Comparison of ring instruments and classic circumcision methods: a systematic review and meta-analysis.

Aim: To determine the advantages and disadvantages of both methods by comparing classic circumcision methods with circumcision methods assisted by ring instruments. Material-Methods: Only studies that compared open procedures and ring devices for male circumcision were included. A total of 6226 patients were examined in 14 studies. The methodological quality of RCT was evaluated using Cochrane collaboration's tools. The Review Manager software statistical package was used to analyze the ORs for dichotomous variables and the mean differences for continuous variables. The proportion of heterogeneity across the studies was tested using the I 2 index. Potential publication bias was assessed by identifying the presence of visual asymmetry/symmetry with funnel plot studies. Results: There were 1812 patients in the open circumcision group and 4414 patients in the ring groups. In total, there was no difference identified between the groups. The open procedure had an advantage compared to the Plastibell subgroup for hemorrhage, while in the other two subgroups, the ring instrument groups had the advantage. Statistically significant in favor of ring devices was found in operating time.There was no difference between the groups for early (postoperative) pain scores. For late-period pain scores, differences with statistical significance were identified in favor of ring devices both in subgroups and in total. For satisfaction, apart from one study in the PrePex group, statistical significance was obtained in favor of ring devices for the other subgroups and in total. Conclusion: The main factors in favor of the use of ring instruments for circumcision are the short total surgical duration, not requiring advanced surgical experience, ease of learning and application, and patient relative satisfaction rates. However, it is a condition to know open circumcision methods and to have experience of this surgery for use in situations with hemorrhage complications, mainly, and without ring instruments of appropriate size.

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.

Clinical Outcomes And Risk Factors In Patients Circumcised By Chinese Shang Ring: A Prospective Study Based On Age And Types Of Penile Disease.

PURPOSES: To explore the efficacy of circumcision with Chinese Shang Ring (CSR) in the different cohorts so that can obtain the best applicable population and manage complications better. METHODS: This study consisted of 657 patients who were circumcised with CSR in our institute between August 2017 and August 2018. All cases were followed up at post-operation for 3 to 15 months. The surgery time (ST), wound healing time (WHT), satisfaction with the appearance of postoperative penis and complications were collected and comparatively analyzed. Multivariate analysis was used to determine the independent risk factors associated with efficacy, which were presented by odd ratios and its 95% confidence index. RESULTS: All cases wore the CSR successfully. The ST and WHT respectively were 5.75 ± 2.27 mins and 21.15 ± 5.05 days. The long-term complications, total complications (TC), satisfaction and successful circumcision (SC) respectively were 5.30%, 11.70%, 97.70% and 94.70%. For TC and SC, there was a difference between phimosis and redundant foreskin (21.30% vs 6.20%, P<0.001 and 89.20% vs 97.8%, P<0.001, respectively). In terms of satisfaction and SC, adolescents were higher than children (98.70% vs 94.70%, P=0.035 and 96.80% vs 90.10%, P=0.024, respectively) but was similar to adults (98.70% vs 100.00%, P=0.071 and 96.80% vs 98.00%, P=0.257, respectively). The degree of pain and the incidence of wound dehiscence in adults was higher than adolescents (P<0.05). The phimosis (OR= 1.47, 95% CI=1.26-1.79, P<0.001) and childhood (OR= 1.13, 95% CI =1.06-1.36, P<0.001) were associated with poor efficacy. CONCLUSION: The curative effect of circumcision by CSR in adolescents was similar to adults, both higher than that of children. However, adults have more severe pain and a higher probability of wound dehiscence in the later stage than adolescents. So, adolescence is probably the best time to be circumcised with CSR.

Chinese Shang Ring Male Circumcision: A Review.

