Comments by opponents on the British Medical Association’s guidance on non-therapeutic male circumcision of children seem one-sided and may undermine public health

The British Medical Association(BMA)guidance on non-therapeutic circumcision(NTMC)of male children is limited to ethical,legal and religious issues.Here we evaluate criticisms of the BMA’s guidance by Lempert et al.While their arguments promoting autonomy and consent might be superficially appealing,their claim of high procedural risks and negligible benefits seem one-sided and contrast with high quality evidence of low risk and lifelong benefits.Extensive literature reviews by the American Academy of Pediatrics and the United States Centers for Disease Control and Prevention in developing evidence-based policies,as well as risk-benefit analyses,have found that the medical benefits of infant NTMC greatly exceed the risks,and there is no reduction in sexual function and pleasure.The BMA’s failure to consider the medical benefits of early childhood NTMC may partly explain why this prophylactic intervention is discouraged in the United Kingdom.The consequence is higher prevalence of preventable infections,adverse medical conditions,suffering and net costs to the UK’s National Health Service for treatment of these.Many of the issues and contradictions in the BMA guidance identified by Lempert et al stem from the BMA’s guidance not being sufficiently evidence-based.Indeed,that document called for a review by others of the medical issues surrounding NTMC.While societal factors apply,ultimately,NTMC can only be justified rationally on scientific,evidence-based grounds.Parents are entitled to an accurate presentation of the medical evidence so that they can make an informed decision.Their decision either for or against NTMC should then be respected.

Traumatic Penile Amputation Post Circumcision: A Series of 3 Cases

Circumcision remains a frequently performed surgical procedure and could be associated with various complications, ranging from mild to catastrophic. Penile amputation is a rare and severe complication usually complex and challenging to manage. We describe three cases of penile amputation injuries following circumcision referred within a week at the urological service of the Yaoundé Central Hospital. The first case was a 5-year-old who had complete penile amputation during circumcision by a nurse assistant at a rural health center. The second was a 7-year-old boy who sustained total penile glans amputation while undergoing circumcision by a nurse under local anesthesia at a rural health facility. The third involved a 6-year-old who had total penile amputation with loss of the amputated stump during circumcision by a traditional practitioner at home. Non-microsurgical penile re-implantations were done with diverse outcomes. The preservation of the amputated stump, the ischemic time and the severity of injury are factors affecting surgical outcome. The aim of this study is to evaluate our management experience and outcome of penile amputation injuries in resource-limited settings. Microsurgical replantation remains the gold standard in the management of penile amputation injuries. However, in resource-limited settings macroscopic replantation could be used as an alternative remedy to salvage the amputated penis.

Complications of Circumcision: Epidemiological, Anatomo-Clinical and Therapeutic Aspects

Circumcision refers, in its most widespread form, to the total or partial removal of the foreskin, leaving the glans exposed. It is a ritual practice imposed by Mosaic law for Israelites, a tradition for Muslims, a rite of passage to adulthood for many people of Africa and the East. Circumcision is also a widely used therapeutic surgical procedure for a number of balanopreputial affections. The aim of this study was to list cases of circumcision complications received in a urological hospital (CHR Saint Louis) and to analyze their epidemiological, anatomo-clinical and therapeutic aspects. Patients and methods: This was a retrospective, descriptive study of circumcision complications, carried out in the urology department of the Saint Louis regional hospital in Senegal over a 5-year period (January 1, 2013 to December 31, 2017). Results: Thirty-three (33) complications of circumcision were collated. The mean age of patients was 7.63 years [9 months - 16 years]. Duration of time for Consultation varied according to the type of complication, with an average of 1.6 years [1 day - 10 years]. Penile granuloma accounted for 36.3% of the complications (n = 12), local infection for 30.3% (n = 10) and urethro-cutaneous fistula for 18.2% (n = 6). For six patients with urethro-cutaneous fistula, we performed urethro-cutaneous splitting in 5 patients, while the same complication necessitated urethroplasty in another patient. We noted five cases of verge plasty for verge granuloma, one glan reimplantation and one glan plasty for the two patients with glans amputation. Conclusion: Circumcision is a medical procedure widely practised throughout the world for medical, cultural and aesthetic reasons. In Africa, the lack of health coverage and the shortage of doctors explain why this surgical procedure is so common. In Senegal, circumcision is still carried out in the majority of cases by paramedical staff, which explains the high rate of complications.

