A modified Shang Ring circumcision surgical technique under local anesthesia for penile torsion in children

Introduction

The Shang Ring circumcision (SRC) technique is commonly used to treat phimosis in children. It can be performed under local anesthesia and offers the advantages of simplicity and safety (1). Penile torsion refers to the rotation of the penis along its longitudinal axis, resulting in misalignment of the urethral opening and potentially associated with hypospadias or chrodee (2). The midline of the penis spirals from the ventral root to the distal end, typically rotating counterclockwise. It is often detected during physical examination before circumcision, with an incidence ranging from 1.7% to 33.8% (3). Traditional surgical methods for correcting penile torsion include degloving with reattachment (DR), pubic periosteum fixation, and dorsal penile superficial fascial flap fixation. However, the optimal surgical technique is yet to be established, and Yalçın et al. (4) believe that more complex surgical methods are associated with a higher incidence of complications. This study introduces a simple and easy-to-perform modified SRC technique for correcting penile torsion in children and reports the surgical outcomes in 20 cases. We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2024-698/rc).

Methods

Between July 2018 and August 2023, 20 children with penile torsion underwent the modified SRC technique at Hebei Children’s Hospital, a tertiary hospital. All procedures were performed by a single surgeon (S.Z.) under local anesthesia in the outpatient operating room, requiring only the surgeon and one assistant. The surgeon performs over 100 SRC surgeries annually. Inclusion criteria were as follows: (I) diagnosis of penile torsion combined with phimosis, undergoing SRC surgery; and (II) age <18 years. The following are exclusion criteria: (I) presence of other penile developmental abnormalities, such as hypospadias or chrodee; (II) coexisting coagulation disorders or other surgical contraindications; and (III) non-compliance with treatment or follow-up. Data were retrospectively collected to evaluate this modified technique, including surgical age, direction and angle of penile torsion, surgical duration, time for Shang Ring detachment, post-detachment penile torsion angle, complications, and follow-up through outpatient visits or online consultations at least once every 6 months to record the penile torsion angle at the most recent follow-up. Penile torsion was classified into three degrees based on the angle of deviation from the midline of the glans: mild (≤45°), moderate (>45° and ≤90°), and severe (>90°). A postoperative penile torsion angle of less than 30 degrees was defined as a good surgical outcome, and an angle greater than 30 degrees as a poor surgical outcome (3). This retrospective study was conducted in accordance with the Declaration of Helsinki (as revised in 2013), and was approved by the Ethics Committee of Hebei Children’s Hospital (approval No. 2024191), and was registered in ChiCTR (PID 234422, 2024-6-14). Informed consent was obtained from the legal guardians of all individual participants.

Statistical analysis

The Shapiro-Wilk test was used to assess whether the data followed a normal distribution. Data with a normal distribution were expressed as mean ± standard deviation, while data with a non-normal distribution are expressed as median with interquartile range. Between-group comparisons were performed using the Student’s t-test. A P value of less than 0.05 was considered statistically significant.

In addition, we used ggplot2 package version 3.5.0 (Comprehensive R Archive Network; https://cran.r-project.org/) in R version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria; https://www.R-project.org/) to generate a line chart depicting the trend of changes in the penile torsion angle before and after surgery for each patient, in order to visually demonstrate the surgical outcomes.

Surgical technique

We have modified the standard SRC technique which has been described in previous reports (1,5). A 5% compound lidocaine cream (Tongfang Pharmaceutical Group Co., Ltd., Beijing, China) was evenly applied to the patient’s penis and glans. After 30 minutes, the foreskin outer layer was clamped to assess the adequacy of local anesthesia. The patient was placed in a supine position, the surgical area was disinfected, and sterile drapes were applied. A vascular clamp was applied to the foreskin at the 3 and 9 o’clock positions. A dorsal incision was made at the 12 o’clock position of the penis, the foreskin was everted, and adhesions between the glans and the inner foreskin were separated. The glans was disinfected with tincture of iodine, and a photograph of the glans in the frontal view was taken using a camera. The penile torsion angle was measured with a protractor which defined as the angle between the penile midline and the extended line of the urethral meatus (Figure 1A). The appropriate size of the Shang Ring (Wuhu Shengda Medical Device Technology Co., Ltd., Wuhu, China) was selected according to the size of the patient’s penis. After repositioning the foreskin, the inner ring of the Shang Ring was placed over the glans, adjusted close to the frenulum of the prepuce, and the outer ring was placed outside the foreskin outer layer, with the first notch of the outer ring fastened to semi-lock the foreskin between the inner and outer rings. The position of the foreskin was adjusted to ensure that the length around the glans was appropriate and symmetrical, while the frenulum was adjusted to position the urethral opening in a mildly over-corrected position at the 6 to 7 o’clock direction (Figure 1B,1C). If excessive correction is difficult during surgery and the desired angle cannot be achieved, the surgical plan will be changed to a penile degloving procedure under general anesthesia. Once the position was confirmed, the outer ring was tightened to the second notch to ensure occlusion of blood flow between the inner and outer rings, and excess foreskin tissue was excised with scissors (Figure 1D). The penile torsion angle was measured after the Shang Ring detached naturally (Figure 1E). It will be removed manually by the surgeon if the Shang Ring has not detached spontaneously 1 month after surgery.

