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

Comparison of ring instruments and classic circumcision methods: a systematic review and... ARAB JOURNAL OF UROLOGY 2022, VOL. 20, NO. 3, 144–158 https://doi.org/10.1080/2090598X.2022.2071545 REVIEW ARTICLE Comparison of ring instruments and classic circumcision methods: a systematic review and meta-analysis a b c Yavuz Güler , Gökhun Çağdaş Özmerdiven and Akif Erbin a b Urology Department, İstanbul Rumeli University, Private Safa Hospital, İstanbul, Turkey; Urology Department, İstanbul Aydın Üniversitesi, VM Medical Park Hospital, İstanbul, Turkey; Urology Department, Haseki Training and Research Hospital, İstanbul, Turkey ABSTRACT ARTICLE HISTORY Received 28 February 2022 Aim: To determine the advantages and disadvantages of both methods by comparing classic Accepted 23 April 2022 circumcision methods with circumcision methods assisted by ring instruments. Material-Methods: Only studies that compared open procedures and ring devices for male KEYWORDS circumcision were included. A total of6226 patients were examined in 14 studies. The meth- Circumcision; ring devices; odological quality of RCT was evaluated using Cochrane collaboration’s tools. The Review plastibell; prepex; shang ring Manager software statistical package was used to analyze the ORs for dichotomous variables andthe 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 favorof 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. Introduction As with every surgical procedure, circumcision has Circumcision is the most common surgical proce- some of its own specific complications. These are dure performed on male children, and it is pre- minor and treatable complications like hemorrhage, dicted that one in every three men globally are pain, edema and inadequate skin removal commonly circumcised. Circumcision surgery extends back observed in the early period. However, serious compli- 15,000 years. A variety of studies defined the ben- cations like severe hemorrhage requiring reoperation efits of circumcision. Penis cancer and cervical and amputation of the glans penis may be observed. In cancer risk in partners is reduced. Additionally, it the late period, pain, wound site infection, adhesions, is reported that the risk of catching HIV infection meatal stenosis, fistula, loss of penile sensitivity and reduces by up to 60% [1–3]. Within the scope of sexual dysfunction may be observed [5]. long-term HIV prevention strategies, the World Currently, circumcision is performed with a range of Health Organization (WHO) and the Joint United methods. Dorsal slit, Gomco clamp, Mogen clamp, bone Nations Program on HIV/AIDS (UNAIDS) recom- cutter and Plastibell are the main methods [6]. Due to mended adult circumcision along with neonatal advantages like being quick, easy to perform, a less trau- circumcision [4].Circumcision is performed in neo- matic technique with minimal blood loss, lower complica- natal infants, children and adult males for reli- tion rates and high cosmetic satisfaction, circumcision gious, cultural and medical reasons. It is a radical performed with ring instruments is a very popular and treatment choice for medical problems like phimo- frequently chosen method. While Plastibell ring devices sis that cannot be treated by other treatments, are used in the pediatric age group [7], the PrePex and balanopostitis and chronic urinary tract infections. Shang Ring devices are used in adults over 18 years of age. CONTACT Yavuz Güler yavuzguler1976@gmail.com Urology Department, İstanbul Rumeli University, Private Safa Hospital, İstanbul, Turkey © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ARAB JOURNAL OF UROLOGY 145 In this context, we attempted to perform Data synthesis and analysis a systematic review and meta-analysis about the com- Primary and secondary outcomes were calculated from parative effectiveness of ring device and open proce- the estimates of each study to enumerate pooled odds dure circumcisions by collecting all relevant published ratios (ORs) and confidence intervals (CIs). The Review studies to provide a comprehensive survey that Manager 5.3 software (Cochrane Collaboration, Oxford, addresses this controversy. UK) statistical package was used to analyze the ORs for dichotomous variables and the mean differences for con- tinuous variables. Meta-analyses were performed using Materials and methods this software to determine the ORs and CIs for the follow- Data sources and search strategy ing criteria: bleeding, infection, operating time, overall complications, satisfaction, early and late pain scores. We searched PUBMED, EMBASE, Cochrane Database of The proportion of heterogeneity across the studies was Systematic Review, Web of Science and Google Scholar 2 2 tested using the I index (range: 0%–100%). If I < 50%, from their inception until December 2021. These arch the variation of the studies was considered to be homo- terms used to identify potentially eligible studies from genous and the fixed-effect model was adopted. If each data source were as follows: ‘circumcision’, ‘dorsal I > 50%, the variation of studies was considered to be slit’, ‘ring devices’, ‘plastibell’, and ‘open circumcision’. significantly heterogeneous and the random-effect The reference lists of the relevant studies were also model was adopted. All P values were two-tailed, and searched. Two of our authors independently screened p < 0.05 was considered statistically significant. all citations and abstracts identified by these arch strategy to screen eligible studies. Only English was used as the language for screening. Publication bias Potential publication bias was assessed by identifying the presence of visual asymmetry/symmetry with fun- Data extraction, inclusion and exclusion criteria nel plot studies. Only studies that compared open procedures and ring devices with male circumcision status were included. Results All relevant studies identified from these arch strategy were used for detailed assessment. Case reports, case Search results and study characteristics series, articles not written in English, articles without The details about the literature search and screening full text found or accessible and studies comparing process can be found in Figure 1. Upon completion of circumcision methods apart from the classic open cir- primary screening by scanning titles and abstracts, the cumcision methods (dorsal slit, sleeve circumcision, full texts of 14 potentially relevant studies were forceps-guided) with other ring devices (Mogen, Gomko clamp, guillotine, etc.) were excluded from the study. Data were extracted from the included stu- dies by the authors. The extracted data included data sources, eligibility, methods, participant characteristics, interventions and results. Assessment of study quality The methodological quality of RCT was evaluated using Cochrane collaboration tools, including 6 items: randomization of reviewers, allocation con- cealment, blinding of personnel and participants, blinding of outcome measurement, incomplete outcomes, selective reporting and other bias [8]. The methodological quality of retrospective and prospective non-randomized studies was evaluated using the modified Newcastle-Ottawa scale(NOS), in which a score of 1–9 stars was allocated [9]. This study followed the PRISMA (preferred report- ing items for systematic reviews and meta- Figure 1. Flow chart of the study. analyses) statement [10]. 146 Y. GÜLER ET AL. Table 1. Demographic and quality data of studies. Study Country Study interval Study Type Age, mean(range) No of patients Follow up Quality score (NOS) Open Ring Open Ring Abdullah, 18 Nigeria 2013 RCT 7d-10y 7d-10y 60 60 N/A − Modı, 21 İndia 2017–2019 Retro 4.77 ± 2.4(y) 4.8 ± 2.2(y) 30 30 N/A 5 star Gavade, 20 İndia 2017–2019 RCT 3.1 y 3.7 y 58 58 N/A − <1: 26% 35% 1–5: 53% 48% 6–10: 17% 17% 11–15: 3% 0% Hamza, 20 Nigeria 2016–2017 RCT 3 m (8d-5y) 1 m (9d-5y) 55 55 1 m − Talini, 18 Brasil 2015–2016 Retro 5.27 (10 m-13 y) 501 1940 N/A 5 star Mouniddin,18 İndia 2016–2018 RCT 3.5 ± 2.8 (m) 4.0 ± 3.5 (m) 250 310 15th day (open group), − on day of separation of the ring (ring group) Lei, 16 China 2012–2014 Pros NR 18–44:(69.7%) 75% 76 306 4 w 5 star 45–59: (25%) 20% 60–76:5.3% 5% Mahmood, 15 Pakistan 2012–2014 RCT 1 w-2y 1 w-2y 50 50 5 d − Sokal, 14 Kenya, Zambia 2011 RCT 20.5(18–39) (m) 21(18–41) (m) 201 197 60 d − Kigozi, 14 Uganda 2012–2013 Pros NR 18–25 (m): 65% 67% 68 326 4 w (open group) 5 star 25–29 (m): 17% 15% 7 w (ring group) 30–34 (m): 8% 8% 35–39 (m): 4% 3% 40+ (m): 8% 8% Kigozi, 13 Uganda N/A Pros NR <24 (m): 68% 63% 117 500 4 w 5 star 25–29 (m): 14% 16% 30–34 (m): 10% 7% 35–39 (m): 7% 8% >40 (m): 2% 7% Mutabazi, 12 Rwanda 2011 RCT 24 ± 4.1(21–54) (m) 26 ± 5.2(21–54) (m) 73 144 9 w − Netto, 10 Brasil 2006–2008 RCT 72 ± 32 (m) 71 ± 32 (m) 68 57 87(64–102) d − Mousavi, 08 Iran 2002–2008 RCT 4.4 ± 3.2 (m) 3.1 ± 2.8 (m) 205 381 N/A − ARAB JOURNAL OF UROLOGY 147 identified [11–25]. Two were retrospective, 3 were pro- in favor of ring devices in the other subgroups and spective non-randomized and 9 were prospective, ran- in total (P < 0.01). Weighted odds ratio 95% CI 0.18 domized and controlled (PRC) studies. The (0.11, 0.28) (Figure 5,Table 2). characteristics of the studies are shown in Table 1. The included studies were published between 2008 Bleeding and 2020. A total