Disposable circumcision suture device： clinical effect and patient satisfaction

In our experience patients undergoing circumcision are mostly concerned about pain and penile appearances. We conducted a prospective randomized trial to assess the benefits of a new disposable circumcision suture device （DCSD）. A total of 942 patients were equally divided into three groups （conventional circumcision, Shang ring and disposable suture device group）. Patients in the DCSD group were anesthetized with compound 5% lidocaine cream, the others with a 2% lidocaine penile block. Operation time, intra-operative blood loss, incision healing time, intra-operative and post-operative pain, the penile appearance and overall satisfaction degree were measured. Operation time and intra-operative blood loss were significantly lower in the Shang ring and suture device groups compared to the conventional group （P 〈 0.001）. Intra-operative pain was less in the suture device group compared With the other two groups （P 〈 0.001）; whereas post-operative pain was higher in the conventional group compared to the other two groups （P 〈 0.001）. Patients in the suture device （80.57%） and Shang ring （73,57%） groups were more satisfied with penile appearances compared with the conventional circumcision group （20.06%, P 〈 0.05）. Patients in suture device group also healed markedly faster than the conventional group （P 〈 0.01）. The overall satisfaction rate was better in the suture device group （78.66%） compared with the conventional （47.13%） and Shang ring （50.00%） groups （P 〈 0.05）. The combination of DCSD and lidocaine cream resulted in shorter operation and incision healing times, reduced intra-operative and post-operative pain and improved patient satisfaction with the cosmetic appearances.

Circumcision of Infants and Children: Short-Term Trauma and Long-Term Psychosexual Harm

Non-therapeutic infant male circumcision is a permanent surgical alteration to the penis that may cause significant physical, sexual and psychological harm. Physical harms include unintended adverse effects of the surgery itself (e.g., complications such as bleeding, infection, excessive removal of foreskin leaving insufficient shaft skin to accommodate erections, etc.), as well as the inherent loss of healthy, functional tissue. Sexual harms that necessarily follow from circumcision include the loss of all sensation in the foreskin itself, and the loss of all sexual functions that involve the physical manipulation of the foreskin. Additional sexual harms that may follow circumcision include reduced sexual sensation in the remaining penile structures, difficulty with masturbation, increased chafing in both the circumcised man and his sexual partner, as well as reduced overall psychosexual/psychological tension relief and subjective satisfaction. Psychological harms include short-term trauma as well as the potential for long-term emotional disturbances, including sadness, frustration, distress, and anger—akin to post-traumatic stress disorder (PTSD). In this paper, the extent and severity of these various harms are considered and it is argued that they are more serious and more widespread than is commonly believed.

Combination of Circumcision and Microwave in Treatment of Genital Warts in Uncircumcised Patients

Objective: To investigate the efficacy of combina-tion of circumcision and microwave on genital wartsin uncircumcised men. Methods: A randomized, prospective study of 109uncircumcised adult men with genital warts was con-ducted in a STD clinic in Zhanjiang, Guangdong. Onegroup (n=54) received microwave therapy only, whilethe other group (n=55) was taken the combination ofcircumcision and microwave therapy. The recurrenceswere observed at the end of months 3, 6 and 12, andoperative complications were also recorded. Results: There were no significant differences inthe mean age and duration of the disease between twogroups (P>0.05). No serious operative complicationswere documented. The recurrence rate in circumci-sion plus microwave group was markedly lower thanthat in microwave group (12.7% vs 29.6%, P<0.05),while the differences in early and late recurrencesbetween two groups showed no statistical significance(P>0.05). Conclusion: Circumcision can be safely performedunder local anesthesia in an outpatient setting. Com-bination of circumcision and microwave can produceexcellent effect as well as less tissue damage,therefore, it may be ideal for uncircumcised patientswith extensive condylomas.