Chinese Shang Ring adult male circumcision (SC) is a safe and effective procedure which is easy to learn and to perform. By a specially designed small device, male circumcision (MC) can be performed in 5 min. Compared with conventional adult MC (CC), SC has shorter operation time, less blood loss, less pain score, higher appearance satisfaction rate, and lower complication rate. SC was first developed in China. As recent studies have demonstrated that MC reduced the risk of acquiring human immunodeficiency virus (HIV) infection via vaginal intercourse in African countries, SC was introduced into Africa to fight HIV. Other sexually transmitted diseases such as human papillomavirus infection may also be prevented by SC. In conclusion, Chinese Shang Ring, a small device, provides an easy, quick, safe, and effective method to perform adult MC.

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.

[Shang Ring versus disposable circumcision suture device in the treatment of phimosis or redundant prepuce].

OBJECTIVE: To compare the clinical efficiency of Shang Ring with that of the disposable circumcision suture device (DCSD) in the treatment of phimosis or redundant prepuce. METHODS: From June 2013 to March 2015, we treated 320 patients with phimosis or redundant prepuce using Shang Ring (n=158) or DCSD (n=162). We compared the operation time, intra-operative blood loss, incision healing time, postoperative complications, postoperative satisfaction, and treatment cost between the two groups of patients. RESULTS: Comparison between the Shang Ring and DCSD groups showed that the operation time was (5.6±1.3) vs (5.4±1.2) min, intra-operative blood loss (1.2±0.8) vs (1.3±0.9) ml, postoperative delayed hemorrhage 3.16% (5/158) vs 4.32% (7/162), incision healing time (16.1±7.2) vs (7.5±2.3) d, wound infection 15.82% (25/158) vs 7.41% (12/162), 1-month postoperative incision edema 29.11% (46/158) vs 9.26% (15/162), overall postoperative satisfaction rate 63.92% (101/158) vs 90.12% (146/162), and treatment cost (1121.2±15.6) vs (2142.6±10.8) RMB ¥. There were statistically significant differences between the two groups in the latter five parameters (P<0.05 ), but not in the first three (P>0.05 ). CONCLUSIONS: The DSCD has an obvious superiority over Shang Ring for its relatively lower complication rate, shorter incision healing time, and better cosmetic appearance.

Analysis on curative effect and safety of Shang ring circumcision / 局解手术学杂志

Objective To compare the curative effect and safety of Shang ring circumcision and conventional circumcision .Methods Retrospectively analyzed the clinical data of 329 adult patients who were admitted into our hospital from January 2013 to May 2015, including 205 cases of Shang ring circumcision and 124 cases of conventional circumcision .The operation time , intraoperative and postoperative VAS pain scores , intraoperative bleeding , wound healing time , complications , and degree of penile appearances and overall satisfaction between the two groups were compared .Results Compared with conventional circumcision , Shang ring circumcision was associated with shorter oper-ative time, less intraoperative blood loss , lower intraoperative and postoperative VAS pain scores , lower adverse event rate , higher penile ap-pearances and overall satisfaction , and the difference was statistically significant (P<0.05).Conclusion Shang ring circumcision may be a safer and more effective choice in comparison with conventional circumcision for male patients , as it can shorten the time of operation and save the cost of health care .

Circumcision with "no-flip Shang Ring" and "dorsal Slit" methods for adult males: A single-centered, prospective, clinical study / 亚洲男科学杂志(英文版)