Figure 1 Appearance of the penis during and after the correction of penile torsion surgery. (A) Evert the foreskin and measure the penile torsion angle (α). (B,C) Insert the inner and outer rings, adjusting the frenulum as indicated by the arrow to position the meatus slightly overcorrected position between the 6 and 7 o’clock directions. (D) Once the position is confirmed, tighten the outer ring to the second notch and use scissors to remove the excess foreskin. (E) Measure the penile torsion angle (β) after the wound has fully healed postoperatively.

Results

A total of 20 children with penile torsion underwent the modified SRC procedure, with no cases requiring a change in the surgical plan. Table 1 presents the general information and penile torsion correction status. Four cases of penile torsion were detected preoperatively, while 16 were identified intraoperatively. The average age at surgery was 9.80±2.38 years. All cases involved counterclockwise penile torsion, and the surgeries were performed under local anesthesia, which was well tolerated by all patients. The average surgical time was 8.55±1.61 minutes. The median preoperative penile torsion angle was 45 [45, 60] degrees, with a maximum of 60 degrees. Twelve cases were classified as mild torsion, and eight cases as moderate torsion. The average time for the Shang Ring to detach was 23.10±6.38 days. Three cases of the Shang Ring did not detach naturally and were manually removed 30 days post-surgery. One patient developed significant penile edema postoperatively, which improved after the Shang Ring detached naturally. No patients developed other postoperative complications such as bleeding or wound dehiscence. After the Shang Ring was removed, the median penile torsion angle at follow-up was 10 [0, 10] degrees, with a median correction angle of 42.5 [35, 48.75] degrees. The average follow-up time was 2.06±0.74 years. At the last follow-up, the median penile torsion angle was 10 [0, 10] degrees, with a median correction angle of 42.5 [35, 50] degrees. No significant difference was observed in the postoperative torsion angle between the mild and moderate torsion patients, both after Shang Ring removal (P=0.43) and at the last follow-up (P=0.53). All patients had good surgical outcomes. Figure 2 illustrates the trend in changes of the penile torsion angle before and after surgery.

Figure 2 The line chart of the trend of changes in the penile torsion angle before and after surgery for each patient.

Discussion

Male circumcision has a long history and is one of the most common surgical procedures worldwide (6). Potential benefits of circumcision include easier urination, improved appearance, better local hygiene, and reduced risk of human immunodeficiency virus (HIV) and human papillomavirus (HPV) infections (7-9). The Shang Ring, a circumcision device that has been prequalified by the World Health Organization (WHO), is authorized for use in both adults and adolescents, requiring only local anaesthesia, challenging the traditional view that circumcision must be performed using a scalpel (10,11). SRC offers several advantages over traditional surgical methods: first, it is simple to perform and easy for surgeons to learn; second, it has a significantly shorter surgical time; third, the incidence of complications is low, particularly intraoperative bleeding; more importantly, it does not require suturing or electrocautery for hemostasis, reducing anxiety in children, and can be performed under local anesthesia (12). These advantages are also reflected in the SRC technique for correcting penile torsion.

