[virgone]

Originally Posted by DoctorTan

There has been some discussion here on ShangRing circumcision. Would like to contribute my POV after having done circumcisions for 20 years. Apologies, this is going to be a long post.

First of all there was mention of someone having done circumcision by Dr Taufiq at PULSE clinic. I have worked with Dr Taufiq before and he is an excellent Doctor.

There are many ways to perform circumcision: Laser, Conventional, Device Assisted (like Shangring, Plastibell etc), Stapler etc. Ultimately, there are 2 surgical goals that need to be met:
1. Removal of the skin
2. Holding the skin edges together until they heal
So let's talk about each separately.

1. Removal of the skin

What I find needs most skill and experience begins even before surgery. That is to determine how much skin to remove, which part of the skin to remove (inner or outer skin) and the shaping of the skin (not all circumcisions is just one circle around the penis). Obviously all these decisions are influenced by why the circumcision is necessary (for infections or BXO the skin removal is different from for hygiene) and also the preference of the patient. Some people want to achieve a certain look (example: high and tight). One drawback of device assisted circumcision is that the amount, type and shape of skin removed is fixed. What I call a "cookie cutter" circumcision. What I do prior to surgery is I use a surgical skin marker to draw out the distal and proximal excision lines so that I know exactly what the final outcome would be after skin removal.

The actual removal of the skin can be done with a variety of instruments including scalpel, scissors, laser, electrosurgery etc etc. (There are also various surgical techniques like sleeve removal, forceps guided etc which I will not go through here) I prefer to use laser or electrosurgery as it stops bleeding at the same time it cuts. For the Shangring procedure, any instrument can be used because the ring effectively stops bleeding anyway.

2. Holding the skin edges together until they heal

There are several way to achieve this.

- Shangring
The Shangring device effectively takes the place of stitches. The hold the skin together preventing the wound from opening up and also preventing bleeding. After the ring drops off, a thin raw wound remains. This wound then takes another week or so to dry up and heal. The entire process takes 4 to 6 weeks.

Usually during the first week patients are very comfortable. However during the second week, parts of the skin may start to pull away from the ring. During this time there is a risk of pain and/or bleeding. Some patients are unable to tolerate the ring and request for it to be removed. The problem with this is that the skin may not have achieved enough tensile integrity. In other words, during morning erection, the wound may open up again.

- Staplers
I have never liked this. In my experience, staplers are very poor at controlling bleeding. Also it does not hold the skin together very well. Maybe because of the challenges, no major medical device company has ever made circumcision stapler devices.

- Stitches
This is my preferred method. First of all it gives me most leeway to style the wound. I can make sure the raphe (midline of the penis) aligns perfectly with the frenulum. With new stitching methods, we no longer get the "rail roading" effect. Healing is the fastest. I have patients who heal in as little as 10 days. I use only bio-absorbable sutures so there is no need for stitch removal. That said, stitching takes time. The procedure will take 45 mins vs Shangring which takes 15 mins. However I reassure patients that during the entire time they will feel absolutely nothing. Some patients are still nervous and prefer to do the procedure under general anesthesia (asleep). Honestly, I prefer this too. There is a anesthetist looking after the patient so that I can concentrate purely on the surgery.

So inconclusion, there are many ways to do a circumcision. See a good Doctor who can discuss with you the various methods and why which one is good (or not so good) for you. Then make an informed decision on what is the best method to achieve what you want to achieve.

A quick note on insurance. I have seen many different insurance policies used by my patients. Some cover 100%. Some have a co-pay of 5% to 30%. Some have a cap. Some do not cover at all. The best thing to do is to speak to your agent and find out the details of your policy. There are also companies out there that are so called "insurance claims specialists" who can help you with this.

Hope the above has been helpful

Thanks Doc. Very informative.