1406 | 1 Department of Urology, Haydarpasa Numune Training Hospital, Istanbul, Turkey. 2 Department of Pediatric Hematology and Oncology, Cerrahpaşa Medical School and Oncology Institute, Istanbul University, Istanbul, Turkey. 3 The Hemophilia Society of Turkey, Istanbul, Turkey. Corresponding Author: Orhan Koca, MD Department of Urology, Haydarpasa Numune Training and Research Hospital, Tıbbiye cad. No. 2 Üsküdar ZIP: 34718, Istanbul, Turkey. Tel: +90 216 414 4502 Fax: +90 216 345 5982 E-mail: drorhankoca@hotmail. com Received December 2012 Accepted May 2013 Purpose:‎Circumcision‎is‎a‎very‎common‎surgical‎procedure‎that‎has‎been‎performed‎for‎thou- sands‎of‎years.‎In‎this‎paper,‎we‎report‎the‎long-term‎results‎of‎circumcision‎performed‎by‎using‎ diathermic‎knife‎on‎patients‎with‎bleeding‎diathesis‎and‎the‎amount‎of‎blood‎factors‎used.‎ Materials and Methods:‎A‎total‎of‎147‎patients‎with‎bleeding‎diathesis‎circumcised‎under‎local‎ anesthesia‎by‎using‎diathermic‎knife‎between‎1996‎and‎2010‎were‎recruited‎into‎this‎study.‎Age‎ of‎the‎patients,‎type‎of‎the‎bleeding‎diathesis‎and‎the‎treatment‎protocols‎were‎recorded.‎Post- surgical‎infection‎and‎bleeding‎rates‎of‎2‎different‎factor‎replacement‎protocols‎were‎recorded. Results:‎Mean‎age‎of‎the‎patients‎was‎11.5‎years‎(range,‎1.5-37‎years).‎In‎the‎group‎of‎protocol‎ 1‎applied‎patients,‎3‎patients‎(4%)‎had‎bleeding‎and‎one‎patient‎had‎infection‎whereas‎in‎group‎ of‎protocol‎2,‎4‎patients‎(5.4%)‎had‎bleeding.‎The‎bleeding‎cases‎were‎taken‎under‎control‎after‎ the‎factor‎replacement‎and‎elastic‎bandage.‎ Conclusion:‎Whenever‎it‎is‎necessary‎for‎an‎individual‎to‎be‎circumcised‎for‎any‎reason‎what- soever,‎we‎think‎that‎circumcision‎can‎be‎performed‎in‎the‎patients‎with‎bleeding‎diathesis‎with‎ lower‎costs‎and‎complication‎rates‎by‎using‎diathermic‎knife‎and‎the‎protocol‎that‎we‎used. Keywords:‎circumcision;‎male;‎adverse‎effects;‎hemorrhage;‎prevention‎&‎control;‎electroco- agulation;‎hemophilia‎a;‎complications. Muhammet Ihsan Karaman,1 Bülent Zulfikar,2 Metin Ishak Özturk,1 Orhan Koca,1 Mehmet Akyüz,1 Fikret Bezgal3 Circumcision in Bleeding Disorders: Im- provement of Our Cost Effective Meth- od with Diathermic Knife PEDIATRIC UROLOGY Pediatric Urology 1407Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Circumcision in Bleeding Disorders | Karaman et al INTRODUCTION Circumcision‎is‎a‎very‎common‎surgical‎procedure‎that‎has‎been‎performed‎for‎thousands‎of‎years.‎It‎is‎performed‎as‎a‎religious‎obligation‎in‎certain‎so- cieties,‎as‎a‎tradition‎in‎some‎of‎them‎and‎due‎to‎medical‎ reasons in the others.(1,2) All people with bleeding diathesis including‎the‎hemophilia‎patients‎are‎under‎the‎risk‎of‎ex- cessive‎bleeding‎during‎and‎after‎the‎surgical‎interventions.