商环男性包皮环切术在中国和非洲的临床研究进展

艾滋病毒和性传播感染(HIV/STIs)仍然是全球公共卫生的重大问题。预防和控制HIV/STIs的全球战略是阻断传播链,需要基于科学依据和成本效益的公共卫生方法。在非洲执行男性包皮环切规模化预防HIV项目的优先国家正在面临提供男性包皮环切手术服务相关的人员和技术严重短缺。商环(ShangRing)是一种创新的包皮环切器械和手术方法,自2006年已在中国安全实施超过60万例手术。在中国、肯尼亚、赞比亚和乌干达已经进行了超过3 000例的多项临床评估研究,证明了商环的安全性、有效性、可接受性和容易教学。商环的最显著优势是极短的手术时间(3~6 min)、愈合后外观完美、很容易实现标准化操作与培训。与传统包皮环切方法相比,接受包皮环切手术的男性更偏爱商环,更加满意环切后的阴茎外观。作为一种创新的男性包皮环切技术,商环极有希望和潜力,加快安全和有效的包皮环切服务规模化。本文全面综述商环男性包皮环切术在中国和非洲的临床研究。     

包皮环切术对男性HPV感染影响的相关性研究

目的:观察包皮环切术对男性人乳头瘤病毒(HPV)感染的影响。方法:选取2016年1月至2017年8月我院门诊351例HPV检测男性患者,收集每例患者的阴茎头、阴茎体和阴囊部位分泌物送检。分析患者行包皮环切与HPV感染率之间的相关性,以及进一步分析行包皮环切术时的年龄对HPV感染的影响。结果:351例中HPV感染为135例(38.46%),其中观察组(已行包皮环切术组)HPV感染29例(24.58%),对照组(未行包皮环切术组)106例(45.49%),观察组HPV感染率明显低于对照组,两者差异具有统计学意义(χ~2=14.48,P0.01)。进一步发现,在观察组中,年龄≤17岁行包皮环切术组HPV感染为5例(13.16%),明显低于年龄17岁手术组感染的24例(30.0%),差异具有统计学意义(χ~2=3.942,P=0.047)。结论:包皮环切术能明显降低男性HPV感染率,并且较早进行包皮环切术效果更显著。     

包皮中人乳头瘤病毒的感染及意义

目的和方法：人乳头瘤病毒１６、１８型染与宫颈癌及阴茎癌的发生有密切关系，从预防角度出发，我们采用ＰＣＲ－ＤＮＡ扩增的方法，检测了４８例包皮环切标本中ＨＰＶ６，１１，１６，１８，３３型的ＤＮＡ保守片段。结果：２０例阳性，阳性率为４１．７％，按年龄、有无包皮垢及有无感染史分组，各组间均无显著性差异。结论：主张男孩应尽早行包皮环切术。     

男性包皮状态对女性伴侣宫颈HPV感染的影响

<正>本期刊登的南京医科大学附属南京妇幼保健院雷雨等的调查报告,回顾了2011年5月至12月来该院妇产科门诊就诊的女性人乳头瘤病毒(hu-man papillomavirus,HPV)感染状况及其与配偶阴茎包皮状态的相关性。调查问卷内容包括女性年龄、婚姻状况、近1个月内性生活次数、配偶是否包皮过     

包皮环切后包皮龟头炎、包皮垢及人乳头瘤病毒感染的年龄分布调查

目的：探讨不同年龄包皮环切后人群包皮中包皮龟头炎、包皮垢及人乳头瘤病毒（ Ｈ Ｐ Ｖ）感染的发生率。　方法：对 ２１９ 例包皮环切后通过问诊和体检，了解包皮龟头炎和包皮垢的情况，采用 Ｐ Ｃ Ｒ 扩增的方法检测包皮中 Ｈ Ｐ Ｖ ６、１１、１６、１８ 及 ３３ 型 Ｄ Ｎ Ａ 保守片段。　结果：包皮龟头炎、包皮垢及 Ｈ Ｐ Ｖ 感染的发生率分别为 ２１．０％（４６／２１９）、４３．３％ （９５／２１９）和４１．１％ （９０／２１９）。　结论：包皮环切后包皮中包皮龟头炎、包皮垢及 Ｈ Ｐ Ｖ 感染的发生率较高，对于包茎或包皮过长者，应尽早行包皮环切术。     