This paper was aimed to compare the clinical effectiveness and safety of adult male circumcision using the Shang Ring™ (SR) with the no-flip technique compared with Dorsal Slit (DS) surgical method. A single-centered, prospective study was conducted at the West China Hospital, where patients were circumcised using the no-flip SR (n = 408) or the DS (n = 94) procedure. The adverse events (AEs) and satisfaction were recorded for both groups, and ring-removal time and percentage of delayed removals were recorded for the SR group. Finally, complete follow-up data were collected for 76.1% of patients (SR: n = 306; DS: n = 76). The average ring-removal time for the SR group was 17.62 ± 6.30 days. The operation time (P < 0.001), pain scores during the procedure (P < 0.001) and at 24 h postoperatively (P < 0.001), bleeding (P = 0.001), infection (P = 0.034), and satisfaction with penile appearance (P < 0.001) in the SR group were superior to those in the DS group. After two postoperative weeks, the percentage of patients with edema in the SR group (P = 0.029) was higher but no differences were found at 4 weeks (P = 0.185) between the two groups. In conclusions, the no-flip SR method was found to be superior to the DS method for its short operation time (<5 min), involving less pain, bleeding, infection, and resulting in a satisfactory appearance. However, the time for recovery from edema took longer, and patients may wear device for 2-3 weeks after the procedure.

Shang Ring versus disposable circumcision suture device in the treatment of phimosis or redundant prepuce / 中华男科学杂志

<p><b>Objective</b>To compare the clinical efficiency of Shang Ring with that of the disposable circumcision suture device (DCSD) in the treatment of phimosis or redundant prepuce.</p><p><b>METHODS</b>From June 2013 to March 2015, we treated 320 patients with phimosis or redundant prepuce using Shang Ring (n=158) or DCSD (n=162). We compared the operation time, intra-operative blood loss, incision healing time, postoperative complications, postoperative satisfaction, and treatment cost between the two groups of patients.</p><p><b>RESULTS</b>Comparison between the Shang Ring and DCSD groups showed that the operation time was (5.6±1.3) vs (5.4±1.2) min, intra-operative blood loss (1.2±0.8) vs (1.3±0.9) ml, postoperative delayed hemorrhage 3.16% (5/158) vs 4.32% (7/162), incision healing time (16.1±7.2) vs (7.5±2.3) d, wound infection 15.82% (25/158) vs 7.41% (12/162), 1-month postoperative incision edema 29.11% (46/158) vs 9.26% (15/162), overall postoperative satisfaction rate 63.92% (101/158) vs 90.12% (146/162), and treatment cost (1121.2±15.6) vs (2142.6±10.8) RMB ¥. There were statistically significant differences between the two groups in the latter five parameters (P<0.05 ), but not in the first three (P>0.05 ).</p><p><b>CONCLUSIONS</b>The DSCD has an obvious superiority over Shang Ring for its relatively lower complication rate, shorter incision healing time, and better cosmetic appearance.</p>

Comparative study of the circumcision techniques curative effect between circumcision suture device and Shang Ring / 中国基层医药

Objective To compare the clinical effectiveness among disposable circumcisionsuture device and Shang Ring in treating redundant prepuce and phimosis.Methods The clinical data of 224 cases of circumcisions done by disposable circumcision suture device(n =112)and Shang Ring(n =112)were retrospective1y analyzed. Operation time,intra -operational bleeding and postoperative complications among two techniques were compared. Results Disposable circumcision suture operation and Shang ring circumcision without significant difference in the operation time and intra -operational bleeding.There result was (6.1 ±0.8)min vs (6.5 ±1.7)min and (2.0 ±0.0)mL vs (1.8 ±0.0)mL(P >0.05).The incidence of postoperative complications with incision pain rate was 21.43% vs 50.89%,infection rate was 14.29% vs 6.25%,frenum area incision edema rate was 8.04% vs 25.89%,and the postoperative hematoma and healing time was (8.0 ±1.7)d vs (14.0 ±1.2)d,the differences were statistically significant(P <0.05).Conclusion Each of two techniques has its own advantages and disadvantages.The treatment decision making should be a detailed description to the patients,we propose that school -age children should choose Shang Ring built -in method and the others should use disposable circumcision suture device depending on the situation.

Clinical trials using the Shang Ring device for male circumcision in Africa: a review.

