A systematic review and meta-analysis of circumcision with Shang Ring vs conventional circumcision

Plastic Clamp Versus Conventional Surgical Dissection Technique in Pediatric Circumcision: A Systematic Review and Meta-Analysis

PURPOSE

Phimosis is a common condition of the urinary system in children and often requires surgical treatment. However, the optimal method of circumcision for children has not been determined. We conducted a systematic review and meta-analysis to compare the safety and effectiveness of plastic clamp with conventional surgical circumcision in pediatric circumcision.

METHODS

A literature search was carried out to compare the plastic clamp and conventional dissection technique in the pediatric population. The following search terms were used: "circumcision", "plastic clamp", "conventional", "plastibell", "children" and etc. Meta-analysis was used to pool and evaluate variables such as operative time, blood loss, wound infection, bleeding, edema, and total postoperative complications.

RESULTS

The plastic clamp technique (PCT) was used in 10,412 of the 17,325 participants in the nine studies, while the conventional surgical dissection technique (CST) was used on 6913 patients. When compared to the CST approach, the PCT approach resulted in shorter operative times (mean difference (MD) -17.48, 95% CI -22 to -12.96; P < 0.001), less blood loss (MD -4.25, 95% CI -7.75 to -0.77; P = 0.02), and a higher incidence of postoperative edema (OR 2.33, 95% CI 1.34 to 4.08; P = 0.003). However, no significant difference was found in the incidence of postoperative complications, including wound infection and bleeding between PCT and CST.

CONCLUSIONS

PCT is a safe and time-saving option in the pediatric population. However, this method appeared to have a significant greater rate of postoperative edema.

Comparison of the penile microbiome in infant male circumcision: Mogen clamp versus Shangring

BACKGROUND

This study aimed to characterise the infant penile (coronal sulcus) microbiome and the effects of early infant male circumcision (EIMC), following a standard surgical method (Mogen Clamp) and a non-surgical alternative (ShangRing).

METHODS

We collected coronal sulcus swabs at baseline and on days 7 and 14 post-circumcision from infants assigned to receive EIMC by Mogen Clamp (n = 15) or ShangRing (n = 15), in a randomised trial in Rakai and Kakuuto, Uganda. We used 16S rRNA gene-based sequencing and broad-coverage qPCR to characterise the infant penile microbiome and assess the effects of EIMC in both study arms.

FINDINGS

Prior to EIMC, the infant penile microbiome had a mixture of facultative and strict anaerobes. In both study arms, EIMC caused penile microbiome proportional abundance changes characterised by decreases in penile anaerobes [ShangRing Prevotella: -15.0%, (SD = 19.1); Mogen clamp Prevotella: -3.6% (11.2); ShangRing Veillonella: -11.3% (17.2); Mogen clamp Veillonella: -2.6% (11.8)] and increases in skin-associated facultative anaerobes [ShangRing Corynebacterium: 24.9%, (22.4); Mogen clamp Corynebacterium: 4.7% (21.3); ShangRing Staphylococcus: 21.1% (20.5); Mogen clamp Staphylococcus: 18.1% (20.1)]. Clostridium tetani was not detected during the study.

INTERPRETATION

Mogen Clamp and ShangRing EIMC both changed the composition of the infant penile microbiome by reducing the proportional abundances of anaerobes and uropathogens, which is consistent with medical male circumcision findings in adults. C. tetani was not increased by either EIMC method.

FUNDING

Bill and Melinda Gates Foundation.

Wound healing rates and wound problems of conventional circumcision compared with ring circumcision: A meta-analysis

A meta-analysis investigation was executed to measure the wound healing rates (WHRs) and wound problems (WPs) of conventional circumcision (CC) compared with ring circumcision (RC). A comprehensive literature investigation till March 2023 was applied and 2347 interrelated investigations were reviewed. The 16 chosen investigations enclosed 25 838 individuals, with circumcision, were in the chosen investigations' starting point, 3252 of them were RC, and 2586 were CC. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the WHRs and WPs of CC compared with RC by the dichotomous or continuous approaches and a fixed or random model. RC had a significantly lower wound infection rate (WIR) (OR, 0.58; 95% CI, 0.37-0.91, P = .002) and wound bleeding rate (WBR) (OR, 0.22; 95% CI, 0.12-0.42, P < .001) compared with those with CC. However, RC and CC had no significant difference in WHR (OR, 2.18; 95% CI, -0.73 to 5.09, P = .14), wound edema rate (WER) (OR, 1.11; 95% CI, 0.92-1.33, P = .28), and wound dehiscence rate (WDR) (OR, 0.98; 95% CI, 0.60-1.58, P = .93). RC had significantly lower WIR, and WBR, however, no significant difference in WHR, WER, and WDR compared with those with CC. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta-analysis.

