PEDIATRIC UROLOGY Incidence of Complications Following Thermocautery-assisted Circumcisions Ahmet Ali Tuncer1*, Mutlu Deger2 Purpose: This study aimed to examine the short- and long-term complications of thermocautery-assisted circum- cisions. Materials and Methods: A total of 1780 children who consecutively underwent thermocautery-assisted circum- cisions from May 2014 to May 2016 in Yuksekova State Hospital in Turkey were included in this study. These children were classified into perioperative, early postoperative, and long-term complication groups. In addition, the age groups were compared in terms of complications. Results: The patient age and surgical duration means were 4.16 ± 3.805 years old and 6.14 ± 1.703 minutes, respectively. Complications were observed in twelve patients, or 0.6% of the whole observation set. One patient exhibited bleeding and was included in the perioperative complications group. Four patients were included in the early postoperative complications group; three of them had bleeding and one had an infection. Finally, three pa- tients had trapped penises, two patients had meatitis, one patient had a delayed wound healing issue, and one had a glans-skin bridge. These seven patients fell into the long-term complications group. The patients younger than 3 years old had significantly higher complication rates when compared to the older patients, and this comparison was statistically significant (P = 0.001). Conclusion: The results showed that thermocautery-assisted circumcision is a safe and efficient surgical technique for use in children. Keywords: circumcision; child; complication; surgical technique; thermocautery INTRODUCTION Male circumcision is a well-known surgical proce-dure performed worldwide(1). Statistically, one out of every six men is circumcised globally. Circum- cisions can be performed using different approaches, including scalpels and scissors, clamps (Ali’s clamp, Mogen clamp, or Shang ring), and electrical devices (thermocautery or bipolar cautery)(1,2). A circumcision reduces the risks of several serious illnesses, like uri- nary system infections, pyelonephritis, penile and pros- tate cancers, cervical cancer in female partners, human papillomavirus, herpes simplex virus 2, human immu- nodeficiency virus (HIV), and other sexually transmit- ted diseases(3,4). Thermocautery has also been proven to be a cheap and practical circumcision method, and it has become more popular. However, there are not yet adequate academ- ic studies of the short- and long-term complications of the thermocautery-assisted circumcision technique. This paper provides several statistical results and com- parisons within a huge set of patients that underwent thermocautery-assisted circumcisions. The short- and long-term complications were examined, and the ther- mocautery-assisted circumcision technique was dis- cussed in light of the current literature. PATIENTS AND METHODS This research was carried out in accordance with the 1Afyon Kocatepe University, Medical Faculty, Department of Pediatric Surgery, Afyonkarahisar, Turkey. 2Yuksekova State Hospital, Clinic of Urology, Hakkari, Turkey. *Correspondence: Afyon Kocatepe University, Medical Faculty, Department of Pediatric Surgery, Ankara-Izmir Karayolu 8. km. 03200, Afyonkarahisar, Turkey. E-mail: drtaali@yahoo.com. Received November 2017 & Accepted January 2018 Helsinki Declaration rules, and with the approval of the local ethics committee (Clinical Ethics Committee of Afyon Kocatepe University, date 02/03/2017, issue 2017/2-52). In addition, consent forms were obtained from the legal representatives of the patients for the use of the medical images. A total of 2700 children underwent circumcisions from May 2014 to May 2016 at the Yuksekova State Hospi- tal in Turkey. Of those children, 737 were circumcised by a different surgeon. Another circumcision method was used for 20 of the children. Five patients were older than 18 years old, and 17 had systemic diseases. One hundred and fifteen patients had concurrent ingui- nal pathologies, 11 underwent recircumcisions due to complications, and 15 had megameatus intact prepu- tium variants of hypospadias. Therefore, in total, 920 of the 2700 enrolled patients were excluded from the statistical analysis. The remaining 1780 patients were classified into perioperative, early postoperative, and long-term complications groups. The perioperative complications group included bleeding during the cir- cumcision or during the hospital stay. The early post- operative complications group included complications emerging during the first ten days after discharge from the hospital. The long-term complications group includ- ed those complications occurring ten or more days after discharge from the hospital. The surgical complications related to the circumcisions were evaluated according to the modified Clavien-Dindo classification system(5). Pediatric Urology 359 Vol 15 No 06 November-December 