Use of a disposable circumcision suture device versus conventional circumcision: a systematic review and meta-analysis

Optimizing treatment strategies for pediatric phimosis and redundant prepuce: a comparative study of traditional circumcision and disposable circumcision stapler

Objective

To investigate the surgical outcomes and complication rates of traditional circumcision and disposable circumcision stapler in the treatment of pediatric patients with phimosis and redundant prepuce.

Methods

A retrospective analysis was conducted on pediatric patients with phimosis or preputial redundancy treated at our pediatric surgery department from January 2022 to December 2023. The patients were divided into two groups: treated with traditional circumcision (control group) and treated with a disposable circumcision stapler (experimental group). Surgical parameters (operation time, intraoperative bleeding), postoperative outcomes (postoperative pain scores, wound healing time, severe edge swelling, wound dehiscence, postoperative rebleeding, postoperative infection, aesthetic satisfaction), were compared between the two groups.

Results

A total of 301 pediatric patients were included in our study, with 146 in the traditional group and 155 in the stapler group. The stapler group showed significantly lower values in operation time, intraoperative bleeding, and postoperative rebleeding compared to the traditional group (P < 0.05). However, the traditional group had a significant advantage in postoperative wound healing time and the occurrence of severe edge swelling (P < 0.05). There were no significant differences between the two groups in terms of anesthetic drug dosage, postoperative pain level, postoperative infection rate, wound dehiscence, and aesthetic satisfaction (P > 0.05).

Conclusion

In the treatment of pediatric phimosis and redundant prepuce, the advantage of traditional circumcision lies in faster postoperative recovery and less severe edge swelling. The disposable circumcision stapler excels in thorough hemostasis, easy and safe operation, suitable for primary medical use, but lags behind in postoperative recovery compared to the traditional method. Each treatment approach has its own advantages, and the choice should be based on the actual condition and circumstances of the patient. Personalized treatment decisions should be made collaboratively to achieve the best therapeutic outcomes.

Evaluating Safety of Ring Versus Clamp Devices in Neonatal Circumcision: A Meta-Analysis

BACKGROUND

While device-based circumcision is considered non-inferior to traditional dissection, there is no consensus on the efficacy and safety of ring devices in comparison with clamp devices. We aimed to compare the safety outcomes of ring-based versus clamp-based circumcision techniques in neonates.

METHODS

MEDLINE, EMBASE, Scopus, and CINAHL were searched following the Cochrane collaboration (PRISMA guidelines), without language restrictions, to identify relevant randomized controlled trials. Adverse events, bleeding events, infection events, and procedure time were extracted and analyzed from the selected studies.

RESULTS

From 1661 citations, seven trials were included, encompassing 3390 patients. These studies compared ring-based to clamp-based circumcision devices in neonates. No significant difference was found in overall adverse events between the two groups. However, ring devices showed significantly fewer bleeding events compared to clamp devices. Infection events and procedure time were similar for both groups.

CONCLUSIONS

Both ring and clamp devices have similar safety profiles, with ring devices potentially offering a reduced risk of bleeding. A comprehensive understanding of ring-specific complications and cosmetic outcomes is necessary for a more complete evaluation of these circumcision techniques. Our analysis is limited from a lack of detailed examination of ring-specific complications and their impact on cosmetic results. The included studies varied in quality, and some exhibited a risk of bias.

LEVEL OF EVIDENCE

Level IV Treatment Study.

Efficacy and safety of two disposable circumcision suture devices for circumcision in adults: a prospective comparative multicenter study

The objective of this study was to evaluate and compare efficacy and safety of two different Disposable circumcision suture devices (DCSDs). A prospective comparative non-randomized multicenter study was performed between November 2019 and February 2023. Patients underwent circumcision using a DCSD (CircCurerTM or the ZSR® device) according to the surgeon preference and device availability. A total of 378 patients were circumcised; 184 using CircCurerTM and 194 patients using ZSR®. No differences in baseline characteristics were observed. CircCurer and ZSR Groups showed similar rates of operative time (7.7 ±2.1 vs 7.3 ±2.0 min), surgical site infection (1.1% Vs 1.5%), edema (13% Vs 8.2%), hematomas (2.7% Vs 1.1%), and postoperative pain (2.5 Vs 2.0 points). ZSR Group had a significantly higher rate of clip fallout (62.9% Vs 38%, p < 0.001). At 2 months, patients of both groups reported a median satisfaction of 9 (8-9) points. Main limitation consist in non-randomized study. DCSDs seem to be effective and safe, with short operative times, uncommon and mild complications, and high patient satisfaction. ZSR® device has a higher rate of spontaneous staple dropout.

Type 2 diabetes mellitus increases the risk of circumcision among men aged between 30 and 69 years using a nationwide population-based dataset in Taiwan: a five-year follow-up study

BACKGROUND

Diabetes is an important factor in the development of penile inflammation. We studied whether type 2 diabetes (DM), with/without hypertension and hyperlipidemia increased the risk of circumcision among men aged between 30 and 69 using a population-based dataset in Taiwan during a 5-year follow-up period.