‎ Although‎ the‎ circumcision‎ is‎ a‎ relatively‎ minor‎ surgical‎ intervention,‎these‎patients‎can‎also‎have‎prolonged‎bleed- ing‎even‎after‎the‎circumcision‎procedure.(3)‎However,‎al- though‎many‎parents‎know‎this‎risk,‎they‎insist‎on‎circum- cision‎due‎to‎religious‎and‎cultural‎reasons.‎The‎measures‎ taken‎ to‎ perform‎ circumcision‎ in‎ children‎ with‎ bleeding‎ diathesis‎bring‎a‎serious‎economic‎burden‎due‎to‎the‎high‎ cost‎of‎factor‎replacement.‎It‎will‎be‎more‎appropriate‎to‎ perform‎circumcision‎to‎prevent‎these‎children‎from‎feel- ing‎excluded‎from‎the‎society‎and‎with‎lower‎complication‎ rates‎and‎costs.‎In‎Turkey,‎88%‎of‎parents‎reported‎that‎it‎is‎ not‎acceptable‎to‎be‎uncircumcised,‎yet‎again‎another‎study‎ showed‎that‎the‎hemophilic‎children‎and‎their‎parents‎have‎ inferiority‎complex‎due‎to‎being‎uncircumcised.(4,5)‎ The‎ methods‎ that‎ increase‎ hemostasis‎ on‎ the‎ wound‎ site‎ reduce‎the‎risk‎of‎bleeding‎and‎diminish‎the‎factor‎require- ment‎but‎high‎treatment‎cost‎still‎remains‎as‎a‎problem.(6) We already‎showed‎that‎circumcision‎can‎be‎performed‎in‎the‎ patients‎with‎bleeding‎diathesis‎by‎using‎the‎diathermic‎knife‎ with‎relatively‎lower‎cost‎and‎complication‎ratios.(4)‎We‎have‎ aimed‎to‎reduce‎the‎cost‎further‎by‎improving‎our‎factor‎re- placement‎protocols‎for‎the‎last‎6‎years.‎The‎purpose‎of‎this‎ study‎is‎to‎compare‎the‎success,‎cost‎and‎complication‎rates‎ obtained‎after‎circumcisions‎performed‎using‎the‎diathermic‎ knife‎in‎patients‎with‎bleeding‎diathesis‎by‎administrating‎of‎ two‎different‎factor‎replacement‎protocols.‎At‎the‎same‎time,‎ we‎hereby‎report‎the‎long‎term‎results‎of‎circumcision‎per- formed‎by‎using‎the‎diathermic‎knife,‎which‎is‎an‎original‎ technique,‎with‎a‎larger‎number‎of‎patients. MATERIALS AND METHODS A‎total‎of‎147‎patients‎with‎bleeding‎diathesis‎circumcised‎ under‎ local‎ anesthesia‎ by‎ using‎ diathermic‎ knife‎ between‎ 1996‎and‎2010‎were‎enrolled‎into‎this‎study.‎Age‎of‎the‎pa- tients,‎type‎of‎the‎bleeding‎diathesis‎and‎the‎treatment‎pro- tocols‎were‎recorded.‎The‎bleeding‎and‎infection‎rates‎were‎ recorded‎after‎the‎procedure.‎If‎the‎wound‎was‎still‎bleeding‎ after‎circumcision‎and‎there‎was‎a‎need‎for‎an‎additional‎in- tervention,‎this‎was‎defined‎as‎"bleeding". Between‎1996‎and‎2004‎the‎factor‎replacement‎was‎applied‎ according‎to‎protocol‎1,‎whereas‎between‎2005‎and‎2010‎ the‎factor‎replacement‎was‎applied‎according‎to‎the‎protocol‎ 2.‎All‎the‎patients‎were‎hospitalized‎for‎minimum‎4‎hours‎ before‎ the‎ procedure‎ and‎ their‎ informed‎ consent‎ for‎ sur- gery‎was‎obtained‎and‎the‎required‎factor‎replacement‎was‎ applied.‎For‎the‎purpose‎of‎local‎anesthesia,‎2-4‎mL‎2%‎li- docaine‎hydrochloride‎was‎injected‎around‎the‎base‎of‎the‎ penis‎ to‎ obtain‎ a‎ ring‎ blockage.