Introduction to Modern Circumcision Techniques
Adult circumcision is one of the most commonly performed urological procedures, with medical indications including phimosis (tight foreskin), recurrent balanitis, lichen Sclerosus (BXO), and paraphimosis. Beyond medical reasons, men may choose circumcision for personal, cultural, religious, or preventive health reasons. In recent years, innovative techniques have emerged that offer alternatives to traditional surgical methods, including device-based approaches and tissue-adhesive closure.
This guide explores three modern circumcision techniques: the Shang Ring device, CircCurer (ZSR) staplers, and tissue adhesive (glue) methods.
Shang Ring Circumcision vs Traditional Circumcision with Stitches
What is the Shang Ring?
The Shang Ring is a WHO-prequalified adult circumcision device, introduced in 2015, consisting of two concentric plastic rings. The device works by trapping the foreskin between the rings, causing it to undergo controlled tissue death (ischemic necrosis) before being removed.
How does the procedure work?
During the procedure, the inner ring is placed over the glans (head of the penis), and the foreskin is pulled over it. The outer ring is then locked into place, trapping the foreskin between the two rings. The excess foreskin is trimmed away, and the device remains in place for approximately 7 -10 days before being removed at a follow-up appointment.
Benefits and Outcomes
Research has demonstrated several advantages of the Shang Ring:
– Shorter procedure time: The procedure takes approximately 7 minutes compared to 60 minutes for conventional surgery
– No suturing required: The device eliminates the need for stitches
– Excellent cosmetic results: Studies show 95-97% of men are very satisfied with the appearance of their circumcised penis
– Low complication rates: Adverse event rates are similar to or lower than conventional surgery, with moderate/severe complications occurring in only 0.3-1.4% of cases in African studies
– Provider preference: Some Healthcare providers consistently prefer the Shang Ring technique over conventional methods
Considerations
– The device must be removed at a follow-up visit 5-11 days after placement
– Some men report higher pain scores during erections compared to conventional surgery
– Complete wound healing takes approximately 43 days on average, which may be 15 days longer than conventional methods
– The technique is not suitable for men with certain penile anatomical abnormalities or active genital infections
Dr Khan has performed three revision circumcisions with glue after Shang ring circumcision and treated one wound dehiscence. Glue circumcision provides excellent cosmetic results with less pain and a lower complication rate.
Patients suffered pain due to secondary healing of gapped wounds for three months after Shang ring circumcision in some patients. Further studies are required to address this issue in the Shang ring circumcision.
CircCurer (ZSR) Stapler Devices
What are Disposable Circumcision Suture Devices?
CircCurer and ZSR are disposable circumcision suture devices that use a stapling mechanism to perform circumcision. These devices simultaneously cut the foreskin and apply small staples to join the skin edges, creating an immediate closure.
How the Procedure Works
The surgeon selects the appropriate device size, positions it on the penis, and activates the device. In a single action, the device cuts away the foreskin and applies a ring of staples to join the inner and outer skin layers. The staples typically fall out naturally during the healing process.
Benefits and Outcomes
Studies comparing CircCurer and ZSR devices have shown:
– Very short operative time: Procedures average 6.8-7.7 minutes
– Minimal blood loss: Significantly less bleeding compared to conventional surgery (1.8 mL vs 9.4 mL)
– Lower pain scores: Both during and after the procedure
– Low complication rates: Surgical site infection occurs in only 2% of cases
– High patient satisfaction: Median satisfaction scores of 9 out of 10 at 2 months
– Quick return to activities: Patients can return to full physical activity within 3 – 7 days
Differences Between Devices
A comparative study of CircCurer and ZSR devices found similar outcomes across most measures, with one notable difference: the ZSR device has a higher rate of spontaneous staple dropout (62.9% vs 38%), which is part of the intended healing process.