Most cases of penile torsion are discovered during circumcision or in conjunction with other penile abnormalities, such as hypospadias or chordee. Notably, the incidence of penile torsion in distal hypospadias can be as high as 32.8% (3). The etiology of penile torsion is unclear but may be attributed to abnormal attachment between Buck’s fascia, the tunica albuginea, and the corpora cavernosa to the penile skin. It may also be related to asymmetric development of the corpora cavernosa around the penile axis or abnormal fibrous bands connecting the corpora cavernosa to the pubic periosteum (13). Published data indicate that 79–99% of penile torsion cases are counterclockwise, consistent with the results of our study, although the cause remains unexplained (14). Penile torsion is typically asymptomatic, and its functional impact in adulthood is difficult to predict. A study found that 60% of penile torsion cases exhibited varying degrees of urinary flow abnormalities (15). Other reports indicate that no adult patients reported of sexual dysfunction related to penile torsion (16). A survey on adolescent male genital satisfaction found no cases of dissatisfaction with genital appearance due to penile torsion (17). Although some studies suggest that penile torsion less than 60° does not require treatment, parents often seek correction due to concerns about appearance and potential future functional impairment (3,18). Since penile torsion is commonly identified during circumcision, its correction necessitates an alteration in the surgical technique, which includes a penile degloving procedure under general anesthesia—an approach that may be deemed unacceptable by both the patient and their family. Our study confirms that the modified SRC technique can correct mild to moderate penile torsion with an angle of less than 60 degrees during circumcision when requested by the family or patients, achieving satisfactory correction results.

A review of recent literature identifies several commonly used clinical techniques for correcting penile torsion. Bar-Yosef et al. (19) described a penile skin degloving and reattachment technique, with only 2 of 39 patients (5%) showing residual torsion postoperatively. Fisher et al. (20) reported the Fisher technique for correcting penile torsion using a dorsal superficial fascial flap (dartos flap). The technique involves degloving the dartos flap from the dorsal foreskin and rotating it around the right side of the penis in cases of counterclockwise torsion, then securing it with absorbable sutures to the left tunica albuginea of the penile shaft, applying some tension. In cases of clockwise torsion, fixation is performed in the reverse direction. They reported a 100% success rate with this technique. However, Bauer et al. (21), using the same technique for correcting penile torsion, found that only 64% of patients achieved complete correction. The failure or recurrence of this technique may be due to improper attachment or incorrect placement of the flap. Zhou et al. (13) described another technique, pubic fixation (corporopexy technique), in which the penile skin is degloved down to the pubis and the penile corpora are fixed to the pubic bone periosteum, though this carries a risk of damaging the neurovascular bundle of the penis. Aldaqadossi et al. (15) compared the Fisher technique and corporopexy technique in a prospective study, finding both methods to yield good corrective outcomes. The Fisher technique avoids the risk of neurovascular bundle injury and is considered an easier, safer, and more effective surgical option for urologists trained in hypospadias surgery. Snow et al. (22) introduced a diagonal folding technique for the tunica albuginea, which is simpler and more effective than the corporopexy technique, but requires long-term follow-up in more patients to verify its effectiveness.

The principle of this technique for correcting penile torsion primarily relies on excessive traction of the foreskin. However, severe penile torsion is often associated with developmental abnormalities of the corpora cavernosa or abnormal fibrous connections between the corpora and the pubic bone. Therefore, relying solely on foreskin traction may lead to suboptimal correction outcomes. Additionally, the assessment of penile torsion angle after erection remains insufficient, necessitating further follow-up beyond puberty. Moreover, experience with this technique in adult patients is limited, and those who undergo the procedure may require additional anesthesia. Due to the uncertainty regarding the effectiveness of this technique, the surgery is only applied to children with mild to moderate penile torsion, with a torsion angle of less than 60 degrees. Our results showed that the median correction angle postoperatively was 42.5 degrees. Therefore, to achieve better correction outcomes, we recommend using traditional techniques for more severe cases of penile torsion.

We hope that the modified SRC technique can be standardized. However, the procedure was performed by a single surgeon, and the sample size was insufficient, lacking a more detailed analysis of how varying penile torsion angles affect surgical outcomes. The inclusion of surgical patients was influenced by both the surgeon’s and the parents’ subjective judgment, which may have affected the determination of surgical indications. Furthermore, given the correction principles of this technique, its application to other common circumcision methods, such as the Mogen clamp, Gomco clamp, or Plastibell device, may be challenging (23). The most significant limitation is the single-center, retrospective nature of the analysis, which lacks a control group. Addressing these limitations will be crucial for future research.

Conclusions

The modified SRC technique offers a viable, safe, and effective approach to correcting mild to moderate penile torsion with angles under 60 degrees when performed under local anesthesia, presenting a novel surgical option for pediatric patients. Nevertheless, further studies with larger sample sizes are needed for more comprehensive evaluation.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-698/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-698/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2024-698/prf

Funding: This work was supported by the Medical Science Research Project of Hebei (No. 20231130).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2024-698/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013), and was approved by the Ethics Committee of Hebei Children’s Hospital (approval No. 2024191), and was registered in ChiCTR (PID 234422, 2024-6-14). Informed consent was obtained from the legal guardians of all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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