‎ Following‎ the‎ necessary‎ cleaning‎and‎coverage,‎the‎stretched‎foreskin‎was‎aligned‎to‎ the‎coronal‎sulcus‎and‎clamped‎using‎a‎personally‎modified‎ clamp‎(Figure‎1),‎and‎then‎the‎foreskin‎on‎the‎distal‎side‎of‎ the‎clamp‎was‎excised‎using‎the‎diathermic‎knife‎developed‎ in‎our‎country‎for‎bloodless‎circumcision‎(Figure‎2).‎The‎ skin‎and‎mucosa‎were‎sutured‎with‎5-0‎absorbable‎sutures.‎ The‎antibiotic‎cream‎was‎locally‎administered,‎dressing‎or‎ systematic‎antibiotic‎was‎not‎administered.‎The‎15‎mg/kg/ dose‎of‎paracetamol‎was‎administered‎orally‎for‎analgesic‎ purposes when necessary. Statistical‎analysis‎was‎performed‎by‎the‎t‎test‎using‎the‎sta- tistical‎package‎for‎the‎social‎science‎(SPSS‎Inc,‎Chicago,‎ Illinois,‎USA)‎version‎13.0.‎A‎P‎value‎<‎.05‎was‎considered‎ statistically‎significant. RESULTS In‎protocol‎1‎group‎the‎mean‎age‎of‎the‎75‎patients‎was‎11‎ years‎(range,‎1.5-25‎years),‎while‎in‎protocol‎2‎group‎the‎ mean‎age‎of‎72‎patients‎was‎12‎years‎(range,‎4.5-37‎years)‎ (Table‎1).‎For‎the‎patients‎in‎whom‎the‎factor‎replacement‎ was‎administered‎according‎to‎the‎protocol‎1,‎hospitaliza- tion‎time‎was‎2-3‎days‎and‎the‎duration‎of‎factor‎administra- tion‎was‎9-18‎days‎while‎for‎patients‎in‎group‎of‎protocol‎2‎ hospitalization‎time‎was‎1-2‎days‎and‎the‎duration‎of‎factor‎ administration‎was‎9-13‎days‎(Table‎2).‎Twenty-four‎patients‎ requiring‎surgical‎intervention‎for‎another‎reason‎were‎cir- cumcised‎using‎diathermic‎knife‎under‎general‎anesthesia.‎ Bleeding‎was‎observed‎in‎3‎(4%)‎of‎the‎patients‎for‎whom‎ the‎protocol‎1‎was‎administered,‎infection‎was‎observed‎in‎ one‎patient‎and‎bleeding‎was‎observed‎in‎4‎(5.4%)‎of‎the‎ patients‎ for‎ whom‎ the‎ protocol‎ 2‎ was‎ administered.‎ The‎ bleeding‎cases‎were‎taken‎under‎control‎after‎the‎factor‎re- 1408 | placement‎and‎applying‎elastic‎bandage.‎A‎mild‎edema‎was‎ detected‎on‎the‎line‎of‎the‎circumcision‎in‎all‎patients‎but‎it‎ spontaneously‎recovered‎within‎3-4‎days.‎Serious‎scar‎tis- sues‎were‎not‎found‎in‎the‎biopsies‎taken‎from‎the‎cases‎fol- lowing‎the‎circumcision‎performed‎with‎the‎diathermic‎knife‎ and‎it‎was‎previously‎demonstrated‎that‎it‎did‎not‎have‎any‎ negative‎impact‎on‎the‎vessels‎and‎nerves.(4)‎The‎cost‎of‎both‎ protocol‎are‎given‎in‎Table‎3.‎Statically‎there‎is‎a‎significant‎ difference‎between‎protocol‎1‎and‎protocol‎2,‎in‎which‎pro- tocol 1 has higher cost (P‎<‎.001). DISCUSSION The‎modern‎hemophilia‎treatment‎aims‎to‎achieve‎a‎full‎so- cial‎and‎cultural‎integration‎of‎the‎hemophilic‎child‎with‎the‎ society.