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Concept: Preputioplasty


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.

Concepts: Clinical trial, Foreskin, Penis, Circumcision, Brit milah, Phimosis, Preputioplasty, Dorsal slit


PURPOSE: Men are particularly concerned about pain after circumcision. Concerns about pain can be a reason to decline surgery. Our aim was to assess the severity of postoperative pain and to investigate factors that may influence postoperative pain. MATERIALS AND METHODS: This was a prospective observational cohort study on patients undergoing circumcision. Patients were asked to fill in a questionnaire using visual analogue scales for pain (severity 0-10) on days 1,2,3,7, 21 and to record analgesia used, complications and time off work. Other data recorded were patient age, clinical indication of surgery, foreskin retractility, presence of adhesions and histology. RESULTS: 112 of 211 questionnaires were returned (53.1%). Mean age of patients was 46.4yrs. Commonest clinical indication for circumcision was phimosis (75%). Postoperative pain was scored as mild to moderate (means: 2.4 on days 1-3, 2.1 on day 7 and 0.5 on day 21). Patients younger than 35 yrs of age (p=0.025) and patients with wound infections (p=0.036) had higher pain scores. Only 11 patients (9.8%) had severe pains at any time during the recovery of which 8 had wound problems. The average time off work in the employed population was 6.6 days (SD-6.5), 5 days for light work and 11 days for heavy physical activity. CONCLUSION: Pain following adult circumcision under general anaesthetic administration with intra-operative penile block administration is mild to moderate. Severe pain is rare and mostly related to complications. Younger patients have more discomfort in general.

Concepts: Cohort study, Pain, Foreskin, Penis, Circumcision, Glans penis, Phimosis, Preputioplasty


Background  In adults, human papillomaviruses (HPV), lichen sclerosus et atrophicus (LSA) and phimosis are considered to be major risk factors for penile cancer. In boys, a possible association between phimosis, LSA and HPV has been suggested. Objective  To investigate the role of HPV in the persistence of phimosis in children. Patients and methods  Out of a cohort of 420 boys presenting with foreskin problems, we prospectively sampled the preputial tissue of 82 patients during circumcision: 46 with steroid-naïve and 36 with steroid-resistant phimosis. All foreskins were assessed clinically and histopathologically with regard to appearance, inflammation, oedema, epithelial degeneration and fibrosis. The viral status of the foreskins was determined by immunohistochemistry and highly sensitive PCR, with subsequent subtyping by DNA hybridization (HPV types 6, 11, 16, 18, 31, 33, 35, 39, 42, 44, 45, 51-54, 56, 58, 59, 61, 62, 66-68, 70, 72, 73, 81-84, 90, 91). Results  The foreskins appeared normal in 62 boys and suggestive of LSA in one single case. Small cracks or white scars were present in seven steroid-naïve and 12 steroid-resistant foreskins. LSA was diagnosed microscopically in two of the steroid-naïve and six of the steroid-pretreated group. No evidence of HPV was found in any of the juvenile foreskins. Conclusions  Our prospective study has provided evidence that HPV is not usually present in the foreskin of boys with persistent phimosis after their first year of life and that topical glucocorticoid treatment failure is not associated with HPV or any specific histopathological changes.

Concepts: Human papillomavirus, Foreskin, Penis, Circumcision, Masturbation, Lichen sclerosus, Phimosis, Preputioplasty


Surgery is required for phimosis with a contracted fibrous ring or when the medical treatment with steroids has been unsuccessful. Surgical teams often opt for circumcision when a conservative technique can be used. This surgery could have some psychologic consequences, and when the circumcision in not according to religious convictions, it cannot be live well for the patient and his family. Furthermore, some surgery procedures for prepuce conservation seem to give some unaesthesics aspects with cutaneous excess. The objective of this study was to evaluate our new preputioplasty technique according to the initial diagnosis (phimosis with scarred foreskin or long and narrow foreskin), in situation where circumcision is required currently. Outcome evaluated was: easy and painless foreskin retraction, absence of postoperative phimosis as well as cosmetic aspects of the penis. In this study, 90 children benefited from this technique and subsequent follow-up. The mean age was 7.9 years for the 32 children in the sclerotic phimosis group and 6.8 years for the 58 children in the long and narrow foreskin group. We observed complete foreskin retraction without any recurrence in 100% of children with a phimosis resistant to medical treatment which consisted of progressive foreskin retraction and application of topical steroids, with a mean postoperative follow-up of 1.4 years. Results showed an excellent cosmetic aspect of the penis with absence of enlarged foreskin in all our subjects. This study underlines the relevance of this surgical technique.