of 6226 participants were included from Brazil, Nigeria, India, China, Pakistan, Kenya, This parameter was recorded in a total of 13 studies Zambia, Uganda, Rwanda and Iran. The number of (Table 2). Data related to hemorrhage complications participants in each study was 60–2441. The follow- were found in 8 studies using Plastibell, 1 study up durations for the studies were 5–90 days. using PrePex and 3 studies using Shang Ring. While there was an advantage in favor of the open procedure for the Plastibell subgroup Assessment of study quality (p = 0.04), the advantage was in favor of the ring Quality assessment was performed according to NOS devices for the other two subgroups (p < 0.001). In for 2 retrospective and 3 prospective non-randomized total, there were no differences identified between studies. The 5 studies were assessed as having fair the groups (P = 0.59). Total weighted odds ratio quality with 5 stars each. Prospective randomized con- 95% CI 0.75 (0.27–2.10) (Figure 6a,Table 2). trolled studies were rated as high risk for questions about blinding of participants and personnel (perfor- Infection mance bias) and blinding of outcome assessment (detection bias) as surgical methods preclude blind- This was reported in a total of 9 studies, with 8 using ing(Figure 2). Plastibell and 2 using Shang Ring. There was no statistical significance for the open vs. ring group for the Plastibell subgroup (P = 0.42). For the Shang Ring group, the Primary outcomes difference was in favor of the ring device (P = 0.005). No In studies comparing Plastibell ring device and open statistical difference was present in total (P = 0.64). procedures, mean age extended from the neonatal Weighted odds ratio 95% CI 0.89 (0.56–1.43) (Figure 6b, period to 15 years of age. In studies comparing the Table 2). Shang Ring [11,13], PrePex device [12,14] and open procedures, the studies included adult males over 18 years. Comparisons with open procedures used Edema the Plastibell in 9 studies, PrePex in 2 studies and This was investigated in 3 studies from the Shang Shang Ring in 3 studies. Ring group and 2 studies from the PrePex group. Edema reports were not encountered in any study Operating times from the Plastibell group. Statistically significant differences were not identified for the subgroups This parameter was included in 9 studies. Statistical or in total (P = 0.32). Weighted odds ratio 95% CI significance was present in favor of ring devices 1.36 (0.74,2.51) (Figure 6c,Table 2). (p < 0.01). Weighted odds ratio 95% CI 1.45 (0.51, 2.58) (Figure 3,Table 2). Adhesion Overall complications In the subgroups, only 2 studies from the Plastibell group reported adhesion. There was a statistically Overall complications were considered in a total of 7 significant difference in favor of the Plastibell group studies, 4 with Plastibell, 2 with PrePex and 1 with for comparisons between Plastibell devices and Shang Ring. Statistical significance was not present open procedures (P = 0.01). Weighted odds ratio for subgroups or in total on the meta-analysis 95% CI 0.29 (0.11,0.74) (Figure 6d,Table 2). (p = 0.69). Weight odds ratio 95% CI 1.18 (053–2.63) (Figure 4,Table 2). Insufficient skin removal Satisfaction Inadequate tissue removal was reported in 3 studies in Satisfaction scoring was performed in 6 studies. In the Plastibell subgroup and 1 study in the Shang Ring terms of subgroups, there were 2 studies using subgroup. Statistical differences were not present Plastibell, 3 studies using Shang Ring and 1 study between open procedures and ring devices in the sub- using PrePex. Apart from the single study in the groups or in total (P = 0.18). Weighted odds ratio 95% CI PrePex group, statistical significance was obtained 2.3(0.39,7.65)(Figure 6e,Table 2). 148 Y. GÜLER ET AL. Figure 2. Cochrane collaboration tools study chart. Wound dehiscence Early (perioperative) pain scores Data related to wound dehiscence were only accessed in Only one study in the Shang Ring and one study in the three studies in the Shang Ring group. Significant statis- PrePex subgroup assessed pain scoring in the early tical differences were not identified between the open postoperative period. While differences were identified procedure and Shang Ring group (p = 0.72). Weighted between the subgroups, a statistically significant odds ratio 95% CI 1.22 (0.42, 3.53) (Figure 6f,Table 2). ARAB JOURNAL OF UROLOGY 149 Figure 3. Forest plot for operation time - Weighted odds ratio 95% CI -8.46(-11.6,-5.32). difference was not identified in total (p = 0.89). 1.7% in the PrePex study [15]. Two studies con- Weighted mean difference 0.22, 95% CI −2.86 to 3.30 sidered whether there was a correlation between (Figure 7a,Table 2). age and ring separation rates [16,22]. In both stu- dies, as age increased, spontaneous separation was reported to be delayed. Only one study Late pain scores assessed the correlation between ring diameter and separation duration and found no correlation Only one study in the Shang Ring and one study in [22]. The same study examined the correlation the PrePex subgroup performed pain scoring stu- between age and complications and reported dies in the late postoperative period. Statistical sig- that as age increased, complication rates nificance in favor of ring devices was identified in increased. Another study researching the correla- both subgroups and in total (p < 0.01). Weighted tion between patient body weight and sponta- mean difference −2.22, 95% CI −3.10 to −1.34 neous ring separation reported that as weight (Figure 7b,Table 2). increased, separation was delayed [16] (Table 3). Outcomes related to ring instruments Other outcomes Spontaneous ring removal time was given in a total of 5 studies [13,17,19,22,24]. In the Plastibell group, Two studies considered complete wound healing. 3 studies [19,22,24] had similar spontaneous separa- These studies revealed a statistical advantage for tion durations (5.2, 6 and 6.2 days, respectively). the classic circumcision group compared to the Only one study reported 16 days [17]. The fifth ring group (SMD IVR 95% CI; 0.54(0.19,0.88), study was in the Shang Ring group and the mean p = 0.003) [12,14] (Figure 8a). Kigozi et al. [15] separation duration was 18 days [13]. The sponta- reported wound healing rates in the 4th and 7th neous separation rate was given in 8 studies weeks. While 98.7% full healing was observed in [16,17,19–22,24]-Plastibell; 13-Shang Ring Group). the open group in the 4th week, this rate was The lowest spontaneous separation rate in the 56.7% in the ring group. By the 7th week, the Plastibell group was 70% [20], while another study healing rate in the ring group had reached 98.6%. had rate of 85.5% [22] and the other studies were Only one study gave reoperation and cicatricial all above 90%.The other study in the Shang Ring data [17]. In the ring and open circumcision group had spontaneous separation rate of groups, there was no statistically significant differ - nearly 80%. ence for both parameters (reoperation and scar In 2 studies, data about ‘device removal by p values 0.57 and 0.24, respectively) (Figure 8b,c). participants’ were given [11,15]. Ring devices Three studies considered postprocedural pain rates were reported to be removed by participants at [12,18,19]. In terms of postprocedural pain rates, rates of 0.6% in the Shang Ring study [11] and there was no statistically significant difference 150 Y. GÜLER ET AL. Table 2. Operative and postoperative data. Open/Ring devices Total Wound Excess complications İnfection Bleeding Edema Adhesion Cicatricical dehiscence Wound healing mucosa Pain scores Satisfaction Procedures performed Anesthesia Studies Operation time (min) (%) (%) (%) (no) (%) (%) (no) time(day) (no) Pain scores early late (%) by type Abdullah,18 12/7 N/A 1.7/2.6 1.7/5 N/A N/A N/A N/A 8/10 N/A N/A N/A 91 Surgeon N/A Modi,21 19.73 ± 2.3/10.17 ± 1.82 N/A 3.3/3.3 0/3.3 N/A N/A N/A N/A N/A 0/1 N/A N/A N/A Trained resident Local/ doctors General Gavade,20 N/A N/A N/A 1.7/5.2 N/A N/A N/A N/A N/A N/A N/A N/A N/A Surgeon N/A Hamza,20 N/A 9.1/29.1 N/A 0/9.1 N/A 1/0 N/A N/A N/A N/A N/A N/A N/A Surgeon Local: < 1 year age General: > 1 year age Talini,18 N/A 3/3.4 N/A 0.6/1.2 N/A N/A N/A N/A N/A N/A N/A N/A N/A Surgeon General Monuiddin,18 10 ± 3.5/4 ± 2 8/21 3.2/5.2 4/8.1 N/A N/A N/A N/A N/A 2/4 N/A N/A N/A Surgeon Local Lei,16 23.4 ± 4.3/4.8 ± 0.9 N/A 9.2/2.9 13.2/1 3/29 N/A N/A 0/3 N/A N/A 3.1 ± 1.4/ 5.8 ± 1.4/ 72.3/96.4 Surgeon Local 1.8 ± 1.3 4.0 ± 1.2 Mahmood,15 N/A N/A 4/0 6/0 N/A N/A N/A N/A N/A N/A N/A N/A N/A Surgeon Local Sokal,14 29.5 ± 4.5/7.2 ± 2.0 N/A 1/0 0.5/0 0/1 N/A N/A 4/6 38.6 ± 12.6/ N/A N/A N/A 78.6/96.3 Non-physicians 82% Local 44.1 ± 12.6 Phsicians and nonphysician 17% Physicians 2% Kigozi,14 N/A 0/9 N/A N/A 0/1 N/A N/A N/A 98.7%(at 4 week)/ N/A N/A N/A N/A Clinical officers Local gel (For 98.6%(at prepex 7 week) group) Kigozi,13 17.7 ± 7.3/6.1 ± 2.7 3/14 0.85/0 0/0.2 0/1 N/A N/A 1/1 N/A 0/1 N/A N/A 100/99.1 Clinical officers Local Mutabazi,12 8.8 ± 2.0/3.4 ± 1.1 11/2.7 N/A 19.2/0.7 11/21 N/A N/A N/A 23 ± 7.5/ N/A 3.8 ± 2.1/ 5.2 ± 2.2/ N/A Surgeon Local 31.0 ± 12.1 5.6 ± 1.8 2.5 ± 1.8 Netto,10 14.6 ± 1.9/3.3 ± 1.5 26/10.5 0/0 10.3/5.3 N/A 29.4/10.5 8.8/3.5 N/A N/A N/A Use of Plastibell N/A Surgeon General paracetamol group was similar in reguired the firsth more 2 days. painkiller Mousavi,08 N/A N/A 0/1 2/1.3 N/A N/A N/A N/A N/A 0/5 N/A N/A N/A Surgeon Local ARAB JOURNAL OF UROLOGY 151 Figure 4. Forest plot for overall complications - Weighted odds ratio 95% CI 1.15(0.51,2.58. Figure 5. Forest plot for satisfaction. found between the groups (p = 0.18) (Figure 8d). Discussion One study considered oozing and clear exudate Circumcision is performed for medical (phimosis, para- [14]. The ring group was found to be statistically phimosis, balanopostitis, etc.), cultural and religious advantaged for both parameters, (p values 0.0008 reasons in the world in general [25]. Geographies and 0.008, respectively) (Figure 8e,f). 