Clinical application of a new device for minimally invasive circumcision

Aim： To study the clinical effects of a disposable circumcision device in treatment of male patients of different ages with either phimosis or excess foreskin. Methods： One thousand two hundred patients between the age of 5 and 95 years underwent circumcision using this procedure in the 2-year period between October 2005 and September 2007. Of these cases, 904 had excess foreskin and 296 were cases of phimosis. Results： In 96.33% of the cases the incision healed, leaving a minimal amount of the inner foreskin with no scarring and producing good cosmetic results. There were no incidents of device dislocation or damage to the frenulum. The average operative time was 2.5 min for excess foreskin, and 3.5 min for phimosis. During the 7 days of wearing the device, mild to moderate edema occurred in 10.08 % of cases with excess foreskin and in 2.58 % of those with phimosis. Edema in the frenulum was seen in 1.67% of patients, and only 0.67% had an infection of the incision. A total of 86.25% of patients reported pain due to penile erection. After removal of the device, 0.58% of the cases had minimal bleeding around the incision, and 2.42% had wound dehiscence. Conclusion： The new device can be applied to an overwhelming majority of patients with phimosis and excess foreskin. This technique is relatively simple to perform, and patients who underwent this surgery had very few complications. Antibiotics were not required and patients reported less pain than those who were circumcised using conventional methods. Circumcision with this device requires minimal tissue manipulation, and is quicker and safer than circumcision using conventional techniques.

Effects of circumcision on male sexual functions： systematic review and meta-analysis

This meta-analysis was performed to assess sexual functions following adult male circumcision. We searched the Cochrane Central Register of Controlled Trials, PUBMED, EMBASE, the Cochrane Database of Systematic Review and Web of Science from their inception until January 2013 to identify all eligible studies that reported on men＇s sexual function after circumcision. The Cochrane Collaboration＇s RevMan 5.2 software was employed for data analysis, and the fixed or the random effect model was selected depending on the proportion of heterogeneity. We identified 10 studies, which described a total of 9317 circumcised and 9423 uncircumcised men who were evaluated for the association of circumcision with male sexual function. There were no significant differences in sexual desire （odds ratio （OR）： 0.99; 95% confidence interval （CI）： 0.92-1.06）, dyspareunia （OR： 1.12; 95% Ch 0.52-2.44）, premature ejaculation （OR. 1.13; 95% Ch 0.83-1.54）, ejaculation latency time （OR： 1.33; 95% Ch 0.69-1.97）, erectile dysfunctions （OR： 0.90; 95% Ch 0.65-1.25） and orgasm difficulties （OR： 0.97; 95% Ch 0.83-1.13）. These findings suggest that circumcision is unlikely to adversely affect male sexual functions. However, these results should be evaluated in light of the low quality of the existing evidence and the significant heterogeneity across the various studies. Well-designed and prospective studies are required for a further understanding of this topic.

Male circumcision： towards a World Health Organisation normative practice in resource limited settings

There is now grade 1 evidence that male circumcision （MC） reduces the risk of a man acquiring HIV. Modelling studies indicate MC could in the next 10 years save up to 2 million lives in those African countries with high HIV prevalence. Several African countries are now scaling up public health MC programmes. The most effective immediate public health MC programmes in Africa will need to target 18-20 years old men. In the longer term there is a need for infant circumcision programmes. In order to implement more widespread MC there is a need to make the surgical procedures as simple as possible so that safe operations can be performed by paramedical staff. The WHO Manual of Male Circumcision under local anaesthetic was written with these objectives in mind. Included in the manual are three adult techniques and four paediatric procedures. The adult procedures are the dorsal slit, the for- ceps guided and the sleeve resection methods. Paediatric methods included are the plastibell technique, the Mogen and Gomco shield method and a standard surgical dorsal slit procedure. Each method is described in a step by step manner with photographic and line drawing illustrations. In addition to the WHO manual of surgical technique a teaching course has been developed and using this course it has been possible in one week to train a circumcision surgeon who has had no or minimal previous surgical experience. Further scaling will require training of circumcision surgeons, monitoring performance, training the trainer workshops as well as advocacy at national, international and government meetings. In addition to proceeding with standardised methods work is in progress to assess novel techniques in adults such as stay on ring devices and policies are being formulated as to how to assess new devices. Also work is in progress to explore efficiencies in surgical processing by task sharing. Proper informed consent and safety remain paramount and great care has to be taken as programmes in Africa scale up. In continental China where the HIV epidemic is at a much earlier stage there may be a case for considering infant circumcision but great care will be needed to ensure that there is no harm.