2018 360 The following symptoms were not evaluated as com- plications: foreskin swelling, glans penis incrustation due to a phimosis opening, or a temporary color change after local anesthesia. Circumcision technique The circumcisions were performed under local anesthe- sia using bupivacaine HCl (Marcaine 0.5%; AstraZene- ca, Istanbul, Turkey) and prilocaine HCl (Citanest 2%; AstraZeneca, Istanbul, Turkey). While the guillotine technique was being applied, the cutting and bleeding control were performed using a thermocautery device (Thermo-Med TM 802-B; Thermo Medical, Adana, Turkey). While cutting, the appropriate heat level was chosen from among the six different device adjustments (degrees) according to the patient’s age and foreskin thickness. After the bleeding was controlled with the thermocautery device, the skin-mucosa connection was provided with 5/0 absorbable sutures, and the wound was dressed. Two different surgeons (the authors of this paper) performed the circumcisions as described above. The patient was observed for one hour after the circum- cision. After that, the patient and parents were advised to continue with their daily life routines. In those cases in which an excoriation due to phimosis opening, the patient or his parents were advised to apply epithelizing cream to the wound. After all the circumcised infants and children were con- trolled on the 10th postoperative day, only the patients with complications were followed for the long-term. The possible complications were explained to the pa- tients and parents, and we asked them to visit the hos- pital if any symptoms developed, such as penile bleed- ing, color change, or shape change. In those cases, the patients were assessed, followed up, and treated by the first author of this paper. Statistical analysis The observation set, which consisted of those patients circumcised using the thermocautery-assisted method, was evaluated with the Statistical Package for the So- cial Sciences software (SPSS Inc., Chicago, IL, USA). The data distribution was examined using the Kol- mogorov-Smirnov test. The continuous variables were expressed as the mean ± standard deviation (range: minimum–maximum), and the appropriate categorical variables were denoted as the numbers and percentages. The chi-squared and Mann-Whitney U tests were ap- plied to evaluate the categorical data and the quantita- tive variables, respectively. Two-tailed P values of less than 0.05 were accepted as statistically significant. RESULTS The mean age of the patients was 4.16 ± 3.805 years old (range: 14 days–18 years old). The average surgical duration was 6.14 ± 1.703 minutes (range: 4–15 min- utes). Complications were observed in twelve patients, or 0.6% of the whole dataset. The complications were evaluated according to the modified Clavien-Dindo classification method (Table 1). One patient had bleed- ing from the suture line, which was classified as a pe- rioperative complication. The bleeding was stopped immediately via cauterization. One infection and three bleeding cases were classified as early postoperative Table 1. Thermocautery circumcision complication rates. Patient age Clavien-Dindo classification Treatment Complication Perioperative Bleeding (n=1) 1y 3a Cauterization Early postoperative (< 10 days) Bleeding (n=3) 15y, 1y, 2y 3a, 3a, 3a Cauterization, dorsal vein knotting, frenular artery knotting Infection (n=1) 1 2 Medical Late postoperative (> 10 days) Secondary phimosis/trapped 3m, 6m, 8m 3b, 3b, 3b Redo surgery penis (n=3) Meatitis (n=2) Delay in wound healing (n=1) Glans-skin bridge (n=1) 40d, 2y 2 Medical 2y 1 Medical 6m 3a Surgical Abbreviations: d, day; m, month; y, year; n, number Figure 1. Long-term complications of thermocautery-assisted circumcision: a. trapped penis, b. meatitis, c. glans-skin bridge. Thermocautery circumcision complicationsTuncer et al. complications. The infection was treated with antibiot- ics and a dressing. Due to a ligated artery, a one-year- old patient had frenular artery bleeding on the first day after the circumcision. One two-year-old patient had dorsal vein bleeding that was treated via vein ligation. A fifteen-year-old patient had suture line bleeding due to a hard dressing, but the bleeding was stopped via thermocauterization. Seven patients fell into the late complications group (Figure 1). The penises of three patients were trapped, Table 2. A sample of the circumcision techniques and complication rates in the current literature (2, 13, 15-24, 30). First author Technique Number of patients Duration of surgery Complication rate and major complications Tuncer (present study) Thermocautery 1780 6.14 ± 1.703 min 0.67% -Bleeding (n=4, 0.22%) -Trapped penis (n=3, 0.16%) -Meatitis (n=2, 0.11%) -Delay in wound healing (n=1, 0.05%) -Infection (n=1, 0.05%) -Glans-skin bridge (n=1, 0.05%) Aslan (2) Thermocautery 5781 - -Bleeding (0.05%) -Scrotal abscess (0.01%) -Tachycardia and syncope after