152 Y. GÜLER ET AL. Figure 6. Forest plot for a. Bleeding, b. Ä°nfection, c. Edema, d. Adhesion, e. Ä°nsufficient skin removal, f. Wound dehiscence. ARAB JOURNAL OF UROLOGY 153 Figure 7. Forest plot for painscores. a. Early, b. Late. where circumcision is performed generally have dense group was 10–23.4 min (p < 0.001). Classic circumci- populations and are countries with low income struc- sion is a complex surgery including cutting of the ture socioeconomically. For these reasons, it is impor- prepuce skin, bleeding control and primary suturing tant to be able to perform the circumcision procedure of skin-mucosa and requires serious experience and more rapidly with low cost. Due to these features, ring long procedure times [29]. Additionally, considering devices have gained popularity for circumcision that most circumcision procedures in the world in [26,27]. Plastibell ring devices are used with internal general are performed under local anesthesia (without diameter 1–1.7 cm for the neonatal-infant and pedia- much comfort), the need for a circumcision method tric age group. In recent times, ring devices have with the shortest duration that provides the best out- begun to be used for adult circumcisions. Among come is clear. The most serious time advantage of these, the main examples are PrePex and Shang Ring circumcisions with ring devices is that bleeding control devices. and skin-mucosa suturing procedures are not per- It appears the most important advantage of ring formed [30]. devices is the short duration of the procedure for From the studies included, it is understood there circumcision [28]. This situation may reduce stress for was a correlation between circumcision age and patients undergoing circumcision with local anesthe- Plastibell ring separation duration [16]. Studies by sia, especially. Additionally, it may ensure reductions in Hamza and Modi observed that as age reduced the extra costs like anesthetic drug amounts and laryngeal ring separation time symmetrically reduced in sub- mask used during circumcisions performed under gen- group investigations according to the ages of circum- eral anesthesia. In this meta-analysis, the operation cised children [22,24]. In similar studies using the duration for studies in the ring group was 3.3– Plastibell ring device, as the age of circumcision fell, 10.2 min, while the duration for the open procedure the ring separation time was reported to decrease [29]. 154 Y. GÜLER ET AL. Table 3. Ring instrument specific data. Device Spontaneous Displacement removed Ring Ring or Migration by Device Separation Spontaneous(sp) Ring Removing of Ring participant Study Type Rate (%) Time Devices(%) Correlation’s (%) Modi 2021 Plastibell 93.4 0–5 years: 4.4 ± 1.0 6–10 years: 3.3 N/A 8.0 ± 1.6 Total: 5.2 ± 1.9 (day) Hamza 2020 Plastibell 85.5 Neonates: 5.7 ± 2.0 (spontan/sp) N/A -Correlation between the size of the ring N/A 1–11 month:7.1 ± 2.6(sp) 1– and number of days for separation: No 4 years:10.5 ± 0.7(sp) >5: -Correlation between age of subjects 14 day (Surgical) Total: 6(2– and bell separation time: Yes - 11) Correlation between age and freguency of complications:Yes Gavade 2020 Plastibell N/A N/A N/A N/A Abdullah 2018 Plastibell 98.2 N/A 1.7 N/A Talini 2018 Plastibell 70 N/A 1.7 N/A Mouniddin 2018 Plastibell 96.5 6.2(3–12)(day) 2.9 N/A Mahmood 2015 Plastibell N/A N/A N/A N/A Netto 2010 Plastibell 100 16 ± 5(6–30)(day) 0 0 Mousavi 2008 Plastibell 97.4 N/A 0.5 Correlation between weight of subjects N/A and bell separation time:Yes - Correlation between age of subjects and bell separation time: Yes Lei 2016 Shang 79.2 18 ± 6 (day) 0.7 N/A Sokal 2014 Shang 0 Surgical 0 0 Kigozi 2013 Shang 0 Surgical 0.8 0.6 Kigozi 2014 Prepex 0 Surgical 0.3 1.7 Mutabazi 2012 Prepex 0 Surgical 0 0 We think this correlation may be due to the prepuce the advancing postoperative days, complications like being thinner and easier sloughing. When neonatal, infection, adhesion, prepuce stenosis, hypertrophic infant and child circumcision are considered for the skin scar, skin separation, and meatal stenosis may be Plastibell subgroup, mean spontaneous ring separa- observed, while there may be major complications like tion duration was less than 10 days. This duration glans necrosis and urethra-cutaneous fistula. In addi- was laterin only 1 study, even though the mean age tion to these complications specific to the surgical was not different to the other studies [17]. It appears procedure, there appear to be additional complica- that some authors in the Plastibell subgroup deter- tions specific to the device in the ring group (migra- mined a cut-off duration for waiting according to tion, late separation or semi-separation, etc.) [31]. In themselves. Abdullah et al. determined the cut-off studies in this meta-analysis, we did not observe duration as 12 days, while Hamza et al. determined a difference in terms of overall complications between the cut-off as 14 days [21,22]. At the end of this dura- the 3 ring devices and the open procedures (P = 0.73). tion, Hamza observed ring devices had still not sepa- Hemorrhage is the most common complication rated in 15% of patients, while Abdullah found this was observed after circumcision surgery, in spite of the the case for 1.8% of patients. The ring devices that did reduction as the age of circumcision falls [30–32]. not separate by the determined day were surgically When examined in total, a difference was not identified removed. Nearly all of the rings with delayed separa- between the classic and ring circumcision groups in tion were in the advanced pediatric age group. Though terms of hemorrhage (p = 0.0.62). However, in sub- it appears like a second surgery, most procedures were group analysis, the classic operations appeared to be easily performed with administration of a local anes- more advantageous in terms of hemorrhage compared thetic spray and did not take a long duration. In studies to the Plastibell ring group (P = 0.04). Contrary to this, using the Shang Ring and PrePex devices (apart from circumcision with ring devices appeared more advan- Lei et al.), the authors apparently did not wait for tageous in the PrePex and Shang Ring subgroups spontaneous separation of the ring and performed (P < 0.01); however, the low number of studies for surgical removal due to the reduced probability of comparison in these two subgroups should not be spontaneous separation at advanced ages [11–15]. forgotten as it may be misleading. Most postoperative Though observed less in children in the neonatal circumcision hemorrhage stops with compression ban- and infant period compared to older children, compli- daging. However, though rarely, massive hemorrhage cations are observed with all circumcision methods requiring re-operation (suture and/or cauterization) [31]. More complications are reported for circumcision may be observed. Probably these hemorrhages are performed by traditional non-medical circumcision observed due to loosening of sutures, lack of full pla- providers, especially [31]. Hemorrhage is most com- cement of the internal ring, depth of the dorsal slit monly observed among early complications. From incision being below the ring suture and most ARAB JOURNAL OF UROLOGY 155 Figure 8. Forest plot for a. Complet wound healing, b. Reoperation, c. Cicatrical, d. Postprocedural pain, e. Oozing, f. Clear exudate. importantly tearing of the frenula fold by the ring [33]. operations, all open vein ends extending under the Choosing a ring of appropriate size for the penis glans skin and above the dartos fascia should be cauterized diameter and creating sturdy sutures will prevent with bipolar cautery or tiedbefore skin-mucosa primary these hemorrhages. In studies that prevented tearing suturing. Additionally, it is important to cauterize or of the frenulum by changing the ventral portion of the suture actively weeping sites along the skin incision ring device with some modifications, hemorrhage edges. Sometimes hemorrhage does not stop in spite rates were shown to be lower [30]. For this reason, as of compression bandaging [34]. When diluted adrena- experience performing circumcision with ring devices lin ring block anesthesia is performed, these veins may increases, we believe the hemorrhage complication not bleed due to vascular spasm and it should not be rates with reduce further. In open circumcision forgotten that they may be overlooked for this reason. 