Methods: Four neonatal nurse practitioners with 0 to 20 years NNP experience were educated and trained to do
neonatal male circumcisions. One additional NNP, previously trained to perform circumcisions, was hired. Our
Institutional Review Board (IRB) approved this observational study at a single campus of a multispecialty private
medical practice. NNPs obtain informed consent for the procedure, perform a dorsal penile block with 1% lidocaine
with no epinephrine, and use the Gomco clamp. The hourly compensation by specialty is: for a NNP $53.74;
pediatrician $94.41; family practice $115.65; neonatologist $140.38; obstetrician $167.16 and urologist $247.96.
Can a NNP identify an anatomical contraindication to the circumcision procedure, and for complications such as
bleeding requiring a urology consult or a glans injury?
Results: Two-hundred babies (gestational age at birth of 32 to 41 weeks), average birth weight 3.48 + 0.59
kilograms, with 198 newborn males circumcised by a NNP (2/15/2015 - 11/18/2015). The average age of the baby at
the time of the procedure was 69.02 + 116 hours. The circumcision averaged 18 + 4.24 minutes. Of the 198 patients,
the first 99 took 19 minutes + 4.76 minutes and the second 99 took 17 minutes + 3.24 minutes (student’s t-test p
value < 0.001). There was a negative Pearson correlation of -0.37 of subject number versus time for the NNP to
perform the procedure. Two babies had a contraindication and the circumcision was not performed, hypospadias in
one baby and chordee in another. No baby needed an urologist consult.
Conclusions: NNPs can safely perform circumcisions and this results in a 2 to 9 time’s reduction in professional
salary expenses for the practice compared to other specialists performing the procedure. This creates bottom line
savings through decreased semi-variable costs. If the entire U.S.A. applied our model, we estimate a decrease in
professional fees of 105 million 2015 dollars per decade.