Male circumcision can reduce men's risk of HIV infection from heterosexual intercourse by 60% and is therefore recommended as an important strategy for HIV prevention in Africa by WHO and UNAIDS. However, rapid expansion of male circumcision efforts could be greatly facilitated by a safer, more effective and acceptable male circumcision surgical technique or device. Shang Ring is a simple technique developed in China. It allows a circumcision to be completed with minimal bleeding, without suturing, and in only 3-5 min and reported complications are few. A standardized adult male circumcision surgical protocol utilizing the Shang Ring device was developed in 2008 in China. Several surgical training courses using this protocol were successfully held in 2009 and 2010 in China. A recent pilot clinical study of the Shang Ring was conducted to evaluate its safety and efficiency in Kenya in 2009. The results and acceptability among study participants were excellent and confirmed many of the advantages seen in the earlier Chinese studies from Wuhu, Ningbo and Xi'an, suggesting that the Shang Ring is safe for further studies in Africa, thus, could facilitate more rapid roll-out of adult male circumcision through task shifting, surgical efficiencies and better acceptability. Further international investigations of the Shang Ring technique have now been planned for Kenya and Zambia in 2011. Moreover, adult male circumcision utilizing the Shang Ring device is now being considered as ope of the potential candidate techniques to be used in the scale-up of adult male circumcision services for HIV prevention in WHO priority countries in Africa. This review article summarizes Shang Ring related clinical studies, seminars and surgical workshops, publications and presentations conducted between February 2008 and December 2010 in China, the United States and Africa.
Africa ; Circumcision, Male ; instrumentation ; methods ; HIV Infections ; prevention & control ; Humans ; Male

OBJECTIVETo compare the effect and safety of Shang Ring circumcision with those of conventional circumcision in the treatment of redundant prepuce or phimosis.

METHODSWe retrieved the randomized controlled trials on Shang Ring circumcision and conventional circumcision for the treatment of redundant prepuce or phimosis published at home and abroad. Relevant data were selected according to the Cochrane Handbook for Systematic Reviews by two reviewers after quality evaluation of the included trials, and the statistical software RevMan 5.0 was used for meta analysis.

RESULTSTotally 8 randomized controlled trials with 2277 cases were included in this study. Compared with conventional circumcision, Shang Ring circumcision showed a shorter operation time (SMD = -5.82, 95% CI [ -7.39, -4.24], P<0.00001), less intraoperative blood loss (SMD = -3.28, 95% CI [ -3.47, -3.09], P<0.00001), lower rate of infection (OR = 0.44, 95% CI [0.26, 0.72], P=0.001), lower rate of postoperative bleeding (OR =0.05, 95% CI [0.02, 0.12], P<0.00001), higher rate of satisfaction with the postoperative penile appearance (OR=12.72, 95% CI [1.30, 124.56], P=0.03), lower intraoperative pain score (SMD = -3.32, 95% CI [ -3.50, -3.14], P<0.00001), and lower 24-hour-postoperative pain score (SMD = -3.28, 95% CI [ - 3.47, - 3.00], P<0.00001), but longer wound healing time (OR=1.46, 95% CI [1.03, 1.90], P<0.00001).

CONCLUSIONIn comparison with conventional circumcision, Shang Ring circumcision has the advantages of shorter operation time, fewer complications, mild pain, and higher rate of satisfaction with the postoperative penile appearance. However, more high-quality randomized controlled trials with large samples are required to lend further support to our findings.

Circumcision, Male ; methods ; Humans ; Male ; Phimosis ; surgery ; Randomized Controlled Trials as Topic ; Treatment Outcome

OBJECTIVETo observe the clinical effects of using the Chinese Shang Ring in circumcision children with either phimosis or redundant prepuce, and to investigate its superiority over the similar devices available.

METHODSA total of 824 children with phimosis or redundant prepuce underwent circumcision with the Shang Ring. The clinical data were assessed concerning the duration of the procedure, incidence of post-operative complications, time of recovery and appearance of the penis.