156 Y. GÜLER ET AL. Surficial skin infections may be observed after cir- Adhesions may be observed between the penis skin cumcision. In this meta-analysis, both surgical methods and mucosa or glans penis after circumcision. Though it were similar in terms of infection (p = 0.64). When appears to be a minor complication, skin adhesions cause studies with different ring device durations are exam- a dead cavity for accumulation of smegma and debris. If ined, though we did not identify a difference in rates of this is not corrected, it may form an area where infective patients with infection, we think leaving the ring devices agents can lodge. However, though rarely, sharp dissec- for long durations may increase the risk of infections. tion of these skin bridges may be required; generally they Contrary to this, fewer infections were observed in neo- may beeasily opened with steroid creams and/or blunt nates and infants compared to older children [7]. manipulation with the hands. This problem is encoun- Suboptimal local wound checks at home, activity and tered more frequently in those with buried penis espe- inability to restrict contamination among older children cially and infants using diapers [38]. In this meta-analysis, may explain the higher observation of infection in this we noticed that most studies did not report adhesion age group. Full adherence to surgical sterility rules by incidence; the few studies that did report it observed the person performing circumcision is important. more adhesion with the classic methods [17,22]. Infection rates after circumcisions performed by tradi- However, it is difficult to assess whether the ring groups tional circumcision providers are known to be higher or classic methods are more advantageous in terms of than for medical practitioners [35]. However, there is adhesion. To prevent adhesion, there is benefit in recom- benefit in underlining the heterogeneity in infection mending regular manual manipulation by families to definitions between studies. Many authors defined prevent skin adhesion especially in infants with buried infection as clinical infection only, without examining penis and using diapers. Additionally, it is necessary to any culture tests from skin swabs. At the same time, check circumcision patients after full wound healing. presence of pus was not noted in the definition of When the total healing durations are examined, infection. Authors using prophylactic topical antibiotic the ring groups generally emerged as disadvan- ointment applications in the postoperative period taged compared to the open group. Probably, the explained the very low infection rates [16]. resolution of edema and inflammation occurring While there was no statistical difference between the due to vascular and lymphatic obstruction caused groups in terms of postoperative early period pain by the ring device takes longer compared to the scores, late period pain scores were statistically signifi - open procedure [16,32]. cantly higher in the open circumcision group. Studies None of the studies included in our meta-analysis giving pain score data were observed to be studies in reported urinary retention after circumcision with ring the adult age group. Some patients in the ring group devices. Urine retention may be observed due to rea- reported describing pain only during erection [13,20]. In sons such as glandular prolapse, excessive stretching the adult group, it was reported the Shang Ring was of the prepuce and not selecting a ring device with more advantageous compared to Prepex due to its diameter appropriate for the glans [30]. elastic properties and it could be applied with only Factors like not studying the cost of operations, local anesthetic sprays without requiring ring or penile circumcisions not being performed only by surgeons, block anesthesia [15,20]. inclusion of 2 retrospective studies and lack of double- Questioning about parental satisfaction found the blinding of prospective randomized studies may ring device groups were significantly more advanta- reduce the power of this meta-analysis. However, dou- geous. Families attach great importance to the cos- ble-blinding is not possible for surgical procedures like metic appearance of the penis when healing is circumcision. Additionally, some prospective studies complete after circumcision. Factors related more to left the choice of circumcision method to the patient classic procedures like obvious suture sites on the skin, and parents. However, the fact that 9 out of 14 studies surrounding edema, asymmetric skin removal, hyper- were prospective and randomized contributes to the trophic scar tissue and keloids cause the skin of the power of this meta-analysis. penis to appear flawed [36]. Regular and symmetric In conclusion, though circumcisions with ring skin removal is possible with ring devices. Falcao et al devices do not appear to have an advantage in terms [37]. assessed the conventional technique with subcu- of postoperative complications, the most important ticular stitches (SC) and the Plastibell (PB) groups in advantages are the short operation duration, high terms of healing and aesthetics on the postoperative family satisfaction in terms of cosmetic appearance 30th and 60th days in prospective and randomized and ability to be easily learned and performed by studies. Scores were given separately for each patient assisting health personnel in countries without ade- by a dermatologist, pediatrician and plastic surgeon. quate numbers of professional health employees. The pediatrician and plastic surgeons found the PB However, it is a condition to know open circumcision group was the group with best healing, while results methods and to have experience of this surgery for use were similar in aesthetic terms to the SC group. ARAB JOURNAL OF UROLOGY 157 in situations with hemorrhage complications, mainly, a nonsurgical device to a surgical technique in resource-limited settings: a prospective, randomized, and without ring instruments of appropriate size. nonmasked trial. J Acquir Immune Defic Syndr. 2012;61:49–55. [15] Kigozi G, Musoke R, Watya S, et al. The safety and Disclosure statement acceptance of the prepex device for non-surgical adult male circumcision in Rakai, Uganda. A Non- No potential conflict of interest was reported by the Randomized Observational Study PLOS ONE. 2014;9 author(s). (8):e100008. [16] Mousavi SA, Salehifar E. Circumcision complications associated with the plastibell device and conven- ORCID tional dissection surgery: a trial of 586 infants of ages up to 12 months. Adv Urol. 2008;2008:5. Yavuz Güler http://orcid.org/0000-0001-7770-8013 [17] Netto JMB, Araújo JG, Noronha MFA, et al. Prospective randomized trial comparing dissection with Plastibell circumcision. J Pediatr Urol. 2010 Dec;6(6):572–577. References [18] Mahmood K, Asıf K, Imran M. Comparison of operative and post-operative complications of Plastibell with [1] Gray RH, Kigozi G, Serwadda D, et al. Male open technique in circumcision. Pak J Med Health Circumcision for HIV prevention in men in Rakai, Sci. 2015;9:3. Uganda: a randomised trial. Lancet. 2007;369:657–666. [19] Moinuddin M, Shinde N, Devani R, et al. Comparison of [2] Bailey RC, Moses S, Parker CB, et al. Male circumcisionfor Plastibell circumcision with conventional circumcision HIV prevention in young men in Kisumu, Kenya: in infants at tertiary care centre. Asian J Res Surg. a randomized controlled trial. Lancet. 2007;369:643–656. 2018;1(2):1–7. [3] Auvert B, Taljaard D, Lagarde E, et al. Randomized, [20] Talini C, Antunes LA, Carvalho BCN, et al. Circumcision: controlled intervention trial of male circumcision for postoperative complications that required reduction of HIV infection risk: the ANRS 1265 Trial. reoperation. Einstein (Sãopaulo). 2018;16(3):1–5. PLoS Med. 2005;2:e298. [21] Abdullah LB, Mohammad AM, Anyanwu LC, et al. [4] WHO/UNAIDS: new data on male circumcision and HIV Outcome of male circumcision: a comparison between prevention: policyand programme implications: con- plastibell and dorsal slit methods. Niger J Basic Clin Sci. clusions and recommendations. UNAIDS 2007. 2018;15:5–8. [5] Muula AS, Prozesky HW, Mataya RH, et al. Prevalence [22] Hamza BK, Ahmed M, Bello A, et al. Comparison of the of complications of malecircumcision in Anglophone efficacy and safety of circumcision by free hand tech- Africa: a systematic review. BMC Urol. 2007;7:4. nique and Plastibell device in children. Afr J Urol. [6] WHO/UNAIDS: male circumcision: global trends and 2020;26:66. determinants of prevalence, safety and acceptability. [23] Gavade AN, Vaidya M. Comparative study of patient World Health Organization. 2008. satisfaction between traditional and modified [7] Shinde ND, Moinuddin M, Danish ANMO. Plastibell Plastibell method for circumcision in a tertiary care circumcision in neonates and infants at tertiary care centre. MVP J Med Sci. 2020;7(2):170–174. centre. Int Surg J. 2018;5:1488–1491. [24] Modi JB, Shah JD, Shah TA. Plastibell circumcision method [8] Higgins JP, Altman DG, Gotzsche PC, et al. Cochrane vs conventional circumcision method in terms of opera- bias methods group: cochrane statistical methods tive outcomes in paediatric patients- a retrospective study. group: the Cochrane collaboration’s tool for assessing Int J Anatomy Radiol Surg. 2021;10(3):11–14. risk of bias in randomized trials. Bmj. 2011;343:d5928. [9] Stang A. Stang a. Critical evaluation of the [25] Hirji H, Charlton R, Sarmah S. Male circumcision: Newcastle-Ottawa scale for the assessment of the a review of the evidence. Jmhg. 2005;2:21–30. quality of non-randomized studies in meta-analyses. [26] Al-Samarrai AY, Mofti AB, Crankson SJ, et al. Al-Meshari Eır J Epidemiol. 