(7)‎For‎this‎reason,‎if‎the‎hemophilic‎patients‎live‎in‎a‎ society‎in‎which‎the‎circumcision‎has‎a‎socio-cultural‎impor- tance‎and‎most‎importantly‎if‎the‎patient‎wants‎to‎be‎circum- Table 2. Factor replacement protocol 1 (between 1996-2004) and protocol 2 (between 2005-2010). Variables Severe Moderate Mild Day 1, Preoperative 25 20 20 Postoperative 25 20 20 Days 2-3 40 25 15 Days 4-7 30 20 10*** Days 8-10 20 10* 10 (day 9 only) Days 12 and 14 15 10 ----- Days 16 and 18 10 ----- Total 360 U/kg 220 U/kg 120 U/kg Factor Replacement Protocol 2 (U/kg)*,** Variables Severe Moderate/Mild Day 1, Preoperative 25 15 Postoperative 15 10 Days 2-7 15 10*** Days 9, 11 and 13 15 10 (day 9 only) Total 175 U/kg 95 U/kg * Double doses for Hemophilia B, vasopressin not used. ** Tranexamic acid 25 mg/kg/day for 7 days + 10 mg/kg during surgery. *** Plus vasopressin 0.3 µg/kg/day for 3 days. Figure 1. The personally modified clamp for the diathermic knife and diathermic knife device. Figure 2. Clamped foreskin and excision with the diathermic knife and after the circumcision (small picture). Table 1. Characteristics of study patients. Variables Years 1996-2004 (Period 1) Years 2005-2010 (Period 2) Protocol method 1 2 Total patients, no. 75 72 Hemophilia-A 65 57 Hemophilia-B 6 6 von Willebrand disease 1 8 Glanzmann's thrombasthenia 1 ----- Factor VII deficiency 1 ----- Factor XIII deficiency 1 ------ Factor V deficiency ----- 1 Age, years-median (range) 11 (1.5-25) 12 (4.5-37) Body weight, kg-median (range) 30 (9-74) 34 (18-102) Pediatric Urology 1409Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L cised,‎we‎believe‎that‎it‎should‎be‎performed‎by‎creating‎the‎ appropriate conditions. As‎the‎measures‎are‎taken‎for‎the‎patient‎with‎bleeding‎diath- esis,‎it‎is‎a‎priority‎to‎choose‎the‎surgical‎method‎that‎cause‎ less‎bleeding‎as‎much‎as‎possible.(4)‎These‎methods‎include‎ bipolar scissors and laser.(8,9)‎ However,‎ information‎ about‎ the‎use‎of‎these‎methods‎on‎the‎patients‎with‎bleeding‎di- athesis‎is‎limited.‎We‎think‎that‎the‎diathermic‎knife‎device‎ that‎we‎use‎as‎an‎alternative‎to‎the‎above‎mentioned‎methods‎ causes‎significantly‎less‎bleeding.‎In‎the‎first‎series‎that‎we‎ published‎before,‎we‎showed‎that‎circumcision‎can‎be‎per- formed‎on‎the‎patients‎with‎bleeding‎diathesis‎with‎minimal‎ complication‎rates‎by‎using‎diathermic‎knife.(4)‎The‎findings‎ of‎our‎study‎shows‎that‎the‎diathermic‎knife‎is‎reliable‎in‎ long‎term‎and‎can‎be‎used‎with‎the‎updated‎factor‎replace- ment‎protocol‎with‎a‎lower‎cost‎and‎approximately‎the‎same‎ complication‎rates. The‎other‎measures‎that‎can‎be‎taken‎for‎the‎patients‎with‎ bleeding‎diathesis‎include‎the‎factor‎replacement,‎1-deami- no-8-D-arginine‎vasopressin‎(DDAVP)‎infusion,‎fibrinolysis‎ inhibitors,‎local‎fibrin‎glue‎application,‎and‎the‎use‎of‎ankaf- erd blood stopper.(7,10)‎Some‎authors‎claimed‎that‎the‎local‎ fibrin‎glue‎application‎is‎a‎reliable‎and‎inexpensive‎solution‎ for‎the‎hemophilic‎patients.(5,11)‎Avanoğlu‎and‎colleagues‎re- ported‎that‎they‎reduce‎the‎cost‎of‎circumcision‎by‎using‎the‎ fibrin‎glue‎on‎the‎hemophilic‎patients.