The pros and cons of circumcision have fueled a heated debate. Now from the World Health Organization comes evidence that is difficult to ignore: Male circumcision could lower female-to-male HIV transmission rates by 50 to 60 percent, according to 2007 results of three clinical trials conducted on more than 10,000 men in Kenya, Uganda, and South Africa. In the wake of these findings, demand for the procedure has surged among African men, overwhelming government hospitals and fueling fears that untrained hucksters offering unsanitary surgery in makeshift clinics could transmit bloodborne diseases through the reuse of nonsterile scalpels. Botched circumcisions can lead to scarring, partial penile amputation, and even death.
What is needed here is a sterile, disposable, and inexpensive circumcision device to reduce infections and complications while updating a surgical procedure that has not changed in 50 years. Physician David Tomlinson believes he has just the thing: the AccuCirc, an instrument he invented in his spare time and developed with the aid of a team of collaborators at Brown University and Clinical Innovations, a medical device company in Murray, Utah. His sterile device, which permits only one use, protects the glans beneath the foreskin from injury and requires only minimal training.
Tomlinson, who has performed more than 200 circumcisions on newborns, invented the device after he realized that all existing instruments have the potential to cause serious complications. The most popular device in the United States, preferred by 67 percent of physicians, is the Gomco clamp, whose parts come in different sizes to match varying penile diameters; mismatched clamp components increase the risk of laceration. Both the Gomco and the competing Plastibell—used by 19 percent of physicians in the United States—require the insertion of a shield beneath the foreskin to protect the underlying glans from the scalpel; to slide the shield in, doctors first make a slit in the foreskin with scissors, increasing the risk of cutting the urethra as well.
The plastic AccuCirc avoids these problems. A probe is inserted beneath the foreskin, shielding the glans without the need for an incision. The attached clamp, which can be activated only if the shield is in position, is then placed over the probe. When the lever is depressed, it crushes the foreskin, sealing blood vessels and preventing bleeding, while a circular steel blade excises the foreskin in one action. When the clamp is released and removed, the foreskin is withdrawn with the holder in the probe. The device cannot be reused, preventing the spread of HIV.
So far, the AccuCirc is designed only for infants, although Tomlinson plans to reconfigure one for use on adults, too. Until then, results from a clinical trial carried out on babies at the Obafemi Awolowo University Teaching Hospital in Ile-Ife, Nigeria, have encouraged the FDA to clear the AccuCirc for use on infants in the United States.
“From our limited experience,” says Oludayo A. Sowande, a pediatric surgeon at the hospital in Ile-Ife who participated in the trials, the device is “very hygienic for an environment such as ours, where most circumcisions are done outside the hospital.”
Circumcision by the Numbers
• One in six males in the world is circumcised.
• Circumcision originated more than 15,000 years ago, and until the 19th century it was performed solely for religious, ritual, or cultural reasons.
• In communities where circumcision is widely practiced, the incidence of complications varies between 0.034 percent and 7.4 percent.
• A study of 1,010 boys and young men in Bungoma, Kenya, found complication rates of 17.5 percent for independent medical circumcisions and 35 percent for traditional circumcisions. If performed in a public-health facility, the complication rates were reduced to 10 percent.
• In July 2007, 12 young men from the Xhosa ethnic group in South Africa’s Eastern Cape died after circumcision ceremonies.
• A study published in July 2006 in PLoS Medicine found that male circumcision could avert between 1.1 million and 3.8 million new HIV infections over the next 10 years in sub-Saharan Africa.
• Male circumcision does not provide complete protection against HIV infection. Circumcised men can still become infected with the virus and, if HIV-positive, can infect their sexual partners.