The ultrasonic harmonic scalpel for circumcision： experimental evaluation using dogs

Male circumcision is one of the most commonly performed operations worldwide, and many novel techniques have been developed for better postoperative outcomes. The purpose of this study was to explore the feasibility of applying the ultracision harmonic scalpel （UHS） for circumcision by using dogs. Sixteen adult male dogs were divided into two groups： the UHS group and the control group. The dogs were circumcised with either the UHS or a conventional scalpel. The UHS circumcision procedure and the effects were imaged 1 week after surgery. The two groups were compared with respect to the operative time and volume of blood loss. Postoperative complications, including oedema, infection, bleeding of the incision and wound dehiscence, were recorded for both groups. The mean operative time for the UHS group was only 5.1 min compared with the 35.5 min of the conventional group. The mean blood loss was less than 2 ml for the UHS group and 15 ml for the conventional group. There was only one case of mild oedema in the UHS group, but the postoperative complications in the conventional group included two cases of mild oedema, one infection of the incision and one Case of bleeding of the incision. In conclusion, circumcision using UHS is a novel technique to treat patients with phimosis and excessive foreskin, and this method has a short operative time, less blood loss and fewer complications than the conventional scalpel method. This small animal study orovides a basis for embarking on a larger-scale clinical trial of the UHS.

Infant male circumcision: An evidence-based policy statement

Here we review the international evidence for benefits and risks of infant male circumcision (MC) and use this to develop an evidence-based policy statement for a developed nation setting, focusing on Australia. Evidence from good quality studies that include meta-analyses and randomized controlled trials showed that MC provides strong protection against: urinary tract infections and, in infancy, renal parenchymal disease;phimosis;paraphimosis;balanoposthitis;foreskin tearing;some heterosexually transmitted infections including HPV, HSV-2, trichomonas, HIV, and genital ulcer disease;thrush;inferior hygiene;penile cancer and possibly prostate cancer. In women, circumcision of the male partner protects against HPV, HSV-2, cervical cancer, bacterial vaginosis, and possibly Chlamydia. MC has no adverse effect on sexual function, sensitivity, penile sensation or satisfaction and may enhance the male sexual experience. Adverse effects are uncommon (<1%), and virtually all are minor and easily treated. For maximum benefits, safety, convenience and cost savings, MC should be performed in infancy and with local anesthesia. A risk-benefit analysis shows benefits exceed risks by a large margin. Over their lifetime up to half of uncircumcised males will suffer a medical condition as a result of retaining their foreskin. The ethics of infant MC and childhood vaccination are comparable. Our analysis finds MC is beneficial, safe and cost-effective, and should optimally be performed in infancy. In the interests of public health and individual wellbeing, adequate parental education, and steps to facilitate access and affordability should be encouraged in developed countries.

Critical evaluation of unscientific arguments disparaging affirmative infant male circumcision policy

We evaluate recent claims opposing infant male circumcision,a procedure now supported by the evidencebased policy of the American Academy of Pediatrics.We find those criticisms depend on speculative claims about the foreskin and obfuscation of the strong scientific evidence supporting pediatric policy development.An argument that circumcision should be delayed to allow a boy to make up his own mind as an adult fails to appreciate the psychological,scheduling and financial burdens later circumcision entails,so reducing the likelihood that it will occur.In contrast,early infant circumcision is convenient,safer,quicker,lower risk,healing is faster,cosmetic outcome is routinely good and the lifetime benefits accrue immediately.Benefits include reduction in urinary tract infections,inflammatory skin conditions,foreskin problems,and,when older,substantial protection against sexually transmitted infections and genital cancers in the male and his female sexual partners.Some authorities regard the failure to offer parents early infant circumcision as unethical,just as it would be unethical to fail to encourage the vaccination of children.In conclusion,the criticisms of evidence-based infant male circumcision policy are seriously flawed and should be dismissed as unhelpful to evidence-based development and implementation of pediatric policy intended to improve public health and individual wellbeing.