METHODS

The research data in this study were obtained from Taiwan's National Health Insurance Research Database between 1997 and 2010. We identified 23,197 patients who had a new diagnosis of DM and randomly matched 115,985 subjects as controls. We observed whether circumcision was the treatment after a new DM diagnosis. The initial step involved analyzing the data using Poisson regression analysis. To address potential confounding factors, this study employed propensity score matching based on three variables. Additionally, a Cox regression with a Gamma frailty was utilized to compare outcomes between different groups.

RESULTS

Poisson regression analysis showed that DM (RR = 1.75, 95CI = 0.10 ~ 1.22), but not hypertension (RR = 1.14, 95CI=-0.44 ~ 0.70), hyperlipidemia (RR = 0.94, 95CI=-0.66 ~ 0.53), or age (RR = 0.83, 95CI=-0.43 ~ 0.62), had an impact on circumcision treatment. Cox regression with a frailty model found that DM was a risk factor associated with circumcision (HR = 2.31, 95% CI = 1.74 ~ 3.06, p-value < 0.01), whereas no significant difference was noted between circumcision and hypertension (HR = 1.10, 95% CI = 0.80 ~ 1.51), hyperlipidemia (HR = 1.05, 95% CI = 0.79 ~ 1.40), or age (HR = 1.00, 95% CI = 0.99 ~ 1.02).

CONCLUSIONS

Type 2 diabetes mellitus, but not hypertension, hyperlipidemia or age increases the risk of circumcision in men aged between 30 and 69 years.

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.

A Retrospective Taiwanese-Population-Based Clinical Study on Determining the Efficacy and Safety of Disposable Circumcision Anastomat

Traditional approaches for male circumcision are tedious and could lead to complications such as peri-/postoperative pain, bleeding, and infection. Thus, for the first time, we investigated the surgical outcomes of recently the discovered Disposable Circumcision Anastomat Type A (Dongguan ZSR Biomedical Technology Company Ltd., China), a disposable circumcision suture device (DCSD), in terms of the operation time, surgical complexity, safety, satisfaction, and aesthetic outcomes and most importantly the prognostic factors for postoperative infection. A total of 394 individuals were circumcised, with a mean age, body mass index (BMI), stretched penile length (SPL), and penile circumference of 30.1 ± 7.05 years, 25.47 ± 4.73, 10.12 ± 1.61, and 7 ± 0.73 cm, respectively. Associated comorbidities included diabetes mellitus (6.09%), hypertension (2.03%), gout (1.02%), end-stage renal disease (ESRD, 0.25%), and HIV (0.25%). The mean operation time, average postoperative bleeding, and wound infection rate was 31.4 ± 9.96 min, 2.54%, and 9.39%, respectively. The mean VAS postoperative pain scores at D0 and D1 were 4.4 ± 2.4 and 1.9 ± 1.6, respectively. Moreover, 1.27% of subjects required reoperation, and a 2.03% rate of instrument malfunction was noted. The significant factors associated with the post-operative infection group were age (p = 0.0313), BW (p = 0.0081), BMI (p = 0.0026), penile circumference (p = 0.0343), and DM (p ≤ 0.001). Multivariate analyses revealed only DM as a statistically significant factor (p < 0.001). Our box−whisker plot revealed no significant difference between the HbA1c level of infection (Hb1Ac = 7.77 ± 1.39) and non-infection groups (Hb1Ac = 6.92 ± 1.84). However, a trend of higher glycemic index in the infection group was observed. Conclusively, DSCD could be an effective and safe alternative to performing circumcision. However, in the population with advanced aging, phimosis, elevated BMI, and DM (HbA1C > 9%), users should be highly cautious due to the increased risk of infection, dehiscence, and hematoma.

Comparison of NeoAlis™ disposable circumcision device and sleeve technique in circumcision: Results from a referral health-care center in Turkey

BACKGROUND

Circumcision has been one of the most commonly performed surgical procedures worldwide since ancient times. Given the popularity of this procedure, the aim of this study was to evaluate the effectiveness, reliability, and results of circumcision performed using the NeoAlis™ clamp and compare them with those obtained using the sleeve technique.

STUDY DESIGN

The results of 2259 patients circumcised using the two techniques were evaluated retrospectively. The patients who were circumcised using the plastic NeoAlis™ device were classified as group 1 and those circumcised using the sleeve technique were designated as group 2. The groups were compared in terms of operation time, results, cost, complications, and cosmetic satisfaction scores.

RESULTS

A total of 1947 patients who met the inclusion criteria were included in the study. Group 1 consisted of 1454 patients, while group 2 comprised 493 patients. The total rate of complications, excluding bleeding in the form of oozing that stopped spontaneously, was 9.5% (n = 185). In group 1, the operation time was shorter, tolerability of local anesthesia was higher, satisfaction questionnaire scores were higher, cost was lower, and rates of early adhesion and meatal stenosis were lower. All of these parameters were significantly different from those in group 2. Notably, secondary phimosis was significantly higher in group 1. Although the bleeding that stopped with follow-up was significantly higher in group 2, there was no significant difference between the groups in terms of bleeding that required surgical intervention.