2010;25:603–605. A: a review of a Plastibell device in neonatal circumci- [10] Moher D, Liberati A, Tetzlaff J, et al.; PRİSMA Group. sion in 2,000 instances. Surg Gynecol Obstet. 1988;167:341–343. Preferred reporting items for systematic reviews and [27] Fraser IA, Allen MJ, Bagshaw PF, et al. A randomized trial meta-analyses: the prisma statement. PLoS Med. to assess childhood circumcision with the Plastibell 2009;6:e1000097. device compared to a conventional dissection [11] Kigozi G, Musoke R, Watya S, et al. The acceptability technique. Br J Surg. 1981;68:593–595. and safety of the shang ring for adult male circumci- [28] Samad A, Khanzada TW, Kumar B. Plastibell circumcision: sion in Rakai, Uganda. J Acquir Immune Defic Syndr. a minör surgical procedure of majör importance. J Pediatr 2013 August 15;63(5):617–621. Urol. 2010;6:28–31. [12] Sokal DC, Li PS, Zulu R, et al. Randomized controlled trial of [29] Moosa FA, Khan FW, Rao MH. Comparison of complica- the shang ring versus conventional surgical techniques for tions by ‘Plastibell Device Technigue’ in male neonates adult male circumcision: safety and acceptability. J Acquir and infants. J Pak Med Assoc. 2010;60(8):664–667. Immune Defic Syndr. 2014;65:447–455. [30] Hammed A, Helal AA, Badway R, et al. Ten years experi- [13] Lei JH, Liu LR, Wei Q, et al. Circumcision with “no-flip ence with a novel modification of plastibell Shang Ring” and “Dorsal Slit” methods for adult males: circumcision. Afr J Paediatr Surg. 2014;11(11):179–183. a single-centered, prospective, clinical study. Asian [31] Weiss HA, Larke N, Halperin D, et al. Complications of J Androl. 2016;18:798–802. circumcision in male neonates, infants and children: [14] Mutabazi V, Kaplan SA, Rwamasirabo E, et al. HIV pre- a systematic review. BMC Urol. 2010;10:2. vention: male circumcision comparison between 158 Y. GÜLER ET AL. [32] Palit V, Menebhi DK, Taylor I, et al. A unique service in [36] Nagdeve NG, Naik H, Bhingare PD, et al. Parental eva- UK delivering Plastibell circumcision: review of 9-year luation of postoperative outcome of circumcision with results. Pediatr Surg Int. 2007;23(1):45–48. Plastibell or conventional dissection by dorsal slit tech- [33] Lazarus J, Alexander A, Rode H. Circumcision compli- nique: a randomized controlled trial. J Pediatr Urol. cations associated with the Plastibell device. S Afr Med 2013;9(5):675–682. J. 2007;97:192–193. [37] Falcao BP, Stegani MM, Tenorio SB, et al. Postoperative [34] Atikeler MK, Gecit I, Yuzgec V, et al. Complications of aesthetic and healing features of postectomy using circumcision performed within and outside the three different surgical techniques: a randomized, pro- hospital. Int Urol Nephrol. 2005;37:97–99. spective, and interdisciplinary analysis. Rev Col Bras [35] Mogotlane SM, Ntlangulela JT, Ogunbanjo BG. Cir. 2020;47:e20202626. Mortality and morbidity among traditionally circum- [38] Cathcart P, Nuttall M, van der Meulen J. Trends in cised xhosa boys in the Eastern Cape Province, South Paediatric circumcision and its complications in England Africa. Curationis. 2004;27:57–62. between 1997 and 2003. Br J Surg. 2006;93(7):885–890. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Arab Journal of Urology Taylor & Francis

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

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

Abstract

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...
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© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
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2090-598X
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10.1080/2090598X.2022.2071545
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Abstract

ARAB JOURNAL OF UROLOGY 2022, VOL. 20, NO. 3, 144–158 https://doi.org/10.1080/2090598X.2022.2071545 REVIEW ARTICLE Comparison of ring instruments and classic circumcision methods: a systematic review and meta-analysis a b c Yavuz Güler , Gökhun Çağdaş Özmerdiven and Akif Erbin a b Urology Department, İstanbul Rumeli University, Private Safa Hospital, İstanbul, Turkey; Urology Department, İstanbul Aydın Üniversitesi, VM Medical Park Hospital, İstanbul, Turkey; Urology Department, Haseki Training and Research Hospital, İstanbul, Turkey ABSTRACT ARTICLE HISTORY Received 28 February 2022 Aim: To determine the advantages and disadvantages of both methods by comparing classic Accepted 23 April 2022 circumcision methods with circumcision methods assisted by ring instruments. Material-Methods: Only studies that compared open procedures and ring devices for male KEYWORDS circumcision were included. A total of6226 patients were examined in 14 studies. The meth- Circumcision; ring devices; odological quality of RCT was evaluated using Cochrane collaboration’s tools. The Review plastibell; prepex; shang ring Manager software statistical package was used to analyze the ORs for dichotomous variables andthe 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 favorof 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. Introduction As with every surgical procedure, circumcision has Circumcision is the most common surgical proce- some of its own specific complications. These are dure performed on male children, and it is pre- minor and treatable complications like hemorrhage, dicted that one in every three men globally are pain, edema and inadequate skin removal commonly circumcised. Circumcision surgery extends back observed in the early period. However, serious compli- 15,000 years. A variety of studies defined the ben- cations like severe hemorrhage requiring reoperation efits of circumcision. Penis cancer and cervical and amputation of the glans penis may be observed. In cancer risk in partners is reduced. Additionally, it the late period, pain, wound site infection, adhesions, is reported that the risk of catching HIV infection meatal stenosis, fistula, loss of penile sensitivity and reduces by up to 60% [1–3]. Within the scope of sexual dysfunction may be observed [5]. long-term HIV prevention strategies, the World Currently, circumcision is performed with a range of Health Organization (WHO) and the Joint United methods. Dorsal slit, Gomco clamp, Mogen clamp, bone Nations Program on HIV/AIDS (UNAIDS) recom- cutter and Plastibell are the main methods [6]. Due to mended adult circumcision along with neonatal advantages like being quick, easy to perform, a less trau- circumcision [4].Circumcision is performed in neo- matic technique with minimal blood loss, lower complica- natal infants, children and adult males for reli- tion rates and high cosmetic satisfaction, circumcision gious, cultural and medical reasons. It is a radical performed with ring instruments is a very popular and treatment choice for medical problems like phimo- frequently chosen method. While Plastibell ring devices sis that cannot be treated by other treatments, are used in the pediatric age group [7], the PrePex and balanopostitis and chronic urinary tract infections. Shang Ring devices are used in adults over 18 years of age. CONTACT Yavuz Güler yavuzguler1976@gmail.com Urology Department, İstanbul Rumeli University, Private Safa Hospital, İstanbul, Turkey © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ARAB JOURNAL OF UROLOGY 145 In this context, we attempted to perform Data synthesis and analysis a systematic review and meta-analysis about the com- Primary and secondary outcomes were calculated from parative effectiveness of ring device and open proce- the estimates of each study to enumerate pooled odds dure circumcisions by collecting all relevant published ratios (ORs) and confidence intervals (CIs). The Review studies to provide a comprehensive survey that Manager 5.3 software (Cochrane Collaboration, Oxford, addresses this controversy. UK) statistical package was used to analyze the ORs for dichotomous variables and the mean differences for con- tinuous variables. Meta-analyses were performed using Materials and methods this software to determine the ORs and CIs for the follow- Data sources and search strategy ing criteria: bleeding, infection, operating time, overall complications, satisfaction, early and late pain scores. We searched PUBMED, EMBASE, Cochrane Database of The proportion of heterogeneity across the studies was Systematic Review, Web of Science and Google Scholar 2 2 tested using the I index (range: 0%–100%). If I < 50%, from their inception until December 2021. These arch the variation of the studies was considered to be homo- terms used to identify potentially eligible studies from genous and the fixed-effect model was adopted. If each data source were as follows: ‘circumcision’, ‘dorsal I > 50%, the variation of studies was considered to be slit’, ‘ring devices’, ‘plastibell’, and ‘open circumcision’. significantly heterogeneous and the random-effect The reference lists of the relevant studies were also model was adopted. All P values were two-tailed, and searched. Two of our authors independently screened p < 0.05 was considered statistically significant. all citations and abstracts identified by these arch strategy to screen eligible studies. Only English was used as the language for screening. Publication bias Potential publication bias was assessed by identifying the presence of visual