RESULTSThe procedure duration was (2.6 +/-1.2) min, and the complications included infection in 4 (0.6%), edema in 21 (3.2%), delayed removal of the ring in 10 (1.5%), redundant and asymmetric mucosa attributable to performance in 6 (0.9%) of the cases. The wounds healed and the rings were removed at 13.4 +/- 5.8 days after circumcision, with well-smoothed incision and good cosmetic results.

CONCLUSIONChild circumcision with the Chinese Shang Ring is easy and simple in performance, with less operative time, fewer complications and better cosmetic results.

Adolescent ; Child ; Child, Preschool ; Circumcision, Male ; instrumentation ; methods ; Humans ; Male ; Penis ; surgery ; Phimosis ; surgery ; Treatment Outcome

OBJECTIVETo explore the anatomical features and measure the width of the coronal sulcus of the penis.

METHODSWe observed the coronal sulcus of the penis in 269 males aged 19 -66 (mean 28) years. Among them, 137 had redundant prepuce, 11 had phimosis, 90 were normal men, and 30 had been circumcised for redundant prepuce and 1 for phimosis. The width of the sulcus was measured with the vernier caliper at the 12 o'clock position, i. e. , the middle point of the dorsal. The results were compared among different groups.

RESULTSThe mucosa of the sulcus was relatively flat, smooth and not so active. Generally, the anterior line of the coronal sulcus was indistinct, whereas the posterior line was clear and easy to be identified. The widths of the coronal sulcus were (4.32 +/- 3.44), (4.06 +/- 2.68) and (4.22 +/- 3.06) mm in the redundant prepuce, phimosis and normal groups, with no statistically significant differences among the three (P > 0.05).

CONCLUSIONEnough attention should be paid to the width of the coronal sulcus of the penis in clinical practice. The posterior line of the coronal sulcus should be chosen as the positioning standard for inner incision in circumcision.

Adult ; Aged ; Circumcision, Male ; methods ; Humans ; Male ; Middle Aged ; Penis ; anatomy & histology ; surgery ; Young Adult

Phimosis and redundant prepuce, as common problems in andrology, are found in the majority of male neonates. Early treatment of neonatal phimosis and redundant prepuce has the advantages of better cost--effectiveness and higher safety, and contributes much to the prevention of childhood urinary tract infection and adult sexually transmitted diseases, as well as to the improvement of genital hygiene. Neonatal circumcision is commonly performed in some countries, but remains at a low rate in China. This article updates surgical and non-surgical treatments of neonatal phimosis and redundant prepuce, introduces the benefits of neonatal circumcision, and appeals for more attention to the management of neonatal phimosis and redundant prepuce.
Child, Preschool ; Circumcision, Male ; methods ; Humans ; Infant ; Male ; Phimosis ; surgery ; therapy

OBJECTIVETo compare the efficacy and complications of the Shang Ring circumcision with those of conventional surgical procedures.

METHODSA total of 724 patients, 521 with redundant prepuce and 203 with phimosis, were randomly assigned to receive the Shang Ring circumcision (n = 402) and conventional surgical procedures (n = 322). Comparisons were made between the two groups in the surgical duration, blood loss, pain score, as well as postoperative complications, satisfaction with the penile appearance, and the quality of sexual life.

RESULTSThe surgical duration, blood loss, postoperative satisfaction and IIRF-5 score were (4.70 +/- 1.30) min, (2.60 +/- 1.80) ml, 99.50% (400/402) and 23.45 +/- 3.43, respectively, in the Shang Ring group as compared with (25.6 +/- 8.3) min, (11.20 +/- 3.50) ml, 69.57% (224/322) and 23.12 +/- 3.26 in the conventional surgery group, with statistically significant differences in the first three parameters (P < 0.01), but not in IIRF-5 score (P > 0.05).

CONCLUSIONCompared with the conventional surgical procedures, the Shang Ring circumcision has the advantages of shorter operation time, less blood loss, mild pain, fewer complications, better penile appearance, lower expenses, and higher satisfaction and acceptance of the patients.

Adolescent ; Adult ; Circumcision, Male ; methods ; Humans ; Male ; Middle Aged ; Penis ; surgery ; Phimosis ; surgery ; Young Adult

Adolescent ; Adult ; Aged ; Child ; Circumcision, Male ; methods ; Humans ; Male ; Middle Aged ; Young Adult

OBJECTIVETo evaluate the safety and clinical outcomes of the novel simplified no-flip surgical approach to Shang Ring male circumcision in adults.