DISCUSSION

Our study, which reports the results of circumcisions performed using the NeoAlis clamp, has the largest sample size in the literature. Moreover, this is the only study in the literature wherein the results of sleeve circumcision, which is a time-tested surgical procedure, and the results of NeoAlis clamp circumcision, which we applied to a large number of patients, were compared with each other and with the literature. The retrospective design that focused on relatively short-term (one month) results is the major limitation of this study.

CONCLUSION

Mass circumcision performed with a plastic clamp technique is safe, timesaving, easily teachable, and cosmetically advantageous.

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.

A Modified Pressure Dressing to Avoid Severe Bleeding After Circumcision With a Disposable Circumcision Suture Device and a Discussion on the Mechanism of Bleeding With the Disposable Circumcision Suture Device

INTRODUCTION

A novel type of a disposable circumcision suture device (DCSD) has been proved to be effective and safe; however, a few cases of severe bleeding took place after circumcisions.

AIM

To evaluate the effectiveness of a modified double-layer pressure dressing to avoid severe bleeding after circumcision with the DCSD, in our department in a prospective randomized controlled study, and discuss the mechanism of bleeding with DCSD.

METHODS

Patients with redundant foreskin or phimosis were included between September 2018 and November 2019 and divided into 2 groups: In group A, the conventional pressure dressing was performed; in group B, an modified double-layer pressure dressing was performed.

MAIN OUTCOME MEASURE

The main outcomes and complications (surgical time, incidence of glans ischemia, severe bleeding rate, infection rate, pain level, total cost, and overall satisfaction) were collected and analyzed.

RESULTS

A total of 624 patients were recruited for this study. There was no difference in the average age and body mass index between 2 groups. No patient suffered obvious glans ischemia. In group B, lower pain level, lower incidences of severe bleeding, and better satisfaction were recorded.

CONCLUSION

The mechanism of bleeding with the DCSD was discussed in this study, and the modified pressure dressing was proved effective, safe, and easy to perform. W Jiang, J-li Fu, W-l Guo, et al. A Modified Pressure Dressing to Avoid Severe Bleeding After Circumcision With a Disposable Circumcision Suture Device and a Discussion on the Mechanism of Bleeding With the Disposable Circumcision Suture Device. Sex Med 2021;9:100288.

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.

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.

Subcutaneous tissue-sparing dorsal slit with new marking technique: A novel circumcision method

Circumcision is a very common surgical procedure that is performed for medical and traditional purposes in the world. However, many technical of circumcision is needed to improve. Thus, this study introduced a novel method of circumcision that is a refined version of the sleeve technique, termed subcutaneous tissue sparing dorsal slit with new marking, and evaluated the safety and efficacy of this novel method of circumcision.The randomized clinical trial included 93 adult patients with redundant foreskin or phimosis treated from May 2015 to March 2017. Patients were randomly divided into the novel circumcision method (n = 45) or conventional dissection (n = 48). The groups were compared regarding rates of intraoperative hemorrhage, operative time, pain, healing, satisfaction with penis appearance, and relevant adverse events.No patient suffered any obvious complication. Compared with the patients given conventional dissection, the patients who underwent the new surgical device experienced significantly less wound healing time, scar width, and recovery time (P <.05). The new method resulted in greater intraoperative bleeding volume and surgical time (P <.05). The rate of satisfaction with appearance of the penis was significantly higher in the group treated with the novel technique. In addition, the cost of surgery of these 2 methods was similar.Based on the above research, we found that subcutaneous tissue-sparing dorsal slit with new marking technique was an effective and safe procedure for circumcision, and deserved further application in clinical practice.

[Clinical effectiveness of disposable circumcision suture in children: a prospective randomized controlled trial]

OBJECTIVE

To assess the clinical efficacy of disposable circumcision suture device (DCSD) in children receiving circumcision.

METHODS

Children with phimosis and redundant prepuce undergoing circumcision in our hospital were prospectively enrolled in this study hospital and randomized into DCSD group and conventional circumcision (CC) group. A total of 236 boys were enrolled, including 132 in DCSD group and 104 in CC group. The use of local anesthesia, operation time, intraoperative blood loss, intraoperative and postoperative pain scores, penile appearance satisfaction rates, postoperative complications, healing time of the incision, and the overall satisfaction rate were compared between the two groups.

RESULTS

Compared with CC group, DCSD group had a significantly higher proportion of local anesthesia (P < 0.01), shorter operative time (P < 0.001), less intraoperative blood loss (P < 0.001), lower intraoperative and postoperative pain scores (P < 0.001), higher penile appearance satisfaction rates (P=0.03), less postoperative complications (P=0.04), shorter healing time (P < 0.001), and a higher overall satisfaction rate (P < 0.005).

CONCLUSIONS

The use of DCSD can shorten the operative time and is associated with good tolerance of local anesthesia, less pain, quick recovery, and higher penile appearance satisfaction rates in children receiving circumcision.