asymmetry/symmetry with fun- Data extraction, inclusion and exclusion criteria nel plot studies. Only studies that compared open procedures and ring devices with male circumcision status were included. Results All relevant studies identified from these arch strategy were used for detailed assessment. Case reports, case Search results and study characteristics series, articles not written in English, articles without The details about the literature search and screening full text found or accessible and studies comparing process can be found in Figure 1. Upon completion of circumcision methods apart from the classic open cir- primary screening by scanning titles and abstracts, the cumcision methods (dorsal slit, sleeve circumcision, full texts of 14 potentially relevant studies were forceps-guided) with other ring devices (Mogen, Gomko clamp, guillotine, etc.) were excluded from the study. Data were extracted from the included stu- dies by the authors. The extracted data included data sources, eligibility, methods, participant characteristics, interventions and results. Assessment of study quality The methodological quality of RCT was evaluated using Cochrane collaboration tools, including 6 items: randomization of reviewers, allocation con- cealment, blinding of personnel and participants, blinding of outcome measurement, incomplete outcomes, selective reporting and other bias [8]. The methodological quality of retrospective and prospective non-randomized studies was evaluated using the modified Newcastle-Ottawa scale(NOS), in which a score of 1–9 stars was allocated [9]. This study followed the PRISMA (preferred report- ing items for systematic reviews and meta- Figure 1. Flow chart of the study. analyses) statement [10]. 146 Y. GÜLER ET AL. Table 1. Demographic and quality data of studies. Study Country Study interval Study Type Age, mean(range) No of patients Follow up Quality score (NOS) Open Ring Open Ring Abdullah, 18 Nigeria 2013 RCT 7d-10y 7d-10y 60 60 N/A − Modı, 21 İndia 2017–2019 Retro 4.77 ± 2.4(y) 4.8 ± 2.2(y) 30 30 N/A 5 star Gavade, 20 İndia 2017–2019 RCT 3.1 y 3.7 y 58 58 N/A − <1: 26% 35% 1–5: 53% 48% 6–10: 17% 17% 11–15: 3% 0% Hamza, 20 Nigeria 2016–2017 RCT 3 m (8d-5y) 1 m (9d-5y) 55 55 1 m − Talini, 18 Brasil 2015–2016 Retro 5.27 (10 m-13 y) 501 1940 N/A 5 star Mouniddin,18 İndia 2016–2018 RCT 3.5 ± 2.8 (m) 4.0 ± 3.5 (m) 250 310 15th day (open group), − on day of separation of the ring (ring group) Lei, 16 China 2012–2014 Pros NR 18–44:(69.7%) 75% 76 306 4 w 5 star 45–59: (25%) 20% 60–76:5.3% 5% Mahmood, 15 Pakistan 2012–2014 RCT 1 w-2y 1 w-2y 50 50 5 d − Sokal, 14 Kenya, Zambia 2011 RCT 20.5(18–39) (m) 21(18–41) (m) 201 197 60 d − Kigozi, 14 Uganda 2012–2013 Pros NR 18–25 (m): 65% 67% 68 326 4 w (open group) 5 star 25–29 (m): 17% 15% 7 w (ring group) 30–34 (m): 8% 8% 35–39 (m): 4% 3% 40+ (m): 8% 8% Kigozi, 13 Uganda N/A Pros NR <24 (m): 68% 63% 117 500 4 w 5 star 25–29 (m): 14% 16% 30–34 (m): 10% 7% 35–39 (m): 7% 8% >40 (m): 2% 7% Mutabazi, 12 Rwanda 2011 RCT 24 ± 4.1(21–54) (m) 26 ± 5.2(21–54) (m) 73 144 9 w − Netto, 10 Brasil 2006–2008 RCT 72 ± 32 (m) 71 ± 32 (m) 68 57 87(64–102) d − Mousavi, 08 Iran 2002–2008 RCT 4.4 ± 3.2 (m) 3.1 ± 2.8 (m) 205 381 N/A − ARAB JOURNAL OF UROLOGY 147 identified [11–25]. Two were retrospective, 3 were pro- in favor of ring devices in the other subgroups and spective non-randomized and 9 were prospective, ran- in total (P < 0.01). Weighted odds ratio 95% CI 0.18 domized and controlled (PRC) studies. The (0.11, 0.28) (Figure 5,Table 2). characteristics of the studies are shown in Table 1. The included studies were published between 2008 Bleeding and 2020. A total of 6226 participants were included from Brazil, Nigeria, India, China, Pakistan, Kenya, This parameter was recorded in a total of 13 studies Zambia, Uganda, Rwanda and Iran. The number of (Table 2). Data related to hemorrhage complications participants in each study was 60–2441. The follow- were found in 8 studies using Plastibell, 1 study up durations for the studies were 5–90 days. using PrePex and 3 studies using Shang Ring. While there was an advantage in favor of the open procedure for the Plastibell subgroup Assessment of study quality (p = 0.04), the advantage was in favor of the ring Quality assessment was performed according to NOS devices for the other two subgroups (p < 0.001). In for 2 retrospective and 3 prospective non-randomized total, there were no differences identified between studies. The 5 studies were assessed as having fair the groups (P = 0.59). Total weighted odds ratio quality with 5 stars each. Prospective randomized con- 95% CI 0.75 (0.27–2.10) (Figure 6a,Table 2). trolled studies were rated as high risk for questions about blinding of participants and personnel (perfor- Infection mance bias) and blinding of outcome assessment (detection bias) as surgical methods preclude blind- This was reported in a total of 9 studies, with 8 using ing(Figure 2). Plastibell and 2 using Shang Ring. There was no statistical significance for the open vs. ring group for the Plastibell subgroup (P = 0.42). For the Shang Ring group, the Primary outcomes difference was in favor of the ring device (P = 0.005). No In studies comparing Plastibell ring device and open statistical difference was present in total (P = 0.64). procedures, mean age extended from the neonatal Weighted odds ratio 95% CI 0.89 (0.56–1.43) (Figure 6b, period to 15 years of age. In studies comparing the Table 2). Shang Ring [11,13], PrePex device [12,14] and open procedures, the studies included adult males over 18 years. Comparisons with open procedures used Edema the Plastibell in 9 studies, PrePex in 2 studies and This was investigated in 3 studies from the Shang Shang Ring in 3 studies. Ring group and 2 studies from the PrePex group. Edema reports were not encountered in any study Operating times from the Plastibell group. Statistically significant differences were not identified for the subgroups This parameter was included in 9 studies. Statistical or in total (P = 0.32). Weighted odds ratio 95% CI significance was present in favor of ring devices 1.36 (0.74,2.51) (Figure 6c,Table 2). (p < 0.01). Weighted odds ratio 95% CI 1.45 (0.51, 2.58) (Figure 3,Table 2). Adhesion Overall complications In the subgroups, only 2 studies from the Plastibell group reported adhesion. There was a statistically Overall complications were considered in a total of 7 significant difference in favor of the Plastibell group studies, 4 with Plastibell, 2 with PrePex and 1 with for comparisons between Plastibell devices and Shang Ring. Statistical significance was not present open procedures (P = 0.01). Weighted odds ratio for subgroups or in total on the meta-analysis 95% CI 0.29 (0.11,0.74) (Figure 6d,Table 2). (p = 0.69). Weight odds ratio 95% CI 1.18 (053–2.63) (Figure 4,Table 2). Insufficient skin removal Satisfaction Inadequate tissue removal was reported in 3 studies in Satisfaction scoring was performed in 6 studies. In the Plastibell subgroup and 1 study in the Shang Ring terms of subgroups, there were 2 studies using subgroup. Statistical differences were not present Plastibell, 3 studies using Shang Ring and 1 study between open procedures and ring devices in the sub- using PrePex. Apart from the single study in the groups or in total (P = 0.18). Weighted odds ratio 95% CI PrePex group, statistical significance was obtained 2.3(0.39,7.65)(Figure 6e,Table 2). 148 Y. GÜLER ET AL. Figure 2. Cochrane collaboration tools study chart. Wound dehiscence Early (perioperative) pain scores Data related to wound dehiscence were only accessed in Only one study in the Shang Ring and one study in the three studies in the Shang Ring group. Significant statis- PrePex subgroup assessed pain scoring in the early tical differences were not identified between the open postoperative period. While differences were identified procedure and Shang Ring group (p = 0.72). Weighted between the subgroups, a statistically significant odds ratio 95% CI 1.22 (0.42, 3.53) (Figure 6f,Table 2). ARAB JOURNAL OF UROLOGY 149 Figure 3. Forest plot for operation time - Weighted odds ratio 95% CI -8.46(-11.6,-5.32). difference was not identified in total (p = 0.89). 1.7% in the PrePex study [15]. Two studies con- Weighted mean difference 0.22, 95% CI −2.86 to 3.30 sidered whether there was a correlation between (Figure 7a,Table 2). age and ring separation rates [16,22]. In both stu- dies, as age increased, spontaneous separation was reported to be delayed. Only one study Late pain scores assessed the correlation between ring diameter and separation duration and found no correlation Only one study in the Shang Ring and one study in [22]. The same study examined the correlation the PrePex subgroup performed pain scoring stu- between age and complications and reported dies in the late postoperative period. Statistical sig- that as age increased, complication rates nificance in favor of ring devices was identified in increased. Another study researching the correla- both subgroups and in total (p < 0.01). Weighted tion between patient body weight and sponta- mean difference −2.22, 95% CI −3.10 to −1.34 neous ring separation reported that as weight (Figure 7b,Table 2). increased, separation was delayed [16] (Table 3). Outcomes related to ring instruments Other outcomes Spontaneous ring removal time was given in a total of 5 studies [13,17,19,22,24]. In the Plastibell group, Two studies considered complete wound healing. 