injection (0.01%) Saracoglu (15) Thermocautery 55 5.15 min -Hyperesthesia of the glans penis (n=6, 12%) Conventional technique 55 13.55 min -Hyperesthesia of the glans penis (n=5, 10%) -Secondary phimosis (n=1, 1.8%) Kazeem (13) Plastibell device 3760 -Bleeding (0.5%) Frenular manual compression -Urinary retention (0.32%) -Delay in wound healing (0.15%) Ophthalmological 3750 -Bleeding (0.05%) thermal cautery -Urinary retention (0.93%) -Delay in wound healing (0.77%) Méndez-Gallart (16) Bipolar diathermy 115 10.8 ± 1.2 min -Edema (19%) scissors Conventional scalpel 115 19.1 ± 2.6 min -Edema + bleeding (11.3%) technique Jimoh (17) Plastibell 2276 1.1% -Bleeding (n=12, 0.52%) -Retained Plastibell (n=11, 0.48%) -Wound infection (n=1) Young (18) Mogen 1239 2.7% -Bleeding (n=10, 0.80%) -Too little foreskin removed (n=9, 0.72%) -Infection (n=5, 0.40%) -Meatal abrasion (n=3, 0.24%) -Impetigo (n=3, 0.24%) -Damage to the glans (n=1, 0.08%) Senel (19) Ali's clamp 7500 4.5 ± 1.5 min 2% -Buried penis (n=78, 1.04%) -Infection (n=45, 0.6%) -Bleeding (n=30, 0.4%) Conventional 5700 23 ± 4 min 10.4% -Buried penis (n=68, 1.2%) -Infection (n=238, 4.2%) -Bleeding (n=285, 5%) Huang (20) Shang ring 2589 19.16 min 1.27% Awori (21) No-flip Shang ring 80 Circumcision 5% 7.4 ± 3.2 min -Wound disruption (n=2, 2.5%) Ring removal -Pain during removal (n=1, 1.25%) 4.4 ± 4.2 min -Wound disruption with mild infection (n=1, 1.25%) Amir (22) Gomco 1000 - 1.9% -Bleeding (n=6, 0.6%) -Preputial adhesions (n=4, 0.4%) -Superficial sepsis (n=4, 0.4%) -Inadequate (n=3, 0.3%) -Frenular ulcers (n=2, 0.2%) Buwembo (23) -Dorsal slit 2471 22.5 min 0.6% -Bleeding (n=9, 0.36%) -Infections (n=5, 0.20%) -Other (n=1, 0.04%) -Sleeve 2681 25.3 min 1.4% -Bleeding (n=20, 0.75%) -Infections (n=12, 0.45%) -Wound dehiscence and infection (n=2, 0.08%) -Other (n=2, 0.07%) Mavhu (24) PrePex device 1000 - -PrePex removal (n=10, 1%) -Pain (n=12, 1.2%) Shen (30) Langhe disposable 89 8.1 ± 2.0 min -Second operation for bleeding (n=2, 2.2%) circumcision suture device -Infection (n=4, 4.7%) -Blood loss (4.21 ± 1.31 ml) -Cases requiring manual staple removal (7/85) Daming disposable 94 7.6 ± 2.2 min -Infection (n=13, 13.8%) circumcision suture device -Blood loss (2.56 ± 1.45 ml) Abbreviation: min, minute Thermocautery circumcision complicationsTuncer et al. Pediatric Urology 361 Vol 15 No 06 November-December 2018 362 and they were surgically circumcised again. A 40-day- old patient developed meatitis three months after the circumcision, while a two-year-old patient had the same issue six months after the circumcision. Both children were medically treated. One patient exhibited delayed wound healing 20 days after the circumcision, and oint- ment was applied daily to the penis. Finally, one patient had a glans-skin bridge complication six months after the circumcision and was surgically treated. Except for one patient, complications were only ob- served in children younger than 3 years old (n < 3 = 781, n3 ≤ –18 = 999). Therefore, the patients younger than 3 years old had significantly higher complication rates when compared to the older patients (P = 0.001). A total of 1310 circumcisions were performed by the first author, and 9 (0.7%) of these patients developed complications. The second author performed 470 cir- cumcisions, and complications developed in 3 of the patients (0.6%). According to the analysis, these two surgeons had statistically similar complication rates (P = 0.912). DISCUSSION Male circumcisions are very popular worldwide, and they are considered to be simple surgical procedures. However, a circumcision can lead to serious complica- tions(1). Although there are different studies of the vari- ous circumcision methods in the literature, researchers are still debating the most convenient circumcision age and the safest circumcision method. The applied tech- nique should be practical, cheap, and safe, and it should induce very few or no complications. For this purpose, we compared the thermocautery-assisted method with the other circumcision methods in terms of the early and long-term complications. The early complications included bleeding, pain, inadequate skin removal, in- fection, chordee, iatrogenic hypospadias, glanular ne- crosis, and glanular amputation. The long-term com- plications included epidermal inclusion cysts, suture sinus, penile adhesions, phimosis, urethrocutaneous fis- tula, trapped penis, meatitis, and meatal stenosis(3, 6,7). In addition, hydronephrosis and permanent renal damage can be caused by a meatal stenosis(8). The thermocautery-assisted technique exploits the heat energy used for cauterizing. When compared with the monopolar cautery technique, which uses an electrical current, the thermocautery-assisted method carries the heat locally. According to the skin features of the pa- tient, the heat levels are adjustable on the most recent- ly developed thermocautery devices. Previous studies have shown that optimum