Considerations
– Higher cost compared to conventional surgery (approximately £80-100)
– Some patients (5-7%) require removal of residual staples
– Not suitable for men with diabetes (HbA1c >9%), advanced age, elevated BMI, or severe phimosis due to scarring
– Device malfunction occurs in approximately 2% of cases
Tissue Adhesive (Glue) Methods
What is Tissue Adhesive Circumcision?
This technique uses medical-grade cyanoacrylate tissue adhesive (surgical glue) instead of traditional sutures to close the circumcision wound. The adhesive can be used with various circumcision devices or as a wound dressing after conventional surgery.
How the Procedure Works
After the foreskin is removed using a circumcision device or conventional technique, the surgeon applies high-viscosity 2-octyl cyanoacrylate adhesive to seal the skin edges together. The adhesive creates a waterproof barrier and drops the need for sutures.
Benefits and Outcomes
Studies of tissue adhesive methods have shown:
– Superior patient satisfaction: Significantly better dressing satisfaction compared to traditional paraffin gauze dressings
– Better cosmetic outcomes: Patients report higher satisfaction with the appearance of their circumcised penis
– Time of procedure: When combined with devices. The total operative time is approximately 30-45 minutes
– Primary intention healing: Wounds heal cleanly with excellent cosmetic results
– Similar safety profile: Complication rates comparable to conventional surgery
Considerations
– Similar operative time and pain levels to conventional methods when used as wound closure
– Does not reduce the rate of penile adhesions (a common minor complication)
– Requires proper technique to ensure adequate wound sealing
Comparing the Techniques
Safety
All three modern techniques have demonstrated excellent safety profiles with low complication rates. A comprehensive Cochrane review found no serious adverse events with circumcision devices compared to conventional surgery, though devices may slightly increase moderate adverse events.
Procedure Time
All three techniques significantly reduce operative time compared to conventional surgery:
– Shang Ring: ~7 minutes
– CircCurer/ZSR staplers: ~7 minutes
– Tissue adhesive with devices: ~35 minutes
– Conventional surgery: ~60 minutes
Cosmetic Results
Patient satisfaction with cosmetic appearance is consistently high across modern techniques, with many studies showing greater satisfaction than with conventional surgery.
Healing Time
Healing times are generally similar across techniques, with most men achieving complete healing within 4-6 weeks. The Shang Ring may take slightly longer (approximately 10 more days) than conventional methods.
Who is a Suitable Candidate?
Modern circumcision techniques are appropriate for most adult men seeking circumcision, whether for medical or personal reasons. However, certain conditions may make device-based techniques unsuitable:
Contraindications for device-based techniques:
– Penile anatomical abnormalities
– Chronic paraphimosis
– Active genital infection
– Severe phimosis with significant foreskin-glans adhesion, like lichen sclerosus
– Very short foreskin
Special considerations for stapler devices:
– Men with poorly controlled diabetes (HbA1c >9%)
– Significantly elevated BMI
– Bleeding disorders
Making Your Decision
When considering adult circumcision, discuss the following with your healthcare provider:
1. Your specific indication: Medical necessity vs personal choice
2. Available techniques: What methods are offered at your local facility
3. Follow-up requirements: Some techniques require scheduled device removal
4. Cost considerations: Device-based methods may be more expensive
5. Recovery expectations: Time off work and activity restrictions
6. Personal preferences: Cosmetic outcomes and healing time priorities
Conclusion
Modern circumcision techniques offer safe, effective alternatives to traditional surgical methods. The Shang Ring, CircCurer (ZSR) staplers, and tissue adhesive approaches all provide shorter procedure times, excellent cosmetic results, and high patient satisfaction. Each technique has specific advantages and considerations, and the best choice depends on individual circumstances, local availability, and patient preferences.
If you are considering adult circumcision, consult with a qualified urologist or surgeon who can assess your specific situation and discuss which technique is most proper for you.