3 studies [19,22,24] had similar spontaneous separa- These studies revealed a statistical advantage for tion durations (5.2, 6 and 6.2 days, respectively). the classic circumcision group compared to the Only one study reported 16 days [17]. The fifth ring group (SMD IVR 95% CI; 0.54(0.19,0.88), study was in the Shang Ring group and the mean p = 0.003) [12,14] (Figure 8a). Kigozi et al. [15] separation duration was 18 days [13]. The sponta- reported wound healing rates in the 4th and 7th neous separation rate was given in 8 studies weeks. While 98.7% full healing was observed in [16,17,19–22,24]-Plastibell; 13-Shang Ring Group). the open group in the 4th week, this rate was The lowest spontaneous separation rate in the 56.7% in the ring group. By the 7th week, the Plastibell group was 70% [20], while another study healing rate in the ring group had reached 98.6%. had rate of 85.5% [22] and the other studies were Only one study gave reoperation and cicatricial all above 90%.The other study in the Shang Ring data [17]. In the ring and open circumcision group had spontaneous separation rate of groups, there was no statistically significant differ - nearly 80%. ence for both parameters (reoperation and scar In 2 studies, data about ‘device removal by p values 0.57 and 0.24, respectively) (Figure 8b,c). participants’ were given [11,15]. Ring devices Three studies considered postprocedural pain rates were reported to be removed by participants at [12,18,19]. In terms of postprocedural pain rates, rates of 0.6% in the Shang Ring study [11] and there was no statistically significant difference 150 Y. GÜLER ET AL. Table 2. Operative and postoperative data. Open/Ring devices Total Wound Excess complications İnfection Bleeding Edema Adhesion Cicatricical dehiscence Wound healing mucosa Pain scores Satisfaction Procedures performed Anesthesia Studies Operation time (min) (%) (%) (%) (no) (%) (%) (no) time(day) (no) Pain scores early late (%) by type Abdullah,18 12/7 N/A 1.7/2.6 1.7/5 N/A N/A N/A N/A 8/10 N/A N/A N/A 91 Surgeon N/A Modi,21 19.73 ± 2.3/10.17 ± 1.82 N/A 3.3/3.3 0/3.3 N/A N/A N/A N/A N/A 0/1 N/A N/A N/A Trained resident Local/ doctors General Gavade,20 N/A N/A N/A 1.7/5.2 N/A N/A N/A N/A N/A N/A N/A N/A N/A Surgeon N/A Hamza,20 N/A 9.1/29.1 N/A 0/9.1 N/A 1/0 N/A N/A N/A N/A N/A N/A N/A Surgeon Local: < 1 year age General: > 1 year age Talini,18 N/A 3/3.4 N/A 0.6/1.2 N/A N/A N/A N/A N/A N/A N/A N/A N/A Surgeon General Monuiddin,18 10 ± 3.5/4 ± 2 8/21 3.2/5.2 4/8.1 N/A N/A N/A N/A N/A 2/4 N/A N/A N/A Surgeon Local Lei,16 23.4 ± 4.3/4.8 ± 0.9 N/A 9.2/2.9 13.2/1 3/29 N/A N/A 0/3 N/A N/A 3.1 ± 1.4/ 5.8 ± 1.4/ 72.3/96.4 Surgeon Local 1.8 ± 1.3 4.0 ± 1.2 Mahmood,15 N/A N/A 4/0 6/0 N/A N/A N/A N/A N/A N/A N/A N/A N/A Surgeon Local Sokal,14 29.5 ± 4.5/7.2 ± 2.0 N/A 1/0 0.5/0 0/1 N/A N/A 4/6 38.6 ± 12.6/ N/A N/A N/A 78.6/96.3 Non-physicians 82% Local 44.1 ± 12.6 Phsicians and nonphysician 17% Physicians 2% Kigozi,14 N/A 0/9 N/A N/A 0/1 N/A N/A N/A 98.7%(at 4 week)/ N/A N/A N/A N/A Clinical officers Local gel (For 98.6%(at prepex 7 week) group) Kigozi,13 17.7 ± 7.3/6.1 ± 2.7 3/14 0.85/0 0/0.2 0/1 N/A N/A 1/1 N/A 0/1 N/A N/A 100/99.1 Clinical officers Local Mutabazi,12 8.8 ± 2.0/3.4 ± 1.1 11/2.7 N/A 19.2/0.7 11/21 N/A N/A N/A 23 ± 7.5/ N/A 3.8 ± 2.1/ 5.2 ± 2.2/ N/A Surgeon Local 31.0 ± 12.1 5.6 ± 1.8 2.5 ± 1.8 Netto,10 14.6 ± 1.9/3.3 ± 1.5 26/10.5 0/0 10.3/5.3 N/A 29.4/10.5 8.8/3.5 N/A N/A N/A Use of Plastibell N/A Surgeon General paracetamol group was similar in reguired the firsth more 2 days. painkiller Mousavi,08 N/A N/A 0/1 2/1.3 N/A N/A N/A N/A N/A 0/5 N/A N/A N/A Surgeon Local ARAB JOURNAL OF UROLOGY 151 Figure 4. Forest plot for overall complications - Weighted odds ratio 95% CI 1.15(0.51,2.58. Figure 5. Forest plot for satisfaction. found between the groups (p = 0.18) (Figure 8d). Discussion One study considered oozing and clear exudate Circumcision is performed for medical (phimosis, para- [14]. The ring group was found to be statistically phimosis, balanopostitis, etc.), cultural and religious advantaged for both parameters, (p values 0.0008 reasons in the world in general [25]. Geographies and 0.008, respectively) (Figure 8e,f). 152 Y. GÜLER ET AL. Figure 6. Forest plot for a. Bleeding, b. Ä°nfection, c. Edema, d. Adhesion, e. Ä°nsufficient skin removal, f. Wound dehiscence. ARAB JOURNAL OF UROLOGY 153 Figure 7. Forest plot for painscores. a. Early, b. Late. where circumcision is performed generally have dense group was 10–23.4 min (p < 0.001). Classic circumci- populations and are countries with low income struc- sion is a complex surgery including cutting of the ture socioeconomically. For these reasons, it is impor- prepuce skin, bleeding control and primary suturing tant to be able to perform the circumcision procedure of skin-mucosa and requires serious experience and more rapidly with low cost. Due to these features, ring long procedure times [29]. Additionally, considering devices have gained popularity for circumcision that most circumcision procedures in the world in [26,27]. Plastibell ring devices are used with internal general are performed under local anesthesia (without diameter 1–1.7 cm for the neonatal-infant and pedia- much comfort), the need for a circumcision method tric age group. In recent times, ring devices have with the shortest duration that provides the best out- begun to be used for adult circumcisions. Among come is clear. The most serious time advantage of these, the main examples are PrePex and Shang Ring circumcisions with ring devices is that bleeding control devices. and skin-mucosa suturing procedures are not per- It appears the most important advantage of ring formed [30]. devices is the short duration of the procedure for From the studies included, it is understood there circumcision [28]. This situation may reduce stress for was a correlation between circumcision age and patients undergoing circumcision with local anesthe- Plastibell ring separation duration [16]. Studies by sia, especially. Additionally, it may ensure reductions in Hamza and Modi observed that as age reduced the extra costs like anesthetic drug amounts and laryngeal ring separation time symmetrically reduced in sub- mask used during circumcisions performed under gen- group investigations according to the ages of circum- eral anesthesia. In this meta-analysis, the operation cised children [22,24]. In similar studies using the duration for studies in the ring group was 3.3– Plastibell ring device, as the age of circumcision fell, 10.2 min, while the duration for the open procedure the ring separation time was reported to decrease [29]. 154 Y. GÜLER ET AL. Table 3. Ring instrument specific data. Device Spontaneous Displacement removed Ring Ring or Migration by Device Separation Spontaneous(sp) Ring Removing of Ring participant Study Type Rate (%) Time Devices(%) Correlation’s (%) Modi 2021 Plastibell 93.4 0–5 years: 4.4 ± 1.0 6–10 years: 3.3 N/A 8.0 ± 1.6 Total: 5.2 ± 1.9 (day) Hamza 2020 Plastibell 85.5 Neonates: 5.7 ± 2.0 (spontan/sp) N/A -Correlation between the size of the ring N/A 1–11 month:7.1 ± 2.6(sp) 1– and number of days for separation: No 4 years:10.5 ± 0.7(sp) >5: -Correlation between age of subjects 14 day (Surgical) Total: 6(2– and bell separation time: Yes - 11) Correlation between age and freguency of complications:Yes Gavade 2020 Plastibell N/A N/A N/A N/A Abdullah 2018 Plastibell 98.2 N/A 1.7 N/A Talini 2018 Plastibell 70 N/A 1.7 N/A Mouniddin 2018 Plastibell 96.5 6.2(3–12)(day) 2.9 N/A Mahmood 2015 Plastibell N/A N/A N/A N/A Netto 2010 Plastibell 100 16 ± 5(6–30)(day) 0 0 Mousavi 2008 Plastibell 97.4 N/A 0.5 Correlation between weight of subjects N/A and bell separation time:Yes - Correlation between age of subjects and bell separation time: Yes Lei 2016 Shang 79.2 18 ± 6 (day) 0.7 N/A Sokal 2014 Shang 0 Surgical 0 0 Kigozi 2013 Shang 0 Surgical 0.8 0.6 Kigozi 2014 Prepex 0 Surgical 0.3 1.7 Mutabazi 2012 Prepex 0 Surgical 0 0 We think this correlation may be due to the prepuce the advancing postoperative days, complications like being thinner and easier sloughing. When neonatal, infection, adhesion, prepuce stenosis, hypertrophic infant and child circumcision are considered for the skin scar, skin separation, and meatal stenosis may be Plastibell subgroup, mean spontaneous ring separa- observed, while there may be major complications like tion duration was less than 10 days. This duration glans necrosis and urethra-cutaneous fistula. In addi- was laterin only 1 study, even though the mean age tion to these complications specific to the surgical was not different to the other studies [17]. It appears procedure, there appear to be additional complica- that some authors in the Plastibell subgroup deter- tions specific to the device in the ring group (migra- mined a cut-off duration for waiting according to tion, late separation or semi-separation, etc.) [31]. In themselves. Abdullah et al. determined the cut-off studies in this meta-analysis, we did not observe duration as 12 days, while Hamza et al. determined a difference in terms of overall complications between the cut-off as 14 days [21,22]. At the end of this dura- the 3 ring devices and the open procedures (P = 0.73). tion, Hamza observed ring devices had