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Minimally Invasive Male Circumcision

Sokal, David MD*; Barone, Mark DVM, MS; Li, Philip MD; Simba, Raymond MBChB§; Awori, Quentin MBChB; Bowa, Kasonde MSc, MMed; Zulu, Robert MD, MMed#

JAIDS Journal of Acquired Immune Deficiency Syndromes: 15 April 2012 - Volume 59 - Issue 5 - p e100
doi: 10.1097/QAI.0b013e3182467a35
Letters to the Editor

*Clinical Sciences Dept., FHI 360, Durham, NC

EngenderHealth, New York, NY

Dept. of Urology, Weill Cornell Medical Center, New York, NY

§Homa Bay District Hospital, Ministry of Health, Homa Bay, Kenya

EngenderHealth, Kisumu, Kenya

Department of Surgery, School of Medicine, CopperBelt University, Zambia

#Department of Surgery, University Teaching Hospital, Lusaka, Zambia

Correspondence to: David C. Sokal, MD, FHI 360, 2224 East NC Hwy 54, Durham, NC 27713 (e-mail:

The authors are conducting research on the Shang Ring, funded by FHI 360, with a grant from the Bill & Melinda Gates Foundation, but the views expressed do not necessarily reflect the opinions or position of the Foundation.

The authors have no conflicts of interest to disclose.

To the Editors:

The article by Bitega et al1 describes the first pilot study of the PrePex adult male circumcision (MC) technique among 50 men in Rwanda. In the discussion section, the article compares the PrePex results with previously published data on the Shang Ring, but to our knowledge no studies have directly compared the two devices. The Shang Ring has been on the market since 2005 in China, where about 200,000 Shang Ring procedures have been conducted, with numerous publications of findings.2–4 Currently, the Shang Ring is under study in Kenya, Zambia, and Uganda.

The two devices work differently. PrePex “employs fitted rings to clamp the foreskin, leading to distal necrosis,” with no anesthesia required for most men in the pilot study. One week after application, the necrotic foreskin is cut away and the PrePex device is removed. The Shang Ring consists of inner and outer rings, with eversion of the foreskin over the inner ring before application of the outer ring. The foreskin is cut away immediately after device application, and the device is removed 1 week later.

Both devices are best described as “minimally invasive” surgical procedures, and we expect that both could be done by trained providers in similar settings. By a minimally invasive MC technique, we mean that there is (1) no exposure of the subcutaneous tissues of the penile shaft, (2) no need for hemostasis, and (3) no need for sutures for wound closure. With both devices, the surgical procedures take about 5 minutes rather than the 20 to 30 minutes required for conventional MC techniques. We congratulate Bitega et al for their contribution to the advancement of knowledge about new methods for adult MC. Research on these two devices and others is providing encouraging data that should help facilitate more rapid scale-up of adult MC services.5

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1. Bitega JP, Ngeruka ML, Hategekimana T, et al.. Safety and efficacy of the PrePex device for rapid scale up of male circumcision for HIV prevention in resource-limited settings. J Acquir Immune Defic Syndr. 2011;58:e127–e134.
2. Masson P, Li PS, Barone MA, et al.. The ShangRing device for simplified adult circumcision. Nat Rev Urol. 2010;7:638–642.
3. Barone MA, Ndede F, Li PS, et al.. The Shang Ring device for adult male circumcision: a proof of concept study in Kenya. J Acquir Immune Defic Syndr. 2011;57:e7–e12.
4. Lü NQ, Li PS, Sokal D, et al.. Progress in the clinical studies of male circumcision using the Shang Ring [in Chinese]. Zhonghua Nan Ke Xue. 2011;17:195–202.
5. McIntyre JA. Can devices for adult male circumcision help bridge the implementation gap for HIV prevention services? J Acquir Immune Defic Syndr. 2011;58:506–508.

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JAIDS Journal of Acquired Immune Deficiency Syndromes
Reply to “Minimally Invasive Male Circumcision,” from Sokal et al
Binagwaho, A
JAIDS Journal of Acquired Immune Deficiency Syndromes, 59(5): e100-e101.
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