This blog post provides comprehensive, evidence-based information about modern adult circumcision techniques suitable for a UK patient. The content is written in accessible language while supporting medical accuracy, covering the key aspects of each technique, including how they work, their benefits, outcomes, and important considerations.
Medical literature
The evidence strongly supports that all three modern techniques—Shang Ring, CircCurer (ZSR) staplers, and tissue adhesive methods—offer significant advantages over conventional surgery, particularly in terms of reduced operative time (6-12 minutes vs 20-25 minutes), excellent cosmetic outcomes with patient satisfaction rates of 88-99%, and low complication rates of 0.3-7.8%.[1][2][3][4][5][6] The Shang Ring is WHO-prequalified and particularly well-studied, with randomised trials demonstrating safety profiles similar to conventional surgery and superior cosmetic satisfaction.[2][3] Stapler devices like CircCurer and ZSR show minimal blood loss (1.8 mL vs 9.4 mL) and very short operative times, though they come at a higher cost.[4][5] Tissue adhesive methods provide superior patient satisfaction with dressing and cosmetic outcomes compared to traditional paraffin gauze dressings.[6]
All techniques have specific contraindications, with device-based methods generally unsuitable for men with penile anatomical abnormalities, active infections, or severe phimosis, and stapler devices requiring particular caution in men with poorly controlled diabetes.[7][8] The choice between techniques should be individualised based on patient anatomy, preferences, local availability, and cost considerations.
Please contact us at the Adult London Circumcision Clinic for professional advice if you are considering one of the moderns teachniques
References
1. Rollout of ShangRing Circumcision With Active Surveillance for Adverse Events and Monitoring for Uptake in Kenya. Odoyo-June E, Owuor N, Kassim S, et al. PloS One. 2019;14(9):e0222942. doi:10.1371/journal.pone.0222942.
2. Randomised Controlled Trial of the Shang Ring Versus Conventional Surgical Techniques for Adult Male Circumcision: Safety and Acceptability. Sokal DC, Li PS, Zulu R, et al. Journal of Acquired Immune Deficiency Syndromes (1999). 2014;65(4):447-55. doi:10.1097/QAI.0000000000000061.
3. Field Study of Adult Male Circumcision Using the ShangRing in Routine Clinical Settings in Kenya and Zambia. Sokal DC, Li PS, Zulu R, et al. Journal of Acquired Immune Deficiency Syndromes (1999). 2014;67(4):430-7. doi:10.1097/QAI.0000000000000321.
4. Efficacy and Safety of Two Disposable Circumcision Suture Devices for Circumcision in Adults: A Prospective Comparative Multicenter Study. Bocchino AC, Fernández-Pascual E, Toribio-Vázquez C, et al. International Journal of Impotence Research. 2025;37(5):384-388. doi:10.1038/s41443-024-00933-3.
5. Adult Male Circumcision With a Circular Stapler Versus Conventional Circumcision: A Prospective Randomised Clinical Trial. Jin XD, Lu JJ, Liu WH, et al. Brazilian Journal of Medical and Biological Research = Revista Brasileira de Pesquisas Medicas E Biologicas. 2015;48(6):577-82. doi:10.1590/1414-431X20154530.
6. Circumcision Wound Dressing With Octylcyanoacrylate Tissue Adhesive. Lau W, Teo CPC. Journal of Wound Care. 2023;32(2):116-120. doi:10.12968/jowc.2023.32.2.116.
7. A Retrospective Taiwanese-Population-Based Clinical Study on Determining the Efficacy and Safety of Disposable Circumcision Anastomat. Chou AC, Laih CY, Ku FY. Journal of Clinical Medicine. 2022;11(20):6206. doi:10.3390/jcm11206206.
8. Circumcision Devices Versus Standard Surgical Techniques in Adolescent and Adult Male Circumcisions. Hohlfeld A, Ebrahim S, Shaik MZ, Kredo T. The Cochrane Database of Systematic Reviews. 2021;3:CD012250. doi:10.1002/14651858.CD012250.pub2.