Ischemic glans penis after circumcision

A 33-year-old male receiving dorsal penile nerve block (DPNB) for circumcision exhibited a postoperative ischemic change over the glans penis. The event occurred nearly 24 hours after the procedure. The patient was treated with intravenous pentoxifyllin and hyperbaric oxygenation. Total reverse of the ischemia was observed. The complications associated with circumcision and DPNB were reviewed and discussed.

Early infant male circumcision:Systematic review,risk-benefit analysis,and progress in policy

AIM To determine whether recent evidence-based United States polices on male circumcision(MC) apply to comparable Anglophone countries,Australia and New Zealand.METHODS Articles in 2005 through 2015 were retrieved from PubM ed using the keyword "circumcision" together with 36 relevant subtopics.A further PubM ed search was performed for articles published in 2016.Searches of the EMBASE and Cochrane databases did not yield additional citable articles.Articles were assessed for quality and those rated 2+ and above according to the Scottish Intercollegiate Grading System were studied further.The most relevant andrepresentative of the topic were included.Bibliographies were examined to retrieve further key references.Randomized controlled trials,recent high quality systematic reviews or meta-analyses(level 1++ or 1+ evidence) were prioritized for inclusion.A risk-benefit analysis of articles rated for quality was performed.For efficiency and reliability,recent randomized controlled trials,metaanalyses,high quality systematic reviews and large welldesigned studies were used if available.Internet searches were conducted for other relevant information,including policies and Australian data on claims under Medicare for MC.RESULTS Evidence-based policy statements by the American Academy of Pediatrics(AAP) and the Centers for Disease Control and Prevention(CDC) support infant and later age male circumcision(MC) as a desirable public health measure.Our systematic review of relevant literature over the past decade yielded 140 journal articles that met our inclusion criteria.Together,these showed that early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects,phimosis that causes difficult and painful erections and "ballooning" during urination,inflammatory skin conditions,inferior penile hygiene,candidiasis,various sexually transmissible infections in both sexes,genital ulcers,and penile,prostate and cervical cancer.Our risk-benefit analysis showed that benefits exceeded procedural risks,which are predominantly minor,by up to 200 to 1.We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime.Wide-ranging evidence from surveys,physiological measurements,and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that MC has no detrimental effect on sexual function,sensitivity or pleasure.United States studies showed that early infant MC is cost saving.The evidence supporting early infant MC has further strengthened since the positive AAP and CDC reviews.CONCLUSION Affirmative MC policies are needed in Australia and New Zealand.Routine provision of accurate,unbiased education,and access in public hospitals,will maximize health and financial benefits.

A Novel Tool to Predict the Cosmetic Outcome after Circumcision: Penile Visibility Index

Objectives: We aimed to evaluate the circumcision status and complications, and the value of penile visibility index in predicting circumcision complications among elementary school children. Patients and Methods: Elementary school students were evaluated with physical exam in terms of circumcision complications. Visible penile length/stretched penile length ratio was calculated for each subject and recorded as penile visibility index (PVI). Data were assessed with SPSS 15.0 software. Results: Average age was 9.04 (5 - 14) years. Circumcision complications were detected in 84 of 361 circumcised subjects (23.2%). There was no relationship between age at circumcision and complications (p > 0.05). Concealed penis was detected in 3.6% of all subjects. Mean PVI was significantly different between cases with and without glanular adhesion, and between cases with and without residual prepuce. On the overall, mean PVI in complication and no complication groups were 0.52 and 0.59 respectively, and the difference was statistically significant (p < 0.001). Conclusion: PVI calculation before circumcision, might help predict the cosmetic outcome of circumcision beforehand.

Overcoming Barriers to Uptake of Voluntary Medical Male Circumcision in a Traditionally Circumcising Community in Machinga District, Malawi

Introduction: Voluntary medical male circumcision (VMMC) reduces chances of contracting HIV during heterosexual intercourse in males, and risk of cervical cancer in their female sexual partners. However, its uptake among traditionally circumcising communities, where male circumcision carries a cultural significance, has not been studied. Previous research has focused on barriers to uptake of VMMC in non-circumcising communities. This study was conducted to determine socio-cultural barriers to VMMC uptake in order to identify culture-sensitive and evidence-based interventions to increase its uptake. Methodology: This exploratory mixed methods cross-sectional study generated quantitative data from 262 randomly sampled sexually active men;and qualitative data through four focus-group discussions with 58 purposely selected male participants and 10 key informants. Results: The study established that only 6.3% (n = 15) of those circumcised (90.8%, n = 238) were circumcised in clinical setting. Limited access to VMMC services, cost, pain, being attended to by female providers and cultural influences were the major hindrances to uptake of VMMC. Conclusion: Although there is a paradigm shift of preference from traditional male circumcision to VMMC in this community, its uptake is low. The study recommends that besides introducing mobile VMMC services, the Ministry of Health should collaborate with traditional circumcisers and local leaders to provide gender-and-culture-sensitive safer medical male circumcision services.

