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

A comprehensive comparison of the early and late complications of surgical circumcision in neonates and children: A cohort study

BACKGROUND AND AIMS

Major circumcision complications are rare; however, circumcision arouses distress in some special cases. The present study aimed to compare infancy and childhood regarding the frequency and relative risk of early and late complications of circumcision.

METHODS

This study was a retrospective cohort data analysis including 240 neonates and 240 children referred for circumcision from 2015 to 2021. All circumcisions were performed using the surgical dorsal-ventral slits method. A Cox proportional hazard model was used to assess the relative risk (RR) of complications at a confidence Interval of 95%.

RESULTS

The mean age was 19.32 ± 6.5 days for the neonates and 46.1 ± 8.8 months for the children. In general, complications occurred in 61 boys (12.7%), 40 neonates (8.3%), and 21 children (4.4%) (p˂0.001). Bleeding was the most common early complication in six neonates (2.5%) and three children (1.3%), and meatal stenosis was the most common late complication in 10 neonates (4.2%) and four children (1.6%). Meatal web was observed in 11 neonates (4.6%) and four children (1.6%), and the incomplete removal of the prepuce, as "not very satisfactory", was also noticed in nine neonates (3.75%) and three children (1.3%). The circumcision complications were significantly more frequent in neonates than in children (RR = 2.6, 95% CI 1.46-4.71, p<0.001). The neonatal circumcisions had a significant risk of the incomplete removal of the prepuce, meatal web, and meatal stenosis compared to children (RR = 3, 95% CI 5.83-10.81, p<0.04; RR = 2.75, 95% CI 0.9-8.3, p˂0.03; RR = 2.5, 95% CI 0.8-7.75, p<0.04, respectively).

CONCLUSION

The risk of complications is higher in neonates than children. The incomplete removal of prepuce, meatal web, and meatal stenosis are significantly higher in neonates than in children. Before prohibiting or recommending this procedure, practitioners should provide comprehensive information about its risks and benefits. Parents should weigh up the risks and benefits and make the best decision regarding their personal beliefs and customs.

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.

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.

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.

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.

[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.