中国商环(Shang Ring)男性包皮环切技术临床应用研究进展

男性包皮环切能显著降低男性阴茎-阴道性交获得性HIV感染风险大约60%,被WHO和联合国艾滋病规划署(UNAIDS)推荐作为HIV预防策略中的一个重要干预措施。寻求一种更加安全、有效和可接受的男性包皮环切器械和手术方法,以便能够满足加快执行扩大包皮环切预防HIV感染项目的需求,已经成为相关国际组织,特别是非洲国家政府公共卫生事业的当务之急。2008年中国商环(Shang Ring)包皮环切标准化手术方案的建立,以及应用这个标准化手术方案和手术培训在中国以及2009年和2010年在肯尼亚实施中国商环成人包皮环切手术获得有用的和有意义的临床数据,证明了中国商环包皮环切术的诸多优势。手术培训手册和教学视频的多次修订为培训医护人员提供了更加准确的教学指南。经过多家相关国际机构专家的考察和评估,中国商环包皮环切技术已经成为支持在非洲HIV高发地区扩大包皮环切服务预防HIV感染项目最具潜力的候选包皮环切器械之一。可以预计,中国商环包皮环切技术的成功应用将会在改变数百万非洲人的生活方式的同时,也为中国男科学与泌尿外科学医生在包皮环切与HIV预防和生殖健康相关的临床研究领域提供了丰富的机会。本文报告了2008年2月至2010年底期间中国商环包皮环切技术临床应用的国际和国内研究进展。     

军队男性包皮环切的历史回顾与展望

成人包皮环切可以预防大多数生殖道感染,显著降低男性获得性HPV、HSV和HIV的感染风险。有关男性包皮环切对军队服役人员健康益处的报道很少。前线的士兵不能保持阴囊与包皮足够的局部卫生条件,容易受到感染,影响执行任务和作战,辅助治疗也会直接给军队增加开支。在服役期间和在派遣之前进行包皮环切可以节省大量时间和成本,对改善官兵生殖健康状况起到长效的益处。这些研究发现正在受到非洲各国军队卫生部门的重视,将成为未来军队卫生和服务的发展方向。在HIV流行可能恶化的亚洲,在军队倡导男性包皮环切术预防生殖道感染和性传播疾病,对提高战斗力和降低医疗成本,增进全社会公众健康状况与国民经济将具有十分显著的战略意义。     

商环包皮环切术后并发症预防及处理

目的观察商环包皮环切术后并发症探讨其预防方法及处理。方法应用商环对526例包皮过长及包茎患者行包皮环切术,对术后并发症分析处理提出预防办法。结果手术并发症:水肿387例,术后并发感染5例,拆环前环自行脱落3例,内板保留过多5例,误伤阴茎包皮1例,术后出血3例,去环结痂脱落后创口裂开10例,术后创口疼痛剧烈者8例,拆环后系带对合不齐愈合3例。结论商环包皮环切术后并发症通过处理可以达到满意疗效,预防是关键。     

