Circumcision is one of the most commonly performed surgical procedures worldwide. It is known that more than one million children are circumcised annually in the USA alone 1. Moreover, the WHO has begun to recommend circumcision on the basis of studies indicating its positive effects on human health and especially its role in protection from AIDS 2–4. Because of this, thousands of people have been circumcised by many migratory circumcision teams, especially in Africa.
Considering that 1 200 000 children are born annually in Turkey and 51% of them are male, on the basis of data from the Turkish Institute of Statistics, it may be speculated that about 60 000 circumcisions are performed annually in Turkey 5.
However, the circumcision procedure cannot be performed in health institutions as a routine procedure because of health regulations. When the Social Security Institute incorporated circumcision into the social insurance coverage in 2007, it led to circumcision being performed in the health institutions. Health institutions that were already burdened cannot meet the demands for circumcision. Thus, the search has begun for faster and reliable circumcision techniques with fewer complications. The present study aimed to compare bipolar thermal cautery-assisted circumcision technique, considered to be capable of meeting such demands, with the classical circumcision technique.
Patients and methods
The present study was carried out in accordance with the Helsinki Declaration between April and September 2012 after receiving approval from the Ethics Committee (Scientific and Ethics Committee of Sifa University, Decision No: 07/03/2012-6). The study was planned on a group of 110 individuals. The participants were randomized into two groups, with 55 individuals in each group.
Patients with urogenital abnormalities detected on physical examination and those with bleeding diathesis were excluded from the study.
All circumcisions were performed by urologists. Following the procedure, a technician examined and recorded whether frenulotomy was performed, how many vessels were coagulated, how many sutures were made, whether bandage was made after the procedure, and the duration of the surgical procedure by means of a chronometer. Duration of the surgical procedure was considered the time between completion of anesthesia and making the last suture. Local anesthesia was administered using a ring injection to the penis root with a 1% lidocain solution without epinephrine at a dose of 3 mg/kg. For the classical circumcision technique, smegma was cleaned by separating the prepuce from the glans penis after administering antisepsis. The frenulum was inspected and the frenulotomy was performed with bipolar cautery in patients with a short frenulum. Then, the prepuce was held from 6 and 12 o’clock positions with two clamps. A circumcision clamp was placed by protecting the glans penis and compatible with the angle of the coronal sulcus. The prepuce was cut with a scalpel from distal of the circumcision clamp. Bleedings observed after removing the circumcision clamp were coagulated using bipolar cautery. Then, wound lips were approached and sutured. Bandage was made with a foamed patch for patients considered to be at risk of developing complications such as bleeding and infection following the procedure.
The circumcisions performed with bipolar thermal cautery were carried out similar to those with the classical method. Unlike the classical method, the circumcision skin was cut and bleedings observed were coagulated with bipolar thermal cautery. For the bipolar thermal cautery-assisted circumcisions, the Thermo-Med TM 802B device (Thermo Medikal, Adana, Turkey) was used.
On follow-up examinations during the first and fourth weeks after the procedure, the patients were examined for possible complications. Control examination of the patients was performed by a second urologist who was unaware of the method by which the patient had been operated. On the follow-up at week 1, early complications appeared such as bleeding, wound infection, pain, hyperesthesia, necrosis, and laceration of the glans, and ischemia. On the follow-up at week 4, an examination was performed to determine whether late complications occurred. The late complications included failed circumcision (abundance of prepuce), overcutting of the penis skin, laceration on the penis and skin of the scrotum, folding and skin bridges, secondary phimosis, urethral fistula, meatus ulceration and infection, iatrogenic hypospadias, and suture problems.
For statistical assessments, descriptive values of the obtained data were shown in tables and expressed as number or percentage frequencies, average±SD (SS), or median value (minimum–maximum) depending on the type of data. Relationships between the groups in bandage, frenulotomy, and complication frequencies were examined by Pearson’s correlation analysis and Fisher’s exact χ2-analysis (whichever was appropriate) considering the frequency distributions and exact P-values assigned to these tests. In addition, among the numerical variables, only those related to the number of vessels coagulated were determined in terms of whether they showed a normal distribution, and it was found that the in-group variance was high. For this, the Mann–Whitney U-test was used for comparison of two groups. Among the numerical variables, the suture numbers and duration of the surgical procedure showed a normal distribution; thus, these variables were compared using Student’s t-test. P-values less than 0.05 were considered to be statistically significant. For statistical assessments, PASW (SPSS, version 18, SPSS Inc., Chicago, Illinois, USA) was used.
The present study included 110 participants, mean age (range: 1–156 months) 62.46±78.00 months. The mean age of the participants was 62,93±43.57 months for those in the classical circumcision group and 62.00±43.64 for those in the bipolar thermal cautery-assisted circumcision group. No significant difference existed between the groups in age (P=0.91). Seven (6.4%) patients were circumcised under general anesthesia and 103 patients (93.6%) were circumcised under local anesthesia. Of the seven patients circumcised under general anesthesia, five (9%) were in the classical circumcision group and two (3.6%) were in the bipolar thermal cautery-assisted circumcision group. There was no significant difference between groups in the type of anesthesia (P=0.438).
Table 1 shows comparisons of both groups in terms of the rates of frenulotomy, number of the vessels coagulated, suture numbers, duration of the surgical procedure, and bandage rates.
On the basis of statistical assessments, there was no significant difference between the groups in terms of frenulotomy rates. There was a statistically significant difference between the two groups in the number of the vessels coagulated, duration of procedure, number of sutures, and bandage rates.