METHODSA total of 528 adult males, aged 18 - 58 (mean 35) years, 63 with phimosis and 465 with redundant prepuce, underwent no-flip Shang Ring circumcision with or without removal of the outer ring. The operation time and intraoperative blood loss were recorded and observations were made on such complications as postoperative bleeding, infection, edema, and wound dehiscence.

RESULTSThe operation time, intraoperative blood loss, and 2-hour postoperative pain score were (3.8 +/- 0.3) min, (0.6 +/- 0.1) ml, and 7.3 +/-0.3, respectively. Spontaneous ring detachment occurred at 21.6 +/- 2.1 days postoperatively in 12.7% of the patients (67/528) who had chosen not to remove the rings. Of those who preferred removal of the outer ring (87.3% [461/528]), none experienced any pain at the ring removal 7 days after the operation. Postoperative complications included infection in 3 cases (0.56%) and mild edema in 9 (1.70%), but no bleeding and wound dehiscence. Totally, 518 (98.1%) of the patients felt satisfied with the postoperative penile appearance.

CONCLUSIONNo-flip Shang Ring circumcision, with no need for removal of the inner ring, is a safe and simple approach for adult males, which is superior to conventional Shang Ring circumcision for requirement of fewer surgical instruments, shorter operation time, lower incidence of complications, and better satisfaction with the penile appearance. However, these advantages are to be further demonstrated by more randomized controlled trials.

Adolescent ; Adult ; Circumcision, Male ; instrumentation ; methods ; Humans ; Male ; Middle Aged ; Phimosis ; surgery ; Postoperative Complications ; Young Adult

HIV/STIs remain a major global public health problem. One of the global strategies for the prevention and control of HIV/STIs is to interrupt their transmission, which requires the public health methods based on scientific evidence and cost-effectiveness. The scale-up of male circumcision services in the priority countries of the HIV-prevention project in sub-Saharan Africa has been hampered by the scarcity of trained providers and relative technical difficulty of male circumcision techniques recommended by WHO and UNAIDS. Shang Ring is an innovative and disposable device for male circumcision, which has been safely used for over 600 000 males in China since 2006. Clinical studies of more than 3 000 cases of Shang Ring circumcision in China, Kenya, Zambia, and Uganda have demonstrated its safety, effectiveness, acceptability and ease of use. The most obvious advantages of Shang Ring include short procedure time (3-6 min), excellent postoperative cosmesis, low rate of complications, high acceptance by clients and providers, ease of use, and standardization for reliable performance. As an innovative technique, Shang Ring has a great potential for facilitating the safe and effective scale-up of circumcision services. This article comprehensively reviews the clinical studies of Shang Ring male circumcision in China and Africa.
Africa ; China ; Circumcision, Male ; instrumentation ; methods ; HIV Infections ; prevention & control ; Humans ; Male

OBJECTIVETo introduce the advantages of the circumcision with a scalpel by inserting a piece of gauze between the inner prepuce and superficial fascia.

METHODSFrom November 2000 to March 2006, 2 100 patients with redundant prepuce, aged 6-78 years, averaging 23, were circumcised with a scalpel by inserting a piece of gauze between the inner prepuce and superficial fascia. Of all the cases, 1 799 (85.7%) were classified as Type I, 237 (11.3%) as Type II and 64 (3.0%) as Type III redundant prepuce. The mean operation time was 20 minutes (15-35 min).

RESULTSThe incisions were all healed in one stage, with good appearance, no infection and no disruption. Bleeding occurred in 12 cases 648 hours after the operation and delayed bleeding in 3 cases.

CONCLUSIONThe circumcision with a scalpel by inserting a piece of gauze between the inner prepuce and superficial fascia, with easier performance, fewer complications and less bleeding, and capable of preserving more and continuous superficial fascia and giving a better appearance, well deserves to be popularized in clinical practice.

Adolescent ; Adult ; Aged ; Child ; Circumcision, Male ; methods ; Humans ; Male ; Middle Aged ; Phimosis ; surgery ; Surgical Sponges