Comparative analysis on the outcomes in circumcising children using modified Chinese ShangRing and conventional surgical circumcision

OBJECTIVE

To compare the differences and outcomes of surgical procedures, clinical effect, complications and patients' satisfaction between disposable oval-shaped circumcision device (Modified Chinese ShangRing series, Kiddie love^®) and conventional circumcision in the treatment of children with phimosis or redundant prepuce.

METHODS

The clinical data were retrospectively analyzed in 114 children with phimosis or redundant foreskin undergone circumcision using a disposable oval-shaped circumcision device, a modified Chinese ShangRing series, Kiddie Love^® (Kiddie Love group) in our hospital between January 2018 and February 2020, and another 114 children with similar conditions circumcised by conventional surgical procedure before January 2018 (conventional group). The two groups were compared regarding the operative time, intraoperative blood loss, postoperative pain scores, healing time, the incidence of complications and guardian's satisfaction.

RESULTS

Circumcision was successfully completed in children in both groups. The operative time, intraoperative blood loss, postoperative pain scoring in 24 h by VAS, pain at the removal of the device or stitches and wound healing were (6.4 ± 1.6) min, (34.1 ± 6.4) min; (0.7 ± 0.2) ml, (2.6 ± 0.6) ml; (2.2 ± 1.0) points, (1.3 ± 0.5) points; (23.7 ± 3.9)day, (15.9 ± 2.8)day, respectively for Kiddie Love group and conventional group(either P < 0.05 or P > 0.05). The two groups were significantly different in the incidence of hematoma, edema and incision dehiscenceyet were insignificant in incision infection. Children in both groups were followed up from 6 to 31 months (mean: 23 months), and the satisfaction rate was 94.7% (108/114) in parents of the children circumcised by the ShangRing and 83.3% (95/114) in those of children treated by conventional circumcision (P < 0.05).

CONCLUSION

Modified Chinese ShangRing, Kiddie Love^®, has superiorities, including simpler procedure, shorter operative time, less blood loss, fewer complications, better cosmetic results and higher satisfaction of patients over conventional circumcision in the treatment of children with phimosis or redundant foreskin, and worthy of wider clinical recommendation.

Efficacy of three types of circumcision for children in the treatment of phimosis: A retrospective study

Phimosis is a common condition of the urinary system in children and often requires surgical treatment. However, the optimal method of circumcision for children has not been determined. Herein, we analyzed the efficacy of 3 circumcision methods for children with phimosis. A retrospective analysis of 112 cases of pediatric phimosis after circumcision was conducted at our hospital. Among them, 36 cases were subjected to conventional operation (group A), 43 cases to ring circumcision (group B), and 33 cases to suturing device circumcision (group C). The duration of operation, amount of bleeding, pain, complications, healing time, and the satisfaction of the guardians were calculated. The operation time of group B and C was (6.26 ± 1.31) min and (7.67 ± 1.29) min, respectively, which was shorter than group A (27.42 ± 2.42) min (P < .05); besides, group A had the most blood loss volume, (9.67 ± 1.67) mL, and group B was the least (1.26 ± 0.44) mL (P < .05); group B had the strongest postoperative pain (4.05 ± 0.37), the longest pain time (6.84 ± 1.29) days, and the longest healing time (21.84 ± 4.23) days (P < .05). Postoperative complications were lowest in group C (11.11% vs 20.93% vs 6.06%), satisfaction of guardians was highest in group C (86.11% vs 85.27% vs 89.99%), but the difference was not statistically significant (P > .05). Three types of surgical procedures present with advantages and disadvantages. The conventional surgery led to longer operation time and more bleeding but did not require special medical equipment and was easy to carry out; ring surgery had the shortest operation time, the least bleeding, accompanied by the longest recovery time and pain duration; the complications of the suturing device were the least, the parents had the highest degree of satisfaction, however, it also needs a specific suturing device. Therefore, each type had its distinctive characteristics and may be flexibly selected based on their own conditions.

Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions: a Cochrane review

OBJECTIVES

To assess the effects of device-based circumcisions compared with standard surgical techniques in adolescent and adult males (10 years old and above).

METHODS

We performed a comprehensive search with no restrictions to the language of publication or publication status. We included randomised controlled trials (RCTs) of device-based circumcisions compared to standard surgical dissection-based circumcision conducted by health professionals in a medical setting. We reported study results as risk ratios (RRs) or mean differences (MDs) using 95% confidence intervals (CIs) and a random-effects model. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to evaluate the overall certainty of the evidence for each outcome.

RESULTS

A total of 18 trials met the inclusion criteria. These trials did not report severe adverse events (AEs; 11 trials, 3472 participants). There may be a slight increase in moderate AEs for devices compared to surgical techniques (RR 1.31, 95% CI 0.55-3.10; I²  = 68%; 10 trials, 3370 participants; low-certainty evidence); this corresponds to eight more (ranging from 15 fewer to 84 more) moderate AEs per 1000 participants. We are uncertain about the difference in mild AEs between groups when devices are used compared to surgical techniques (RR 1.09, 95% CI 0.44-2.72; I²  = 91%; 10 trials, 3370 participants; very low-certainty evidence).

CONCLUSIONS

We found no serious AEs using a circumcision device compared to surgical techniques. Still, they may slightly increase moderate AEs, and it is unclear whether there is a difference in mild AEs. High-quality trials evaluating this intervention are needed to provide further certainty regarding the rates of AEs. Clinicians, patients, and policymakers can use these results combined with their contextual factors to inform the best approach that suits their healthcare settings.

Acceptability of male circumcision for HIV prevention among men who have sex with men in China: a short report

Recent evidence shows that circumcision is associated with lower HIV prevalence among MSM. We assessed the acceptability of circumcision for preventing HIV and that of Shang Ring circumcision (SRC) among men who have sex with men (MSM) in China. 538 adult MSM were recruited from six cities in China between January and March 2019. Participants were surveyed by an online, self-administered questionnaire. The acceptability of circumcision was assessed before and after the potential protective effect of circumcision against HIV was informed, and subsequently men's willingness to undergo SRC was assessed. The level of circumcision was 16.4%. Of 450 uncircumcised MSM, their willingness to be circumcised in the following six months increased significantly from 32.2% to 55.6% after the information session. Three quarters of men who were willing to undergo circumcision accepted SRC. MSM who perceived that circumcision could maintain genital hygiene were more likely to accept circumcision after the information session, whereas those who regarded circumcision as an embarrassing surgery were disinclined to be circumcised. The low circumcision rate, along with its high acceptability in Chinese MSM, suggests a great potential benefit of circumcision intervention if proved effective. SRC might be a popular circumcision procedure in this population.

Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions

BACKGROUND

Medical circumcisions are among the most common surgical procedures performed in males. The usual indications are phimosis (inability to completely retract the foreskin and expose the glans due to a congenital or acquired constriction of the prepuce), paraphimosis (when the foreskin is not pulled back over the glans after retraction resulting in a tight constricting band which causes swelling of the distal penis and acute discomfort), balanoposthitis (erythema and edema of the prepuce and glans) and balanitis (inflammation is confined to the glans; the foreskin is usually non-retractile). Circumcision devices have been developed to shorten the operative time, simplify techniques, and improve safety and cosmetic outcomes. The devices generally aim to crush the foreskin while simultaneously creating hemostasis, the foreskin is then excised or allowed to slough off. Their use is supposedly safer and easier to replicate than the standard dissection techniques. There are at least 20 devices for male circumcision on the market, yet their effectiveness has not been reviewed to date.

OBJECTIVES

To assess the effects of device-based circumcisions compared with standard surgical techniques in adolescent and adult males (10 years old and above).

SEARCH METHODS

We performed a comprehensive search with no restrictions to the language of publication or publication status. We searched the Cochrane Library, MEDLINE (PubMed), Embase, Web of Science, trials registries, grey literature sources and conference proceedings up to 16 April 2020.

SELECTION CRITERIA

We included randomized controlled trials of device-based circumcisions (crush or ligature circumcision devices) compared to standard surgical dissection-based circumcision conducted by health professionals in a medical setting.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed study eligibility and extracted data from the included studies. We classified adverse events into serious, moderate or mild. We reported study results as risk ratios (RR) or mean differences (MD) using 95% confidence intervals (CI) and a random-effects model. We used the GRADE approach to evaluate the overall certainty of the evidence for each outcome.

