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

Abstract

Background: Penile torsion is a congenital condition characterized by the rotation of the penis along its longitudinal axis. This study aimed to describe a modified Shang Ring circumcision (SRC) surgical technique as a simple and effective approach for correcting penile torsion in children under local anesthesia.

Methods: From July 2018 to August 2023, 20 male children with penile torsion underwent the modified SRC technique under local anesthesia, performed by the same surgeon (S.Z.). In our technique, the inner ring of the Shang Ring is placed over the glans penis, while the outer ring is positioned over the outer layer of the foreskin and secured by the first notch of the outer ring. The foreskin is held in place in a semi-locked state between the inner and outer rings. The frenulum is adjusted to achieve mild overcorrection, positioning the urethral opening between the 6 and 7 o'clock positions to correct penile torsion. A good surgical outcome is defined as a postoperative penile torsion angle of less than 30 degrees, while a poor surgical outcome is one with a postoperative penile torsion angle greater than 30 degrees.

Results: All cases involved counterclockwise penile torsion, and surgeries, performed under local anesthesia, with an average surgical time of 8.55±1.61 minutes. The preoperative median angle of penile torsion was 45 [45, 60] degrees, with a maximum torsion angle of 60 degrees. The average time for the Shang Ring to fall off was 23.10±6.38 days. Three cases of the Shang Ring did not naturally fall off and were manually removed 30 days post-surgery. After the Shang Ring removal, 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 and at the last follow-up (P>0.05). All patients had good surgical outcomes.

Conclusions: The modified SRC technique is feasible, safe, and effective for correcting mild to moderate penile torsion under local anesthesia, offering a new surgical option for children.

Keywords: Penile torsion; Shang Ring; children; circumcision; local anesthesia.

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.

Figure 2

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