To the Editors: We thank Dr Lee et al for their interest in our study and insightful comments. We agree that our study was subject to ascertainment bias from higher retention rates in the Shang Ring versus surgical group (0% vs. 25% loss-to-follow-up—likely because Shang Ring participants had to return for device removal). We allocated favorable outcomes to the participants lost-to-follow-up in the surgical AMC group to conservatively bias estimates for safety and efficacy of the novel Shang Ring device toward the null. Had we assumed that all 16 participants in the surgical group who were lost experienced a minor complication, the relative risk of minor complications would have remained nonsignificantly greater in the Shang Ring group (RR 1.33, 95% CI: 0.96 to 1.88). Lee et al also took note of high rates of complications and short healing times in our study compared to prior studies. The differences in these rates are at least partially explained by differences in study definitions. For example, we included any day 14 need for clinical observation (eg, suture discomfort or unhealed wound) as a minor complication, whereas no such definition was made in the study they cite.1 Moreover, we defined healing as circumferential approximation of the skin, whereas others defined healing as complete re-epitheliaziation.2,3 As the authors stated, we did have a significant difference between groups in healing at day 14 by χ2 testing, but not for overall time to healing by log rank testing (Fig. 1).FIGURE 1: Days to healing by circumcision method in a randomized controlled trial of adult male circumcision techniques in Mbarara, Uganda. The P-value represents results of log-ranked testing, comparing time to healing between the Shang Ring and Forceps study groups.Finally, we recognize that many prior studies of the Shang Ring device were performed with well-resourced randomized controlled trial infrastructures. In contrast, our study was conducted by a single locally trained surgeon without external funding. Scale-up of circumcision techniques across a range of public health settings will confront supply chain issues and variations in procedural expertise. We agree with Dr Lee et al that, while both our study and prior ones have documented high patient satisfaction, relatively short procedure times, and few major complications with Shang Ring-guided AMC,1–4 our findings reinforce the need to invest in both human and logistical resources to minimize complication rates.