MAIN RESULTS

Eighteen trials met the inclusion criteria. Trials were conducted in China, South Africa, Kenya and Zambia, Mozambique, Rwanda, Uganda and Zimbabwe. Primary outcomes Serious adverse events: there were no serious adverse events in either treatment arm (11 trials, 3472 participants). Moderate adverse events: there may be a slight increase in moderate adverse events when devices are used compared to standard surgical techniques (RR 1.31, 95% CI 0.55 to 3.10; I²= 68%; 10 trials, 3370 participants; low-certainty evidence); this corresponds to 8 more (ranging from 15 fewer to 84 more) moderate adverse events per 1000 participants. We downgraded the certainty of the evidence for study limitations and imprecision. Secondary outcomes Mild adverse events: we are uncertain about the difference in mild adverse events between groups when devices are used compared to standard surgical techniques (RR 1.09, 95% CI 0.44 to 2.72; I² = 91%; 10 trials, 3370 participants; very low-certainty evidence). We downgraded the certainty of the evidence for study limitations, imprecision and unexplained inconsistency. Operative time: operative time is probably about 17 minutes shorter when using a device rather than standard surgical techniques, which constitutes a clinically meaningful decrease in a procedure (MD -17.26 minutes, 95% CI -19.96 to -14.57; I² = 99%; 14 trials, 4812 participants; moderate-certainty evidence). We downgraded the certainty of the evidence for serious study limitations. The standard surgical technique generally takes about 24 minutes. There may be less postoperative pain during the first 24 hours when circumcision devices are used compared to standard surgical techniques (measured using a visual analog scale [VAS]; MD 1.30 cm lower, 95% CI 2.37 lower to 0.22 lower; I² = 99%; 9 trials, 3022 participants; low-certainty evidence). We downgraded the certainty of the evidence for study limitations and unexplained heterogeneity. There may be little or no difference in postoperative pain experienced during the first seven days when compared with standard surgical techniques (measured using a VAS; MD 0.11 cm higher, 95% CI 0.89 lower to 1.11 higher; I² = 94%; 4 trials, 1430 participants; low-certainty evidence). We downgraded the certainty of the evidence for study limitations and unexplained inconsistency. A higher score on the VAS indicates greater pain. Participants may slightly prefer circumcision devices compared to standard surgical techniques (RR 1.19, 95% CI 1.04 to 1.37; I² = 97%; 15 trials, 4501 participants; low-certainty evidence). We downgraded the certainty of the evidence for study limitations and unexplained inconsistency. We recorded satisfaction as a dichotomous outcome. Higher rates reflected greater satisfaction.

AUTHORS' CONCLUSIONS

We found that there were no serious adverse events reported when using a circumcision device compared to standard surgical techniques, but they may slightly increase moderate adverse effects, and it is unclear whether there is a difference in mild adverse effects. Use of circumcision devices probably reduces the time of the procedure by about 17 minutes, a clinically meaningful time saving. For patients, use of the circumcision device may result in lower pain scores during the first 24 hours and patients may be slightly more satisfied with it compared with standard surgical techniques. Clinicians, patients and policymakers can use these results in conjunction with their own contextual factors to inform the approach that best suits their healthcare settings. High-quality trials evaluating this intervention are needed to provide further certainty regarding the rates of adverse effects and postoperative pain of using devices compared to standard approaches.

Plastibell circumcision: Comparison between neonates and infants

Background:

The Plastibell circumcision technique has gained popularity worldwide. It has a low bleeding risk which makes it suitable for a vulnerable population and in late circumcision. However, several problems resulting from prolonged retention of the Plastibell ring were reported.

Objectives:

The objectives of this study were to assess the outcomes of circumcision performed using Plastibell devices, report ring-related complications, and compare the complications of the technique between neonates and infants.

Methods:

This was a retrospective cohort study that was conducted in a total of 989 male neonates and infants who had Plastibell circumcision performed by a single surgeon between June 2006 and February 2018. Postoperative complications were reported and compared between the two age groups. The indications of the Plastibell technique were religious in 988 patients and urinary tract infection in 1 patient.

Results:

During the study period, Plastibell circumcision was performed in 633 neonates and 356 infants. The average ages of neonates and infants were 14 ± 2 days and 3 ± 0.5 months, respectively. Complications developed in 89 cases, 4.4% in neonates and 17% in infants (P < 0.001). The retained ring was the most common complication in 46 cases (4.6%), followed by excess skin in 21 cases (2%). Bleeding occurred in 10 cases (1%), infection in 7 cases (0.7%), and hematoma in 2 cases (0.2%).