Complication rates were compared by excluding six (10.9%) patients in the bipolar thermal cautery-assisted circumcision group and five (9%) patients in the classical circumcision group because they did not present for control examinations. On the control examinations at week 1, only hyperesthesia of the glans penis was found to be a complication. Hyperesthesia of the glans penis was found in six (12%) patients in the bipolar thermal cautery-assisted circumcision group and in five (10%) patients in the classical circumcision group, without a significant difference between the groups. As a late complication, only secondary phimosis was found in one patient in the classical circumcision group. There was no significant difference between the groups in the occurrence of late complications.
Although there is no consensus among anthropologists on how long circumcisions have been performed, some suggest that they have been performed for about 15 000 years. However, there is strong evidence that circumcision used to be performed in ancient Egypt 6000 years ago. Furthermore, it is well known that orders existed in the old testament 4000 years ago. With the religion of Islam spreading worldwide, circumcision has become a frequently performed procedure.
Although circumcision is a surgical procedure that has been performed for thousands of years, references to how it may have been performed are scarce. On review the history of medicine, it is clear that information on this topic is scarce in non-Islamic sources. On review of Islamic medical history, it is clear that many physicians have mentioned circumcision in their textbooks.
Halef ibn-Abbas ez-Zehravi is one of the most important physicians in the Umayyad State. The most important work of this well-known physician, who lived between 936 and 1013, is ‘Kitabu’t-tasrif limen’acezeanit-te’lif’. Consisting of 30 parts, this book sheds light on both western and oriental medicine. Especially because of the 30th part on surgery, ez-Zehravi has been considered the father of surgical science. Some of the ∼200 surgical tools he described and illustrated in his book are still on exhibit in Cordoba Museum.
Ez-Zehravi described methods of circumcision in children in Chapter 4 of Part 30. In this chapter, he provides detailed information on the circumcision technique after explaining how to approach the child to be circumcised 6.
Serafettin Sabuncuoglu is a well-known Ottoman physician who lived between 1385 and 1470. One of the books he wrote ‘Cerrahiyyetül Haniye’ resembles current surgical atlases because of the miniatures in it. There are some experts on the history of medicine who claim that this book, which was an important surgical textbook in its era, was written with some additions to Part 30 of Zehravi’s book.
Part 57 of Sabuncuoglu’s book focused on the topic of circumcision of boys. This part explains the importance of circumcision in the Islamic world, the psychological approach to be adopted when dealing with the child to be circumcised, circumcision techniques, and the complications of circumcision 7.
Both scientists described very similar circumcision techniques that are very also very similar to the current techniques. According to these techniques, the circumcision skin is cut with a scissor after it is fixed with a clamp. Wound lips are approached and bandage is made after the bleeding is controlled.
Currently, the most commonly used circumcision techniques are sleeve resection, dorsal or ventral slit, and forceps-assisted circumcision 7,8.
In the sleeve resection technique, the prepuce is removed by a circular incision made separately on its inner and outer layers. The wound lips are approached and sutured following hemostasis. Another technique has been described in which bandage is placed between the prepuce and the glans penis to prevent injury to the glans penis 9. It has been reported that the use of this technique combined with bipolar cautery facilitates the surgical procedure 10,11.
In the slit technique, the prepuce is longitudinally incised from the ventral or the dorsal side of the penis. After the glans penis is uncovered, the inner and outer layers of the prepuce are removed with a circular incision. The wound lips are approached and sutured following hemostasis.
In the forceps-assisted technique, also called the guillotine technique, the prepuce is drawn to distal of the glans penis and held with a forceps and cut with a scalpel. The wound lips are approached and sutured following hemostasis. We preferred this technique in our study, using bipolar thermal cautery for hemostasis and incision in some patients.
Besides these classical techniques, instrumental circumcision techniques have also been defined. These include Gomco, Mogen, Plastibell, Tara, Shang Ring, and Smart clamps 7,12–15.
The search for circumcision techniques is still going and one of the remarkable techniques among these is one in which tissue glue is used instead of suture to approach the wound lips 16.
The search for circumcision techniques is still ongoing with the aim of decreasing the complications circumcision and for a better cosmetic result, although circumcision is a surgical procedure that has been performed for thousands of years.
Circumcision may lead to serious complications, although very rarely, because it is a minor surgical procedure. Major complications include death, gangrene of the penis, glans amputation, penis amputation, necrotizing fasciitis, sepsis, excessive blood loss, and urethral injuries 17–21. Serious bleeding may be encountered especially in patients with bleeding diathesis. A study reported that circumcision may be performed safely using fibrin glue in patients with hemophilia 22.
Although minor complications of circumcision are more common, they can usually be treated easily. The frequent minor complications of circumcision include mild bleeding, wound infection, hyperesthesia of the glans, laceration on the dorsum of the penis and scrotum, folding and formation of skin bridges on the incision area, secondary phimosis, and failed circumcision.
The most common complication following circumcision is bleeding. Although it can be treated easily in many patients, it may sometimes require a second operation. Essentially, the search for new techniques of circumcision continues with the aim of minimizing the complications of bleeding. The fact that no bleeding occurred at all, even during the procedure, in 75% of the patients in the bipolar thermal cautery-assisted circumcision group suggests that this technique is promising.
The fact that no or minimal bleeding occurs during the bipolar thermal cautery-assisted circumcisions makes the procedure faster and safer.
The bipolar thermal cautery technique is an easy to perform and safe circumcision technique that may be carried out in a shorter time and in which much less bleeding occurs compared with other techniques.
Conflicts of interest
There are no conflicts of interest.
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