A Comparative Evaluation of the Voluntary Medical Male Circumcision Program for Seke and Goromonzi Districts, Mashonaland East Province, Zimbabwe, 2017

Background: In 2009, Zimbabwe incorporated Voluntary Medical Male Circumcision (VMMC) to a consortium of measures to eliminate HIV transmission by 2030. Seke and Goromonzi districts simultaneously commenced implementing VMMC. These districts have comparable population, geography, and support yet scored varied performances. Cumulatively, (2009-2016) Seke achieved 83% while Goromonzi achieved 15% of set circumcision targets. We compared the performance of the VMMC program in the 2 districts. Methodology: A process evaluation was conducted modelled on a logical framework. Interviewer-administered questionnaires and checklists were used to collect data. Epi info7 was used to generate frequencies and proportions. Results: Three health facilities in Seke and four in Goromonzi were implementing VMMC. Material resources were maintained at three months buffer stock and human resources equitably distributed between the two districts. Additional support (three nurses), from the national army, was received by Seke, and management provided vehicle support for program activities. Goromonzi conducted half of the targeted mobilisations (6/12) and Seke 12/12. Similar amounts of financial support were simultaneously disbursed. Seke circumcised 99.5% (4716) and Goromonzi 48.5% (2372) of annual targets. Adverse reactions were 0.04% (2) for Seke and 2.3% (55) for Goromonzi for same period with no review meetings conducted. Seke participants attributed performance to effective demand creation (22;100%), effective coordination (20;90.9%) and management support (21;95.5%). Goromonzi participants cited delayed payments (20;90.9%), lack of active leadership involvement in planning and execution (14;63.6%) and weak mobilisations (11;50%) to have worked against the program. Conclusion: Effective demand creation and coordination, manpower boost and leadership support enhanced VMMC program performance for Seke and was therefore recommended for Goromonzi. Resource availability did not translate to performance in Goromonzi where lack of active leadership involvement in planning and execution, weak mobilisations resulted in poor results. Robust demand creation strategies were suggested for both districts.

Twentieth Century Wanzams among the Asante People of Ghana: A Historical Study of the Facts on Male Circumcision

This paper studies the history of circumcision amongst religious and traditional societies and the arguments on the medical or non-medical essence of the practice. The paper further highlights amongst the Asante people of Ghana, a practice argued to have been introduced by Islamic Wanzams who are severally referred to as Muslim Circumcision Surgeons. Often circumcision amongst communities in West, Southern Africa, Asia and other Aboriginal groups has been spurred on by customs and traditions [1]. Yet the case of Asante was different. Hence attention has been paid to the history of circumcision amongst the people of Asante. More significantly, the health implications associated with circumcision surgery in Asante have been highlighted. Possible benefits from the practice of circumcision and the potential dangers associated with it, especially the operations of the Asante circumcision surgeons (Wanzams) have been amply scrutinised in the narrative. In the conclusion, attention is paid to some of the scientific arguments for male circumcision. The study is purely qualitative relying on documentary and non-documentary sources. Some of the documentary sources have been gleaned from journal articles, news papers and books etc. The non-documentary data have been sourced from interviews. Both the documentary and non-documentary sources have been thematically pieced together to form a social history of medicine narrative which has potential ramifications on the essence of male circumcision by Wanzams, as well as the need for further research, training and dialogue in the practice in Ghana and Asante in particular.