Conclusion:

Complications of Plastibell circumcision are significantly higher in infants than in neonates, and ring retention is the most common complication in both the groups. However, the risk of severe hemorrhage is low making it a good option for infants in the outpatient setting.

Modified Circumcision Using the Disposable Circumcision Suture Device in Children: A Randomized Controlled Trial

OBJECTIVE

To evaluate and compare the surgical outcomes and complications of the modified circumcision using disposable circumcision suture device (device group) and the conventional dorsal slit circumcision (conventional group) in children.

METHODS

A total of 284 patients were randomized to either device group or conventional group. All patients were preoperatively assessed and evaluated at 4 weeks after surgery. The perioperative data and postoperative outcomes were compared between the 2 groups.

RESULTS

No statistical differences were observed in the average age and indications between the 2 groups preoperatively (P > .05). Compared with the conventional group, patients in the device group were shorter mean operative time, less blood loss, lower intraoperative and postoperative pain score, faster incision healing time and a higher satisfaction rate of penile cosmetic appearance (P < .01). Similarly, the incidences of complication were significantly lower in the device group than in the conventional group (4.3% vs 12.3%, P < .05).

CONCLUSIONS

The modified circumcision using disposable circumcision suture device is a simple, safe, faster, and effective procedure and may become the attractive alternative to the conventional technique for the children, with a relatively lower complication rate and better cosmetic results. With the improvement of disposable circumcision suture device, the modified circumcision using disposable circumcision suture device has the potential to be widely used in the world.

Simplifying the ShangRing technique for circumcision in boys and men: use of the no-flip technique with randomization to removal at 7 days versus spontaneous detachment

To assess safety of the no-flip ShangRing male circumcision technique and to determine clinical course and safety of spontaneous detachment (i.e., allowing the device to fall off), we conducted a case series of no-flip ShangRing circumcision combined with a randomized controlled trial of removal 7 days postcircumcision versus spontaneous detachment at two health facilities in Kenya. The primary outcome was the safety of the no-flip technique based on moderate and severe adverse events (AEs) during the procedure and through 42-day follow-up. A main secondary outcome was clinical course and safety of spontaneous detachment. Two hundred and thirty males 10 years and older underwent no-flip circumcision; 114 randomized to 7-day removal and 116 to spontaneous detachment. All circumcisions were successfully completed. Overall 5.3% (6/114) of participants in the 7-day group and 1.7% (2/116) in the spontaneous group had an AE; with no differences when compared to the 3% AE rate in historical data from African studies using the original flip technique (P = 0.07 and P = 0.79, respectively). Overall 72.4% (84/116) of participants in the spontaneous group wore the ShangRing until it detached. Among the remaining (27.6%; 32/116), the ring was removed, primarily at the participants' request, due to pain or discomfort. There was no difference in AE rates (P = 0.169), visit day declared healed (P = 0.324), or satisfaction (P = 0.371) between randomization groups. The median time to detachment was 14.0 (IQR: 7–21, range: 5–35) days. The no-flip technique and spontaneous detachment are safe, effective, and acceptable to boys and men 10 years and older. Phimosis and penile adhesions do not limit successful ShangRing circumcision with the no-flip technique.

Reliability of thermocautery-assisted circumcision: retrospective analysis of circumcision performed voluntarily in countries of low socioeconomic status

Objective:

The objective of this study was to evaluate the reliability of thermocautery-assisted circumcision performed voluntarily in patients of poor countries.

Material and methods:

Between 2016 and 2019, 32,000 children aged 7 days to 17 years were circumcised in multiple countries. The patients’ urological examinations were done before the administration of local anaesthesia. Patients revealed to have undescended testicle, inguinal hernia, hypospadias, varicocele, penile rotation anomaly, epispadias and infection were not circumcised. All procedures were performed under local anaesthesia by using thermocautery. Afterwards, mucosa and skin were sutured using absorbable suture and the circumcised penis was dressed. Patients were instructed to remove the dressing after 3 days.

