Biomedical Engineering – From Theory to Applications

Male Circumcision: An Appraisal of Current Instrumentation
view is that, unless or until proof positive emerges to the effect that a “high” style confers as
great a degree of prophylaxis as a “low” style, the Precautionary Principle should be applied
and circumcisions should be done in the “low” style.
Traditional circumcisions done using "tug-&-chop" methods (Fig. 2) already provide us with
ample examples of residual inner foreskin. There appears to be scope for a population study
here, comparing HIV infection rates amongst groups with “high” and “low” styles of
circumcision.
Fig. 2. The “tug-and-chop” method of circumcision.
Another somewhat contentious style issue is the matter of tightness. Often, tightness is
considered to be nothing more than a cosmetic matter. However, theoretical models of STI
transmission tend to suggest that benefit is gained from the sulcus being dry. This implies
that circumcisions should be sufficiently tight to hold the sulcus open, such that no moisture
will accumulate there.
The third style issue to be resolved relates to removal or retention of the frenulum. As well
as having high concentrations of antigen receptor cells targeted by HIV, the highly vascular
frenulum is particularly susceptible to tearing or other damage during intercourse, as well
as being a frequent site of lesions produced by other STIs (Szabo & Short, 2000). Persistent
debate relates to resulting changes in sexual sensitivity; anecdotal evidence from those who
have had their frenulum surgically removed suggest that no loss of sensitivity occurs. It is
also worthy of note that the frenulum can be lost as a result of tearing; such loss does not
appear to give rise to complaint about effects long-term.
In the light of all of the above, there appears to be a good cause not just to circumcise but to
circumcise in a particular way. It seems appropriate for the surgery to specifically target
certain classes of cells for removal, at the same time achieving a result that holds the sulcus
open so that it remains dry and clean, unable to harbour a viral payload either in smegma or
in residues of erogenously triggered body fluids.
5. Methods of circumcision
We will now present information on current approaches to circumcision, mostly stemming
from experience in developed nation settings, the USA in particular. We will start with
infants and then move on to adults and older boys. We will end with speculation about
what is needed for low-resource settings in terms of devising novel devices.
There is no standard circumcision procedure and the issue of standards has been a rallying
call for years. At the Western Section American Urological meeting in 2007 Dr Sam Kunin,
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