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Male Circumcision: An Appraisal of Current Instrumentation
男性包皮环切术:现有器械的评价

Male Circumcision: An Appraisal of Current Instrumentation
男性包皮环切术:现有器械的评价

Brian J. Morris and Chris Eley

Source: Biomedical Engineering - From Theory to Applications
来源:生物医学工程 - 从理论到应用
ISBN 978-953-307-637-9
Edited by: Reza Fazel-Rezai
Publisher: InTech, August 2011

10.5 Shang Ring

Inventor: Shang, J.
Primary patent: CN2003/000903
Patent priority date: 20 Oct 2003
Patient age range: Full-term neonate to adult
Website: http://www.snnda.com/enindex.asp
Category: Ischaemic necrosis device
The Shang Ring device

Fig. 13. The Shang Ring device.


Procedure: The "Shenghuan Disposable Minimally Invasive Circumcision Anastomosis Device", developed in China by Jianzhong Shang, involves minimal tissue manipulation and is said to give a simpler, quicker and safer circumcision than conventional techniques (Masson et al., 2010). It consists of two concentric plastic rings that sandwich the foreskin of the penis, allowing circumcision without stitches or notable bleeding. As well as substantially reduced operating times, MC using this device is associated with a low complication rate, and the technique can easily be taught to both physicians and nonphysicians. The Shang Ring is produced by Wuhu Snnda Medical Treatment Appliance
Technology Co. Ltd, Wuhu City, China.


When tested on 1,200 patients aged 5 to 95 years operating time was 2.5 minutes for patients with excessive foreskin and 3.5 minutes for those with phimosis (Peng et al., 2008). After application it is worn for a week, with no incidents of device dislocation or damage to the frenulum. Peng et al. describe the use of oral diethylstilbestrol (at a dosage of 2 mg/night) as a way to prevent nocturnal erections during the wear period. We do not find favour with this, due to the known environmental persistence of DES and the long-term effects of this synthetic oestrogen (Newbold et al., 2006). In this study by Peng et al. the incision healed in 96.3%, leaving minimal inner foreskin, with no scarring and good cosmetic results. Antibiotics were not used, and only 0.67% got an infection. After removal, of the device 0.58% had some minimal bleeding around the incision and 2.4% had wound dehiscence of the incision caused by nocturnal erection, but this could be prevented by continuation of diethylstilbestrol for 3 days. It was treated by simply closing the incised rim with a butterfly adhesive plaster, followed by topical disinfectant; no stitches were required. Patients reported less pain than occurs for conventional methods.


Use of the Shang Ring has become a method of choice in the People's Republic of China. Evaluation of a standardized surgical protocol for its use, involving 328 men, showed an operating time of 4.7 ± 1.3 minutes, pain scores of 0.2 ± 0.6 during the surgery, 1.6 ± 1.0 24 hours postoperatively, 1.7 ± 1.1 twenty four hours prior to ring removal, and 2.7 ± 1.4 during ring removal (Cheng et al., 2009). In this study, complications included infection in 0.6%, bleeding in 0.6% and wound dehiscence in 0.6%; none of the latter required suturing. Penile oedema occurred in 4.9%. The time for complete wound healing was 20.3 ± 6.7 days. Satisfaction was 99.7%.


A study in 824 boys with phimosis or redundant foreskin found duration was 2.6 ± 1.2 minutes (Yan et al., 2010). Wounds healed and rings were removed at 13.4 ± 5.8 days revealing a well-smoothed incision and good cosmetic results. Complications were low and included infection in 0.6%, oedema in 3.2%, delayed removal of the ring in 1.5%, and redundant and asymmetric mucosa attributable to performance in 0.9%.


Another study in China, of 402 patients, found duration (4.7 ± 1.3) minutes, blood loss (2.6 ± 1.8 ml), and postoperative satisfaction (99.5%) for Shang Ring circumcision were significantly better than conventional circumcision, and International Index of Erectile Dysfunction (IIEF-5; not “IIRF-5” as stated in the paper) was no different (Li et al., 2010). In 351 males aged 4 to 58 (mean 31) circumcised for phimosis or redundant foreskin using the Shang Ring, infection was seen in 1.4%, mild oedema in 2.6%, moderate oedema in 1.4%, and wound dishescence in 1.7%, with no postoperative bleeding being observed (Peng et al., 2010b).


A proof of concept study in Kenya for the roll-out of MC for HIV prevention found a time of 4.8 ± 2.0 minutes for the procedure and 3.9 ± 2.6 minutes for device removal, with 6 mild adverse events in the 40 men who underwent Shang Ring circumcision (Barone et al., 2011). These included 3 penile skin injuries, 2 cases of oedema and one infection, all of which resolved with conservative management. Partial ring detachment occurred in 3 between days 2 to 7, none of which required treatment or ring removal. Erections with the ring were well tolerated. By day 2, eighty percent of the men had returned to work, and at 42 days all said they were very satisfied with their circumcision and would recommend it to others.


Aside from the matter of diethylstilbestrol use, without which there appears to be a danger of an erection displacing the device, possible further criticisms relate to the discontinuity of the clamping ring at both the hinge and clasp. It should also be noted that it gives no protection whatsoever to the glans during the severing of the prepuce.

The same inventor has also obtained a patent in respect of another, more recent but very different design. The relevant patent is CN2009/000406. It is unclear whether the later design is intended to supersede the original, or compete with it.

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