Results:

Bleeding, requiring surgical intervention and drug reactions were not observed. The most observed complication was mucosal oedema, which occurred in approximately one-quarter of patients (26%, 8320/32,000) and continued for 3–5 days after the surgery. The most serious complication was a trapped penis, which occurred in 25 patients (0.078%). In six (0.018%) cases, meatal stenosis developed. Wound infection developed in only 10 (0.03%) cases, through the formation of an aseptic environment. Penile adhesion was seen in 35 cases (0.1%) and improved with anti-inflammatory treatment without any surgical intervention.

Conclusion:

Thermocautery-assisted circumcision can be used as an effective, safe and useful technique with few complications and rapid healing rates.

Men's Understanding of and Experiences During the Postcircumcision Abstinence Period: Results From a Field Study of ShangRing Circumcision During Routine Clinical Services in Kenya and Zambia

Background:

Men's understanding of counseling messages after voluntary medical male circumcision (VMMC) plays an important role in whether they follow them. Data on triggers for early resumption of sex may be useful as scale-up of VMMC for HIV prevention continues in sub-Saharan Africa.

Methods:

Data on understanding of post-VMMC abstinence recommendations, resumption of sex, condom use, and triggers for resuming sex were collected from participants during a follow-up interview 35–42 days after ShangRing circumcision in Kenya and Zambia.

Results:

Of 1149 men who had ShangRing circumcision, 1096 (95.4%) completed follow-up. Nearly all (99.2%) reported being counseled to abstain from sex post-VMMC; among those, most (92.2%) recalled the recommended abstinence period was 6 weeks. Most men (94.1%) reported that the counselor gave reasons for post-VMMC abstinence and recalled appropriate reasons. Few (13.4%) men reported resuming sex at 35–42 days' follow-up. Among those, 54.8% reported never using a condom post-VMMC. Younger participants (odds ratio 0.3, 95% confidence interval: 0.2 to 0.5, P < 0.0001) and those reporting at least some condom use at baseline (odds ratio 0.5, 95% confidence interval: 0.3 to 0.7, P = 0.0003) were less likely to report resuming sex. Among men who reported some condom use, most (71.5%) said condoms were much easier or easier to use after circumcision. Men reported various reasons for early resumption of sex, primarily strong sexual desire (76.4%).

Conclusions:

Most men reported awareness of and adherence to the counseling recommendations for post-VMMC abstinence. A minority reported early resumption of sex, and, among those, condom use was low. Results could be used to improve post-VMMC counseling.

Randomized Controlled Trial of the ShangRing for Adult Medical Male Circumcision: Safety, Effectiveness, and Acceptability of Using 7 Versus 14 Device Sizes

Objectives:

To assess the safety, effectiveness, and acceptability of providing a reduced number of ShangRing sizes for adult voluntary medical male circumcision (VMMC) within routine service delivery in Lusaka, Zambia.

Methods:

We conducted a randomized controlled trial and enrolled 500 HIV-negative men aged 18–49 years at 3 clinics. Participants were randomized to 1 of 2 study arms (Standard Sizing arm vs Modified Sizing arm) in a 1:1 ratio. All 14 adult ShangRing sizes (40–26 mm inner diameter, each varying by 1 mm) were available in the Standard Sizing arm; the Modified Sizing arm used every other size (40, 38, 36, 34, 32, 30, 28 mm inner diameter). Each participant was scheduled for 2 follow-up visits: the removal visit (day 7 after placement) and the healing check visit (day 42 after placement), when they were evaluated for adverse events (AEs), pain, and healing.

Results:

Four hundred and ninety-six men comprised the analysis population, with 255 in the Standard Sizing arm and 241 in the Modified Sizing arm. Three men experienced a moderate or severe AEs (0.6%), including 2 in the Standard Sizing arm (0.8%) and 1 in the Modified Sizing arm (0.4%). 73.2% of participants were completely healed at the scheduled day 42 healing check visit, with similar percentages across study arms. Virtually all (99.6%) men, regardless of study arm, stated that they were very satisfied or satisfied with the appearance of their circumcised penis, and 98.6% stated that they would recommend ShangRing circumcision to family/friends.

Conclusions:

The moderate/severe AE rate was low and similar in the 2 study arms, suggesting that provision of one-half the number of adult device sizes is sufficient for safe service delivery. Effectiveness, time to healing, and acceptability were similar in the study arms. The simplicity of the ShangRing technique, and its relative speed, could facilitate VMMC program goals. In addition, sufficiency of fewer device sizes would simplify logistics and inventory.

