Learning Curve with the No-flip ShangRing Circumcision in Kenya
(PD58-03) LEARNING CURVE WITH THE NO-FLIP SHANGRING
CIRCUMCISION IN KENYA: Omar Al Hussein Alawamlh*, Ryan Flannigan, Quentin Awori, Soo Jeong Kim, Mark Barone, Marc Goldstein, Philip S. Li, Richard K. Lee, New York, NY (2018 AUA Podium Presentation)
INTRODUCTION AND OBJECTIVES: The ShangRing (SR) is one of two male circumcision (MC) devices WHO-prequalified for use in Africa. Advantages of SR MC include shorter surgical time, lack of need for sutures, less bleeding and pain, and high patient and provider satisfaction compared to conventional MC. Given the WHO objective of achieving 27 million circumcisions in sub-Saharan Africa by 2021, the SR may help to accelerate task-shifting from physicians to non-physician providers (NPP) and scale-up MC services. In this study, we assessed the learning curve for MC using the SR.
METHODS: 571 participants aged 10 years and older were enrolled in a study of no-flip SR MC. The no-flip SR technique involves the insertion of an inner plastic ring under the foreskin, followed by secure clamping of an outer ring to provide hemostatic occlusion, and then excision of the foreskin. Operative time, postoperative pain scores using the Visual Analogue Scale (VAS), and adverse event (AE) rates were recorded. All SR procedures were performed by 5 non-physician providers (NPP) and physician. For each provider, performance metrics from the first half of MCs completed was then compared with the second half.
RESULTS: 506 (89%) no-flip SR MC procedures were performed by trained NPPs, while the remaining 65 (11%) were performed by a physician. Providers showed significant improvement in mean operative time for the second half of procedures, compared to the first half (5.79 vs. 6.67, p smaller than 0.0001). Similarly, mean postoperative pain scores also showed significant improvement in the second half of cases vs. the first half (1.06 vs. 2.67, p smaller than 0.0001). AE rates were equivalent (4 vs. 8, p equal to 0.38). All AEs were of mild or moderate severity only and managed conservatively.
CONCLUSIONS: No-flip SR MC is safe, simple and quick in the hands of both physicians and NPP, but a short learning curve is expected. Safe task-shifting to NPP can be achieved with no-flip SR MC in Africa.
Source of Funding: Bill and Melinda Gates Foundation.