应用中国商环包皮环切手术标准化方案对328例成年男性包皮环切的临床报告

目的:成年男性包皮环切手术标准化和培训可显著降低因手术引起的并发症发生率。由于目前国内外尚无可供参考的成年男性包皮环切手术标准化方案和培训制度,使得临床医生开展成年男性包皮环切手术的质量无法保证。为了建立成年男性包皮环切手术标准化和培训制度,便于临床医生和相关医护人员学习和掌握包皮环切器的临床应用技巧,以中国商环(简称"商环,ShangRing")包皮环切技术为例,根据商环的技术特点和临床实践经验,特别制订了商环包皮环切手术标准化方案,并将其标准化操作运用于临床。方法:采用商环包皮环切手术标准化方案对328例受术者(年龄18～58岁,平均27.8岁;已婚134例,未婚194例;包茎25例,包皮过长303例)进行包皮环切手术。对手术时间、疼痛评分(视觉模拟评分法,VAS)、术后并发症、包皮创口愈合时间、术后外观满意情况进行观察和随访。结果:手术时间为(4.70±1.31)min。手术时受术者疼痛(VAS)评分为(0.24±0.59)分,术后24h疼痛评分为(1.59±0.95)分,去环前24h内疼痛评分(1.72±1.11)分,去环时疼痛评分为(2.72±1.37)分。主要并发症发生率为术后感染0.6%(2/328)、出血0.6%(2/328)、伤口裂开0.6%(2/328)和水肿4.89%(16/328)。在发生出血和伤口裂开的受术者中无1例需要缝合。术后包皮创口完全愈合时间为(20.30±6.69)d。受术者对术后外观满意率99.7%(327/328)。结论:商环包皮环切术具有手术方式易于标准化、手术时间短、术中疼痛轻、术后无须特殊护理、容易完整保留系带,并完全暴露冠状沟、术后外观满意度高、受术者易于接受等优点。初步证明了中国商环包皮环切手术标准化方案的可接受性,严格按照此方案实施手术和随访护理,能最大化地实现商环包皮环切技术的诸多临床优势,将并发症发生率控制在可接受的范围内。     

已行和未行包皮环切术的青年男性对包皮及包皮环切术认识和态度的比较研究

目的:探讨青年男性对包皮及包皮环切术知识的掌握程度以及他们是否接受包皮环切术的影响因素。方法:采用自行设计的问卷对泌尿外科门诊已行和未行包皮环切术的青年男性各100名进行调查研究。统计学方法采用SPSS 11.0软件包中χ2检验。结果:已行包皮环切术的青年男性接受该手术的原因依次为:使阴茎更卫生、为预防阴茎癌和期望提高性功能,分别占63%、27%和26%;青年男性未行包皮环切术的主要原因是不清楚包皮环切术的益处和担心术后并发症,分别占47%和24%。同时,周围同龄人的影响也是决定是否接受包皮环切术的重要因素。已行包皮环切术的青年男性对何时进行该手术并不十分清楚。结论:青年男性接受包皮环切术的主要因素是认为术后可改善阴茎局部卫生和期待提高性功能;而拒绝该手术者则不清楚包皮环切术的益处和担心术后并发症。故应加强对包皮和包皮环切术相关知识的宣教工作。     

Circumcision related to urinary tract infections,sexually transmitted infections,human immunodeficiency virus infections,and penile and cervical cancer

Male circumcision has been carried out as a prophylactic measure against future diseases, as well as a rite of passage due to religious practice and definite medical indication. The present review discusses the benefits of male circumcision on the prevention of urinary tract infections, and the importance of circumcision in congenital urinary system anomalies, such as vesicoureteral reflux. Additionally the present review examines the associations between circumcision and sexually transmitted infections, including human immunodeficiency virus, and the preventive effect of circumcision on penile cancer and cervical cancer of female partners.     

Clinical trials using the Shang Ring device for male circumcision in Africa: a review