Comparative efficacy and safety of different circumcisions for patients with redundant prepuce or phimosis: A network meta-analysis

BACKGROUND

Phimosis and redundant prepuce are defined as the inability of the foreskin to be retracted behind the glans penis in uncircumcised males. To synthesize the evidence and provide the hierarchies of different circumcisions for phimosis and redundant prepuce, we performed an overall network meta-analysis (NMA) based on their comparative efficacy and safety.

MATERIAL AND METHODS

Electronic databases including PubMed, Embase, Wan Fang, VIP, CNKI and CBM database were researched from randomized controlled trials (RCTs) for redundant prepuce or phimosis. We conducted the direct and indirect comparisons by aggregate data drug information system (ADDIS) software. Moreover, consistency models were applied to assess the differences among the male circumcision practices, and the ranks based on probabilities of intervention for the different endpoints were performed. Node-splitting analysis was used to test inconsistency.

RESULTS

Eighteen RCTs were included with 6179 participants. Compared with the conventional circumcision(CC), two new styles of circumcisions, the disposable circumcision suture device(DCSD) and Shang Ring circumcision(SRC), provided significantly shorter operation time[DCSD: standardized mean difference (SMD) = -20.60, 95% credible interval(CI) (-23.38, -17.82); SRC: SMD = -19.16, 95%CI (-21.86, -16.52)], shorter wound healing time [DCSD:SMD = -4.19, 95%CI (-8.24,-0.04); SRC: SMD = 4.55, 95%CI (1.62, 7.57); ] and better postoperative penile appearance [DCSD: odds ratios odds ratios (OR) = 11.42, 95%CI (3.60, 37.68); SRC: OR = 3.85,95%CI (1.29, 12.79)]. Additionally, DCSD showed a lower adverse events rate than other two treatments. However, no significant difference was shown in all surgeries for 24 h postoperative pain score. Node-splitting analysis showed that no significant inconsistency was existed (P > 0.05).

CONCLUSIONS

Based on the results of NMA, DCSD may be a most effective and safest choice for phimosis and redundant prepuce. DCSD has the advantages of a shorter operation time, better postoperative penile appearance, fewer complication and shorter wound healing time. However, with the limitations of our study, additional multi-center RCTs are needed to evaluate the outcomes.

Pros and cons of circumcision: an evidence-based overview

Based on three large randomized controlled trials (RCTs) conducted in Africa, it can clearly be stated that circumcision lowers the risk of infection with the human immunodeficiency virus (HIV) and some sexually transmitted infections (STIs) among males in settings of high HIV and STI endemicity. Similar effects on STI risk may exist for females, although this may result from an indirect effect of decreasing risk of infection among male partners. It is unknown whether circumcision prevents HIV acquisition in men who have sex with men (MSM), although there might be a protective effect for men who engage mainly in insertive anal intercourse. When the effects of adult circumcision on sexual function and satisfaction of men are examined, high-quality evidence strongly supports lack of harm. Whether circumcision alters sexual satisfaction of female partners is not known as fewer and smaller studies reported conflicting results. Circumcision rarely causes serious complications if practiced by trained practitioners, in a sterile setting, and with a proper follow-up. These conclusions are limited by the lack of high-quality data from areas outside of Africa. RCTs have not been conducted to assess the effects of circumcising infants or MSM. Circumcision has well-proven benefits for people residing in areas with high prevalence of STIs, including HIV, and is not unethical for those who choose to be circumcised or have their children circumcised on religious, social, or cultural grounds. For many others, a definite pro or con recommendation, based on a risk-benefit ratio, cannot be made.

Innovative Methods of Male Circumcision for HIV Prevention-Getting the Right Evidence

World Health Organization recommends that countries with hyperendemic and generalized HIV epidemics implement voluntary medical male circumcision programs for HIV prevention. Innovative methods of male circumcision including devices have the potential to simplify the procedure, reduce time and cost, increase client acceptability, enhance safety, and expand the numbers of providers who may perform circumcision. We describe work led by World Health Organization and supported by global partners to define a pathway for the evaluation of efficacy and safety of male circumcision devices, to set priority criteria, and to establish a process to guide the use of devices in publicly funded voluntary medical male circumcision programs for HIV prevention. A device classification scheme, an expert Technical Advisory Group on Innovations in Male Circumcision, and a formal prequalification program have also guided considerations on safe use of devices. A rigorous approach was deemed appropriate given the intervention is for use among healthy men for public health purposes. The pathway and processes led to coordinated research, better standardization in research outcomes, and guidance that informed the research, introduction and implementation phases. The lessons learnt from this case study can inform evaluation and use of future public health innovations.