Expertise and Ideology in Statistical Evaluation of Circumcision for Protection against HIV Infection

Aim: To critically evaluate data and arguments by Van Howe defending his stance opposing male circumcision (MC), in particular his meta-regression analyses evaluating the ability of MC to reduce HIV infection risk in heterosexual populations within and outside Africa. Methods: We performed metaregression analysis of log odds of HIV infection between uncircumcised and circumcised men using a single covariate (MC prevalence) in the meta-regression model involving the metareg package in STATA 13 for 103 populations worldwide and for populations within Africa. The meta-regression of log odds and MC prevalence was fitted to a line, as were empirical Bayes estimates resulting from post-estimation. Results: Our critical evaluation of Van Howe’s arguments attempting to undermine the scientific evidence in support of the benefits of MC in protection of men against HIV during heterosexual intercourse, as well as other infections and conditions, together with his use of statistics to support his beliefs, revealed serious flaws, obfuscation and missing data. We therefore performed our own meta-regression analysis using a trivariate model. Doing so revealed that for MC prevalences of 50%, 75% and 100% for general populations within Africa, odds ratios for HIV risk in uncircumcised vs. circumcised men were 1.35, 1.58 and 1.85, respectively. Our meta-regression analysis of data for all countries yielded similar findings. For a general population outside Africa with 100% MC prevalence, OR was 1.5. Van Howe failed to acknowledge that since MC prevalence in US whites (91%) and blacks (76%) exceeds 75% his results support MC having a protective effect in those population groups. Conclusions: The protective effect of MC against HIV infection during heterosexual intercourse applies to populations both within and outside Africa. The debate engineered by MC opponents, and led by Van Howe, now appears to have run its course. The scientific evidence has prevailed.

Suture-Less Circumcision by Glutaraldehyde Albumin Glue Enhanced Laser Tissue Welding—A Comparative Study

Background: Suture-less circumcision by Feracrylate glue creates a weak and non waterproob bond. Hence, there is wound dehiscence and delayed healing which favor infection in many patients. I am describing a new technique for suture-less circumcision which is free from above limitations. Methods: In my center in the time span of 2 years, I did 51 cases of circumcision with Laser tissue welding technique (group A). Age range was 5 months to 21 years. During the same time span, in 56 patients circumcision was done by Feracrylate glue (group B). The age range was 3 months to 22 years. This group was kept as a control. Patients in both groups were randomly distributed. The technique of circumcision by Laser tissue welding is as follows. Patient is under short GA, the prepuce above the artery forceps is chopped off by scissors and bleeders are coagulated by bipolar cautery. Now, 0.9 ml 40% human albumin is taken in 1 ml syringe and mixed with 0.1 ml of 10% glutaraldehyde solution. The syringe is shaken vigorously to mix both the components. The skin and mucosa of penis are held by tooth forceps and a thin layer of this mixture is layered over it all around. Infrared Laser of 5 watts power and 850 nm illuminated over this bond for 60 seconds to polymerize it. Results: In group A, 2 (3.9%) patients developed partial wound gape, no patient had complete wound gape. 3 (5.88%) patients had grade 2 infections which settled with conservative treatment of oral antibiotics. In group B, 6 (10.71%) patients had partial wound gape and 8 (14.28%) patients had complete wound gapping. 11 (19.64%) patients developed grade 2 and 8 (14.28%) patients grade 3 wound infection. All these 19 patients’ post-operative antibiotics were started and given for 7 - 10 days. The Glutaraldehyde albumin mixture bond is already described in medical literature (Bioglue) for its use to seal coronary anastomosis after CABG operation, to seal sutures of cardiac surgery and for aortic dissection, etc. It is a surgical adhesive composed of purified bovine serum albumin (BSA) and glutaraldehyde and is already American FDA approved. It creates a flexible mechanical seal independently of the body’s clotting mechanism. In my technique, 0.9 ml of 40% human albumin is mixed with 0.1 ml 10% glutaraldehyde solution which costs only 50 cents which is a massive 1000 times cost reduction. Laser application polymerizes the glue and forms a waterproob bond in less than a minute. In my technique, percentage of glutaraldehyde used is only 10% compared to 50% in bioglue, hence it is non-toxic to the tissues. Conclusion: Suture-less circumcision by glutaraldehyde albumin glue enhanced Laser tissue welding is a safe, cheap and effective technique of performing circumcision. It is an important advance in circumcision surgery after a long time. The technique becomes a foundation for its vast application in other areas of surgery.