Concepts: Medicine, Surgery, Foreskin, Penis, Blood transfusion, Circumcision, Phimosis, Preputioplasty


To compare the surgical effects and postoperative complications and patient experience of two circumcision methods (novel disposable suture device and conventional suture approach) in Chinese excess foreskin or phimosis patients performed in our Andrology centre in a prospective non-randomized controlled study.

Concepts: Foreskin, Penis, Circumcision, Masturbation, Phimosis, Preputioplasty, Balanitis


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.

Concepts: HIV, Surgery, Foreskin, Penis, Circumcision, Phimosis, Preputioplasty


Background We evaluated the safety and efficacy of a novel disposable male circumcision (MC) device developed by Jiangxi-Yuansheng-Langhe Medical Instrument Co., Ltd. Material and Methods Adult male patients (n=120; mean age, 26.6 years) with redundant foreskin and/or phimosis were included in a randomized, multicenter pilot clinical trial from October 2011 to February 2012. Patients were divided into 2 groups and subjected to MC with a novel disposable device (Device Group) (n=60) or to conventional dissection technique (CDT) (Control Group) (n=60). Intraoperative bleeding, surgery duration, pain, healing, and satisfaction with penis appearance were assessed. Adverse events (AEs) were noted. Results Intraoperative bleeding volume [3.5±2.7 (15-35) ml vs. 13.1±6.1 (4-25) ml] and mean surgical time [7.6±4.5 (2-23) min vs. 23.6±4.4 (15-35) min] in the Device Group were significantly less than in the Control Group (P<0.01). No AEs were observed in either group. There were no significant differences in postoperative pain, healing, or satisfaction with penis appearance between groups (P>0.05). Conclusions This novel disposable circumcision device produced satisfactory preliminary adult MC results compared with CDT treatments. This device may be broadly used in men, such as those with phimosis, who are ineligible for CDT.

Concepts: Clinical trial, Foreskin, Penis, Circumcision, Glans penis, Masturbation, Phimosis, Preputioplasty


Lichen sclerosus (LS) is a chronic dermatosis mainly localised to the anogenital area. The aim of this study was to investigate the clinical features of LS in adult men. A retrospective analysis of records from 771 patients diagnosed with LS was made and a questionnaire was sent to all patients. The results showed that the clinical spectrum was wide. Itch, tenderness and pain were frequently reported and more than half of the patients reported that LS had a negative impact on their sexual health. Phimosis was common and almost 1/3 of the patients were circumcised before or during the study period. Eight cases (1%) of penile squamous cell carcinoma were recorded. This emphasises the need for follow-up of male patients with LS.

Concepts: Squamous cell carcinoma, Squamous epithelium, Foreskin, Penis, Circumcision, Masturbation, Phimosis, Preputioplasty


Most surgical procedures for correction of hypospadias involve the removal of foreskin resulting in a circumcised penis. We report our experience and the medium-term results in the reconstruction of the foreskin during the correction of distal hypospadias.

Concepts: Foreskin, Penis, Circumcision, Hypospadias, Phimosis, Preputioplasty


OBJECTIVES:: Medical male circumcision (MMC) is recommended for HIV prevention in men. We assessed the acceptability and safety of the Shang Ring device compared to the dorsal slit method. METHODS:: HIV-negative, uncircumcised men aged 18 years or older who requested free MMC services in rural Rakai, Uganda were informed about the Shang Ring and dorsal slit procedures and offered a free choice of procedure. Men were followed at 7 days postoperatively to assess adverse events (AEs) related to surgery and to remove the Shang Ring. Wound healing was assessed at 4 weeks postoperatively. RESULTS:: 621 men were enrolled, of whom 508 (81.8%) chose the Shang Ring and 113 the dorsal slit. The Shang Ring was provided to 504 men, among whom there were 4 failures of Ring placement (0.8%) which required surgical hemostasis and wound closure. 500 men received the Shang Ring and postoperative surgery-related moderate AEs were 1.0%, compared to 0.8% among dorsal slit recipients. Complete wound healing at 4 weeks was 84% with the Ring and 100% with dorsal slit (p<0001). Resumption of intercourse before 4 weeks was 7.0% with the Ring and 15.0% with dorsal slit (p=0.01.) The mean time for surgery was 6.1 minutes with the Ring and 17.7 minutes with the dorsal slit. Mean time for Ring removal was 2.2 minutes. CONCLUSION:: The Shang Ring is highly acceptable and safe in this setting, and could improve the efficiency of MMC services. However, back up surgical services are needed in cases of Ring placement failures.

Concepts: HIV, Wound healing, Penis, Circumcision, Phimosis, Preputioplasty, Dorsal slit