The characteristics of circular disposable devices and in situ devices for optimizing male circumcision: a network meta-analysis

In situ device (ISD) and circular disposable device (CDD) are used for optimizing male circumcision (MC), but evidence to explore the characteristics of these two devices is insufficient. In order to explore this issue systematically and provide reliable evidence, ten published randomized controlled trials (RCTs) exploring the safety and efficacy of ISDs and CDDs were included (involving 4649 men). Moderate quality of the RCTs included was found after assessment. Pairwise meta-analyses and network meta-analyses were processed in stata 13.0 and AIDDS v1.16.6 respectively. According to the outcomes that were statistically significant in both pairwise and network meta-analyses, ISD was found to have less intraoperative blood loss (IB), less operative time (OT) and less incidence of wound bleeding (WB) than conventional circumcision (CC); ISD was found to have less WB but more wound healing time (WHT) than CDD; CDD was found to have less IB and less OT than CC. CDD tended to have the best wound healing condition and least pain experience; ISD tended to have the least IB, least OT, least WB, and highest satisfaction rate. With their own superiorities in many aspects, CDD and ISD are both safe and effective devices for optimizing MC.

Voluntary medical male circumcision in resource-constrained settings

Throughout East and Southern Africa, the WHO recommends voluntary medical male circumcision (VMMC) to reduce heterosexual HIV acquisition. Evidence has informed policy and the implementation of VMMC programmes in these countries. VMMC has been incorporated into the HIV prevention portfolio and more than 9 million VMMCs have been performed. Conventional surgical procedures consist of forceps-guided, dorsal slit or sleeve resection techniques. Devices are also becoming available that might help to accelerate the scale-up of adult VMMC. The ideal device should make VMMC easier, safer, faster, sutureless, inexpensive, less painful, require less infrastructure, be more acceptable to patients and should not require follow-up visits. Elastic collar compression devices cause vascular obstruction and necrosis of foreskin tissue and do not require sutures or injectable anaesthesia. Collar clamp devices compress the proximal part of the foreskin to reach haemostasis; the distal foreskin is removed, but the device remains and therefore no sutures are required. Newer techniques and designs, such as tissue adhesives and a circular cutter with stapled anastomosis, are improvements, but none of these methods have achieved all desirable characteristics. Further research, design and development are needed to address this gap to enable the expansion of the already successful VMMC programmes for HIV prevention.

Longer-Term Follow-Up of Kenyan Men Circumcised Using the ShangRing Device

OBJECTIVES

To ascertain clinical sequelae, client satisfaction and sexual behavior 2+ years after male circumcision using the ShangRing device.

METHODS

We enrolled 199 men from the Kenya sites (Homa Bay district) participating in a 2012 study of the ShangRing device used in routine male circumcision services (N = 552). We enrolled men who had had the ShangRing placed successfully, and over-sampled men who had had an adverse event and/or were HIV-positive during the field study. In the present study, each participant was examined and interviewed by a study clinician, and penile photographs were taken to document longer-term cosmetic results and any abnormal findings.

RESULTS

194 men were included in the analysis. The mean and median times between circumcision and the longer-term follow-up visit in this study were 31.8 and 32 months, respectively. Four men (2.1%) had signs/symptoms of a sexually transmitted infection (STI). Virtually all (99.5%) of the men were very satisfied with the appearance of their circumcised penis, and all would recommend a ShangRing circumcision to friends or family members. The most prevalent reported advantage of the circumcision was the ease of bathing and enhanced cleanliness of the penis (75.8%). 94.3% of the men did not cite a single negative feature of their circumcision. 87.5% of men reported more sexual pleasure post-MC, the most common reason being more prolonged intercourse. The majority of men (52.6%) reported one sexual partner post-MC, but more than a quarter of the men (28.1%) reported an increased number of partners post-MC. Less than half of the men (44.3%) reported using condoms half of the time or more, but the great majority of condom users stated that condom use was much easier post-MC, and 76.9% of users said they used condoms more after circumcision than before.

CONCLUSIONS

This study supports the safety and acceptability of ShangRing male circumcision during 2-3 years of follow-up. It should allay worries that the ShangRing procedure could lead to delayed complications later than the observation period of most clinical studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01567436.