still not sepa- Hemorrhage is the most common complication rated in 15% of patients, while Abdullah found this was observed after circumcision surgery, in spite of the the case for 1.8% of patients. The ring devices that did reduction as the age of circumcision falls [30–32]. not separate by the determined day were surgically When examined in total, a difference was not identified removed. Nearly all of the rings with delayed separa- between the classic and ring circumcision groups in tion were in the advanced pediatric age group. Though terms of hemorrhage (p = 0.0.62). However, in sub- it appears like a second surgery, most procedures were group analysis, the classic operations appeared to be easily performed with administration of a local anes- more advantageous in terms of hemorrhage compared thetic spray and did not take a long duration. In studies to the Plastibell ring group (P = 0.04). Contrary to this, using the Shang Ring and PrePex devices (apart from circumcision with ring devices appeared more advan- Lei et al.), the authors apparently did not wait for tageous in the PrePex and Shang Ring subgroups spontaneous separation of the ring and performed (P < 0.01); however, the low number of studies for surgical removal due to the reduced probability of comparison in these two subgroups should not be spontaneous separation at advanced ages [11–15]. forgotten as it may be misleading. Most postoperative Though observed less in children in the neonatal circumcision hemorrhage stops with compression ban- and infant period compared to older children, compli- daging. However, though rarely, massive hemorrhage cations are observed with all circumcision methods requiring re-operation (suture and/or cauterization) [31]. More complications are reported for circumcision may be observed. Probably these hemorrhages are performed by traditional non-medical circumcision observed due to loosening of sutures, lack of full pla- providers, especially [31]. Hemorrhage is most com- cement of the internal ring, depth of the dorsal slit monly observed among early complications. From incision being below the ring suture and most ARAB JOURNAL OF UROLOGY 155 Figure 8. Forest plot for a. Complet wound healing, b. Reoperation, c. Cicatrical, d. Postprocedural pain, e. Oozing, f. Clear exudate. importantly tearing of the frenula fold by the ring [33]. operations, all open vein ends extending under the Choosing a ring of appropriate size for the penis glans skin and above the dartos fascia should be cauterized diameter and creating sturdy sutures will prevent with bipolar cautery or tiedbefore skin-mucosa primary these hemorrhages. In studies that prevented tearing suturing. Additionally, it is important to cauterize or of the frenulum by changing the ventral portion of the suture actively weeping sites along the skin incision ring device with some modifications, hemorrhage edges. Sometimes hemorrhage does not stop in spite rates were shown to be lower [30]. For this reason, as of compression bandaging [34]. When diluted adrena- experience performing circumcision with ring devices lin ring block anesthesia is performed, these veins may increases, we believe the hemorrhage complication not bleed due to vascular spasm and it should not be rates with reduce further. In open circumcision forgotten that they may be overlooked for this reason. 156 Y. GÜLER ET AL. Surficial skin infections may be observed after cir- Adhesions may be observed between the penis skin cumcision. In this meta-analysis, both surgical methods and mucosa or glans penis after circumcision. Though it were similar in terms of infection (p = 0.64). When appears to be a minor complication, skin adhesions cause studies with different ring device durations are exam- a dead cavity for accumulation of smegma and debris. If ined, though we did not identify a difference in rates of this is not corrected, it may form an area where infective patients with infection, we think leaving the ring devices agents can lodge. However, though rarely, sharp dissec- for long durations may increase the risk of infections. tion of these skin bridges may be required; generally they Contrary to this, fewer infections were observed in neo- may beeasily opened with steroid creams and/or blunt nates and infants compared to older children [7]. manipulation with the hands. This problem is encoun- Suboptimal local wound checks at home, activity and tered more frequently in those with buried penis espe- inability to restrict contamination among older children cially and infants using diapers [38]. In this meta-analysis, may explain the higher observation of infection in this we noticed that most studies did not report adhesion age group. Full adherence to surgical sterility rules by incidence; the few studies that did report it observed the person performing circumcision is important. more adhesion with the classic methods [17,22]. Infection rates after circumcisions performed by tradi- However, it is difficult to assess whether the ring groups tional circumcision providers are known to be higher or classic methods are more advantageous in terms of than for medical practitioners [35]. However, there is adhesion. To prevent adhesion, there is benefit in recom- benefit in underlining the heterogeneity in infection mending regular manual manipulation by families to definitions between studies. Many authors defined prevent skin adhesion especially in infants with buried infection as clinical infection only, without examining penis and using diapers. Additionally, it is necessary to any culture tests from skin swabs. At the same time, check circumcision patients after full wound healing. presence of pus was not noted in the definition of When the total healing durations are examined, infection. Authors using prophylactic topical antibiotic the ring groups generally emerged as disadvan- ointment applications in the postoperative period taged compared to the open group. Probably, the explained the very low infection rates [16]. resolution of edema and inflammation occurring While there was no statistical difference between the due to vascular and lymphatic obstruction caused groups in terms of postoperative early period pain by the ring device takes longer compared to the scores, late period pain scores were statistically signifi - open procedure [16,32]. cantly higher in the open circumcision group. Studies None of the studies included in our meta-analysis giving pain score data were observed to be studies in reported urinary retention after circumcision with ring the adult age group. Some patients in the ring group devices. Urine retention may be observed due to rea- reported describing pain only during erection [13,20]. In sons such as glandular prolapse, excessive stretching the adult group, it was reported the Shang Ring was of the prepuce and not selecting a ring device with more advantageous compared to Prepex due to its diameter appropriate for the glans [30]. elastic properties and it could be applied with only Factors like not studying the cost of operations, local anesthetic sprays without requiring ring or penile circumcisions not being performed only by surgeons, block anesthesia [15,20]. inclusion of 2 retrospective studies and lack of double- Questioning about parental satisfaction found the blinding of prospective randomized studies may ring device groups were significantly more advanta- reduce the power of this meta-analysis. However, dou- geous. Families attach great importance to the cos- ble-blinding is not possible for surgical procedures like metic appearance of the penis when healing is circumcision. Additionally, some prospective studies complete after circumcision. Factors related more to left the choice of circumcision method to the patient classic procedures like obvious suture sites on the skin, and parents. However, the fact that 9 out of 14 studies surrounding edema, asymmetric skin removal, hyper- were prospective and randomized contributes to the trophic scar tissue and keloids cause the skin of the power of this meta-analysis. penis to appear flawed [36]. Regular and symmetric In conclusion, though circumcisions with ring skin removal is possible with ring devices. Falcao et al devices do not appear to have an advantage in terms [37]. assessed the conventional technique with subcu- of postoperative complications, the most important ticular stitches (SC) and the Plastibell (PB) groups in advantages are the short operation duration, high terms of healing and aesthetics on the postoperative family satisfaction in terms of cosmetic appearance 30th and 60th days in prospective and randomized and ability to be easily learned and performed by studies. Scores were given separately for each patient assisting health personnel in countries without ade- by a dermatologist, pediatrician and plastic surgeon. quate numbers of professional health employees. The pediatrician and plastic surgeons found the PB However, it is a condition to know open circumcision group was the group with best healing, while results methods and to have experience of this surgery for use were similar in aesthetic terms to the SC group. 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Journal

Arab Journal of UrologyTaylor & Francis

Published: Jul 3, 2022

Keywords: Circumcision; ring devices; plastibell; prepex; shang ring

References