(6)‎However,‎the‎cost‎ they‎reported‎is‎much‎higher‎than‎the‎cost‎we‎found‎in‎our‎ study‎for‎both‎protocols.‎Even‎though‎we‎did‎not‎use‎any‎ agents‎to‎prevent‎local‎bleeding‎following‎the‎circumcision,‎ the‎bleeding‎rates‎are‎tremendously‎low.‎This‎indicates‎the‎ reliability‎of‎our‎method.‎The‎use‎of‎the‎classic‎electrocau- tery‎on‎penis‎is‎avoided‎as‎an‎undesired‎damage‎may‎occur‎ on‎the‎penis‎as‎a‎result‎of‎uncontrolled‎transmission‎of‎elec- tric current.(12)‎However,‎our‎device‎is‎not‎an‎electrocautery‎ and the electric current is not conducted to the tissue. As a matter‎of‎fact,‎only‎a‎limited‎damage‎on‎the‎tissue‎was‎dem- onstrated in the histopathology test.(4)‎ The‎positive‎results‎of‎the‎patients,‎who‎got‎circumcised‎by‎ protocol‎1,‎encouraged‎us‎to‎reduce‎factor‎levels.‎Protocol‎2‎ was‎created‎after‎consultation‎with‎hematology.‎Whenever‎ it‎is‎necessary‎for‎an‎individual‎to‎be‎circumcised‎for‎any‎ reason‎whatsoever,‎we‎think‎that‎circumcision‎can‎be‎per- formed‎in‎the‎patients‎who‎have‎bleeding‎diathesis‎with‎low‎ costs‎and‎complication‎rates‎by‎using‎diathermic‎knife‎and‎ protocol‎2‎that‎we‎applied.‎Still‎there‎is‎no‎need‎to‎rush‎for‎ performing‎circumcision‎and‎when‎there‎is‎an‎obligation‎for‎ another‎surgical‎procedure‎performing‎circumcision‎at‎ the‎ same‎session‎with‎this‎surgery‎seems‎to‎be‎a‎more‎economic‎ and‎less‎morbid‎way.‎Also,‎to‎avoid‎the‎development‎of‎in- hibitors‎due‎to‎factor‎usage‎which‎can‎be‎a‎problem‎for‎such‎ a‎surgical‎intervention,‎it‎is‎appropriate‎to‎delay‎circumcision‎ after‎12‎months‎of‎life.(13) The‎limitations‎of‎our‎study‎are‎wide‎range‎of‎patient's‎ages‎ and‎not‎all‎procedures‎were‎made‎by‎the‎same‎surgeon.‎Also‎ the‎cost‎factor‎differs‎from‎one‎country‎to‎another. CONCLUSION In‎our‎study‎we‎found‎that‎the‎cost‎of‎protocol‎1‎is‎higher‎ than‎protocol‎2.‎This‎situation‎shows‎us,‎the‎cost‎of‎the‎cir- cumcisions‎performed‎with‎the‎"diathermic‎knife"‎in‎the‎pa- tients with bleeding diathesis is lower. CONFLICTS OF INTEREST None declared. Table 3. Total cost (US$) of the circumcision in hemophilia.* Protocol 1 Protocol 2 Variables Severe Moderate Mild Severe Moderate Mild Concentrate 216/kg 120/kg 72/kg 105/kg 57/kg 57/kg Other medications 10 10 + 0.3/kg 10 + 0.3/kg 10 10 + 0.3/kg 10 + 0.3/kg Hospitalization 170 140 140 170 140 140 Total 225/kg 127.8/kg 79.8/kg 114/kg 64.3/kg 64.3/kg * Total cost includes factor replacement + other medications + hospitalization. Circumcision in Bleeding Disorders | Karaman et al 1410 | REFERENCES 1. Massry SG. History of circumcision: a religious obligation or a medi- cal necessity. J Nephrol. 2011;24 (Suppl 17):100-2. 2. Shittu OB, Shokunbi WA. Circumcision in haemophiliacs: the Nige- rian experience. 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