Male circumcision (MC) reduces the risk of HIV and other sexually transmitted infections (STIs), including human papillomavirus (HPV) and herpes simplex virus type 2 (HSV-2), and is recommended as an important component of a comprehensive package of HIV prevention interventions. While computer modeling has demonstrated that substantial reductions in HIV could be achieved with rapid scale-up of MC services in sub-Saharan Africa, scale-up has lagged due to scarcity of trained providers coupled with relative technical difficulty of recommended surgical MC techniques. Simplified techniques, such as devices, have the potential to allow for a more rapid roll-out of MC. One such device is the Shang Ring, a novel disposable MC device that eliminates the need for suturing and has been on the Chinese market since 2005. Results from Chinese studies have demonstrated that the Shang Ring is both safe and easy to use. Since 2008, a series of studies using the Shang Ring for adult MC have been carried out in Kenya, Uganda and Zambia, according to guidelines established by World Health Organization (WHO) for clinical evaluation of new devices for adult MC. These include a proof of concept study, a study of delayed removal of the Shang Ring, two studies comparing Shang Ring circumcision to conventional surgical approaches, and a large field trial to evaluate safety of Shang Ring circumcision during routine service delivery. Results from these studies demonstrate that the Shang Ring has an excellent safety profile and that Shang Ring circumcision is relatively easy to teach and learn, making Shang Ring MC an appealing technique for use in sub-Saharan Africa where doctors are in short supply and non-physician providers such as nurses and clinical officers are playing a major role in providing MC through task shifting. Shang Ring MC and device removals were uneventfully performed by trained nurses and clinical officers, who preferred the Shang Ring to conventional surgical techniques. Adverse event rates were similar to those observed with conventional surgical circumcision and were managed with, at most, minor interventions, resolving with no long-term sequale. Perhaps one of the biggest advantages of the Shang Ring is the relatively short 3-6 minutes procedure time. Importantly, men also preferred the Shang Ring compared to conventional circumcision and satisfaction with cosmetic appearance of their circumcised penis was very high. The vast majority of participants in studies in Africa as well as China have reported few problems and little disruption to daily life while wearing the device. The Shang Ring holds great promise as an innovative technology that has the potential to facilitate the safe and effective scale-up of circumcision services in settings where MC is not widely used and where the burden of HIV-disease is high.     

HIV infection of the male genital tract – consequences for sexual transmission and reproduction

Despite semen being the main vector of human immunodeficiency virus (HIV) dissemination worldwide, the origin of the virus in this bodily fluid remains unclear. It was recently shown that several organs of the male genital tract (MGT) are infected by HIV/simian immunodeficiency virus (SIV) and likely to contribute to semen viral load during the primary and chronic stages of the infection. These findings are important in helping answer the following questions: (i) does the MGT constitute a viral reservoir responsible for the persistence of virus release into the semen of a subset of HIV-infected men under antiretroviral therapy, who otherwise show an undetectable blood viral load? (ii) What is the aetiology of the semen abnormalities observed in asymptomatic HIV-infected men? (iii) What is the exact nature of the interactions between the spermatozoa, their testicular progenitors and HIV, an important issue in the context of assisted reproductive techniques proposed for HIV-seropositive (HIV+) men? Answers to these questions are crucial for the design of new therapeutic strategies aimed at eradicating the virus from the genital tract of HIV+ men – thus reducing its sexual transmission – and for improving the care of serodiscordant couples wishing to have children. This review summarizes the most recent literature on HIV infection of the male genital tract, discusses the above issues in light of the latest findings and highlights future directions of research.     

男性不育患者生精细胞HCMV、HSV感染检测及形态学研究

目的：探讨男性不育患者精液中生精细胞人类巨细胞病毒（HCMV）、单纯疱疹病毒Ⅱ型（HSV-Ⅱ）感染状况及其形态学特征。方法：收集83例精液检查中发现较多生精细胞男性不育患者精液，洗涤收集细胞后提取DNA，用PCR方法进行HCMV、HSV-Ⅱ筛查，阳性者精液细胞涂片用免疫细胞化学法（ICC）做相应的病毒标记，并另行细胞学染色作形态学观察。结果：83例精液样本PCR检测HCMV阳性8例，HSV-Ⅱ阳性4例，未发现2种病毒同时阳性病例。8例HCMV阳性病例ICC标记生精细胞HCMV晚期抗原均见阳性表达，HCMV早期抗原均为阴性表达；4例HSV-Ⅱ阳性病例ICC标记生精细胞3例阳性表达，1例弱阳性。12例病毒阳性病例均发现较多未成熟生精细胞，并有不同程度的核染色质固缩、出现空泡、核膜破损、核崩解、凋亡小体等凋亡现象，但未能找到病毒感染的特异性形态学改变（如病毒包涵体）。病毒感染阳性组精子密度明显低于阴性组（P〈0．05）。结论：生精细胞HCMV、HSV-Ⅱ感染时可出现不同程度的病理性损害，影响生精功能，感染的生精细胞形态学表现为出现凋亡现象等病理性改变；不育男性患者精液中出现病理性生精细胞，其生精细胞HCMV感染率可能较高。     