Male circumcision (MC) reduces the risk of HIV and other sexually transmitted infections (STIs), including human papillomavirus (HPV) and herpes simplex virus type 2 (HSV-2), and is recommended as an important component of a comprehensive package of HIV prevention interventions. While computer modeling has demonstrated that substantial reductions in HIV could be achieved with rapid scale-up of MC services in sub-Saharan Africa, scale-up has lagged due to scarcity of trained providers coupled with relative technical difficulty of recommended surgical MC techniques. Simplified techniques, such as devices, have the potential to allow for a more rapid roll-out of MC. One such device is the Shang Ring, a novel disposable MC device that eliminates the need for suturing and has been on the Chinese market since 2005. Results from Chinese studies have demonstrated that the Shang Ring is both safe and easy to use. Since 2008, a series of studies using the Shang Ring for adult MC have been carried out in Kenya, Uganda and Zambia, according to guidelines established by World Health Organization (WHO) for clinical evaluation of new devices for adult MC. These include a proof of concept study, a study of delayed removal of the Shang Ring, two studies comparing Shang Ring circumcision to conventional surgical approaches, and a large field trial to evaluate safety of Shang Ring circumcision during routine service delivery. Results from these studies demonstrate that the Shang Ring has an excellent safety profile and that Shang Ring circumcision is relatively easy to teach and learn, making Shang Ring MC an appealing technique for use in sub-Saharan Africa where doctors are in short supply and non-physician providers such as nurses and clinical officers are playing a major role in providing MC through task shifting. Shang Ring MC and device removals were uneventfully performed by trained nurses and clinical officers, who preferred the Shang Ring to conventional surgical techniques. Adverse event rates were similar to those observed with conventional surgical circumcision and were managed with, at most, minor interventions, resolving with no long-term sequale. Perhaps one of the biggest advantages of the Shang Ring is the relatively short 3-6 minutes procedure time. Importantly, men also preferred the Shang Ring compared to conventional circumcision and satisfaction with cosmetic appearance of their circumcised penis was very high. The vast majority of participants in studies in Africa as well as China have reported few problems and little disruption to daily life while wearing the device. The Shang Ring holds great promise as an innovative technology that has the potential to facilitate the safe and effective scale-up of circumcision services in settings where MC is not widely used and where the burden of HIV-disease is high.

A clinical comparative study of Chinese Shang Ring circumcision versus conventional circumcision / 中华泌尿外科杂志

Objective To compare the efficacy and complications of Chinese Shang Ring circumcision with conventional circumcisiom Methods Clinical data of 479 cases of Chinese Shang Ring circumcision and 354 cases of conventional circumcision with complete follow-up were analyzed.Comparisons were made between the two groups on operation time,pain score,blood loss,postoperative complications,postoperative satisfaction with penile appearance,wound healing time and treatment costs. Results There was no statistical difference in age and foreskin status between the two groups (P＞0.05).For the Shang Ring group,the operation time was(5±1)rain,blood loss was (0.98±1.14)ml,pain score during operation was 0.25±0.54,24-hour pain score after operation was 1.63±0.87,the postoperative complication rate was 6.89% (33/479),wound healing time was (20±5)d,the satisfaction rate of appearance was 99.79% (478/479),and treatment cost was (871±52) yuan.For the conventional group,the operation time was (27±5) min,blood loss was (8.30±3.60)ml,pain score during operation was 3.29±1.57,24-hour pain score after operation was 5.56±1.42,the postoperative complication rate was 13.28%(47/354),wound healing time was (13±2)d,satisfaction rate of appearance was 92.37% (327/354),and treatment cost was (554±46) yuan.Compared with the conventional group,the Shang Ring group had a shorter operation time,less blood loss,less pain score,higher appearance satisfaction rate and a lower complication rate (P＜0.05).But wound healing time was longer and treatment cost was higher in the Shang Ring group (P＜0.05). Conclusions Chinese Shang Ring circumcision is simpler and an improved approach over conventional circumeision with shorter operative time,less blood loss,less pain,relatively lower complication rate and higher satisfaction and acceptability.