男性不育患者生精细胞HCMV、HSV感染检测及形态学研究

目的:探讨男性不育患者精液中生精细胞人类巨细胞病毒(HCMV)、单纯疱疹病毒Ⅱ型(HSV-Ⅱ)感染状况及其形态学特征。方法:收集83例精液检查中发现较多生精细胞男性不育患者精液,洗涤收集细胞后提取DNA,用PCR方法进行HCMV、HSV-Ⅱ筛查,阳性者精液细胞涂片用免疫细胞化学法(ICC)做相应的病毒标记,并另行细胞学染色作形态学观察。结果:83例精液样本PCR检测HCMV阳性8例,HSV-Ⅱ阳性4例,未发现2种病毒同时阳性病例。8例HCMV阳性病例ICC标记生精细胞HCMV晚期抗原均见阳性表达,HCMV早期抗原均为阴性表达;4例HSV-Ⅱ阳性病例ICC标记生精细胞3例阳性表达,1例弱阳性。12例病毒阳性病例均发现较多未成熟生精细胞,并有不同程度的核染色质固缩、出现空泡、核膜破损、核崩解、凋亡小体等凋亡现象,但未能找到病毒感染的特异性形态学改变(如病毒包涵体)。病毒感染阳性组精子密度明显低于阴性组(P<0.05)。结论:生精细胞HCMV、HSV-Ⅱ感染时可出现不同程度的病理性损害,影响生精功能,感染的生精细胞形态学表现为出现凋亡现象等病理性改变;不育男性患者精液中出现病理性生精细胞,其生精细胞HCMV感染率可能较高。     

Assessing the performance of international pre‐exposure prophylaxis (PrEP) eligibility guidelines in a cohort of Chinese MSM,Beijing, China 2009 to 2016

IntroductionPrEP is a powerful HIV prevention tool, and locally relevant eligibility criteria are necessary to optimize the prevention impact of PrEP. We assessed performance of existing national and international PrEP eligibility criteria to predict future HIV seroconversion among MSM in Beijing, China.MethodsParticipants were MSM aged ≥18 years who enrolled in a cohort study between July 2009 and March 2016. Participants completed HIV testing, syphilis testing, and a questionnaire on recent sexual health behaviours at each follow‐up visit and were followed until HIV seroconversion or dropout. We assessed PrEP eligibility at the most recent follow‐up visit prior to the final study visit. Participants were classified as indicated for PrEP (or not) based on criteria from guidelines from Europe, Korea, South Africa, Taiwan, the United Kingdom, United States and the World Health Organization. To compare guideline performance, we calculated sensitivity, specificity, Youden’s Index (YI), Matthew’s Correlation Coefficient (MCC), F1 scores and diagnostic odds ratios. For each guideline, performance measures were compared to random allocation of PrEP by randomly selecting a proportion of participants equal to the proportion indicated.ResultsThere were 287 (17∙3%) incident HIV seroconversions among 1663 MSM. The number of men indicated for PrEP from different guidelines ranged from 556 (33∙4%) to 1569 (94∙2%). Compared to random allocation, sensitivity of algorithms to predict seroconversion ranged from slightly worse (−4∙7%) to 30∙2% better than random. However, in absolute terms, none of the sensitivity values increased by more than 11% when compared to random allocation. For all guidelines, specificity was not meaningfully better than random allocation. No guidelines had high binary classification performance measures.ConclusionsThe performance of international indication guidelines in this sample was only slightly better than random allocation. Using such guidelines to screen out MSM self‐identifying as interested in PrEP could lead to misallocation of resources and to good candidates for PrEP being denied access. For settings in which international guidelines perform poorly, alternative indication approaches should be considered.