hemostasis is achieved with a temperature ranging between 100°C and 400°C. Al- though a range between 350°C and 900°C can be ob- tained within in vivo environments, the highest heat level is reduced by half in a bloody environment(9). Thermocautery devices have been used successfully in local dermatological excisions with the implementation of cardiac devices(9). However, there have been few studies on the use of thermocauterization in circumci- sions(2,10-12). It has been shown that the thermocautery technique results in similar wound healing when com- pared to the scalpel technique(11). Aslan et al. performed mass circumcisions with ther- mocautery devices in Sudan, and they reported a com- plication rate of 0.086% in the early postsurgical peri- od (3 weeks). These complications included bleeding, scrotal abscess, tachycardia, and syncope after the local anesthesia injection(2). Kazem et al. performed 3-minute manual frenular compressions for bleeding control in 3760 newborn patients undergoing Plastibell circumci- sions. They also used an ophthalmological thermocau- tery technique on a different study set including 3750 patients. While a 0.5% complication rate was observed in the first group, the thermocautery method exhibited a 0.05% complication rate(13). Although urinary retention has been reported when using the Plastibell technique, the ophthalmological thermocautery-assisted circumci- sions took longer with regard to urinary retention and wound healing(13,14). According to our observations, the circumcision line usually heals within 7 days when using the thermo- cautery technique. We observed that the wound heal- ing was extended to 20 days in only one patient in our data set. Moreover, urinary retention was not observed in any of our thermocautery-assisted circumcisions. Saraçoglu et al. compared the thermocautery technique with conventional circumcisions in their prospective study. Hyperesthesia of the glans penis was observed in 12% of the patients with the thermocautery method and 10% of the patients with the surgical method. In the long-term follow-up, 0.9% of the patients who un- derwent the surgical circumcisions had secondary phi- mosis(15). Although the short-term complications were examined in these studies, there have not been adequate observations of the long-term complications. This pa- per provides a complete evaluation of the thermocau- tery-assisted circumcision technique with respect to the short- and long-term complications. The patients in our dataset were followed up postoperatively for one to three years. Since the cauterization is performed during the cutting process in the thermocautery technique, the bleeding risk is less when compared to the other methods. Here, the long-term complications observed when using the thermocautery technique have been reported for the first time in the English literature. All of the complica- tions, except for one patient, were observed in children under three years old, and a statistically significant dif- ference was found among the age groups in terms of the complications. In recent years in Turkey, circumcisions have been increasingly preferred for children at earlier ages, due to the belief that this leads to faster wound healing. However, our study results show that this may not be accurate. Our observations show that children older than three years have less short- and long-term complications when undergoing circumcisions. There are many different circumcision techniques cur- rently in use, and these have been summarized in the context of the current literature in Table 2 (2,13,15-24, 30). For example, the Plastibell circumcision technique can be applied safely in infants from newborns to one-year- olds(25). The operation takes between five and ten min- utes, and the Plastibell is abandoned in the penis for one or two weeks until it comes off by itself. Complications related to this method have been reported in 3% of the patients(25), and Jimoh et al. reported a complication rate of 1.1% in their Plastibell study of 2276 patients(17). The Mogen clamp is often used among the Jewish popula- tion(26), and Young et al. reported a complication rate of 2.7% in their Mogen clamp study of 1239 patients(18). Ali’s clamp is a tool widely used in Turkey. It consists of a whistle-shaped tube on the glans and a ring that Thermocautery circumcision complicationsTuncer et al. compresses the foreskin through it. The average dura- tion of this application is approximately five minutes. Senel et al. reported a complication rate of 2% in their Ali's clamp study of 7500 patients(19). They showed that Ali’s clamp is easier to apply, and the operation time was less than in the other current methods, with few- er complications(19). Another technique uses the Shang ring, which was developed in China. It is an apparatus that compresses the foreskin between two rings; howev- er, this method carries the risk of glans amputation(27). The ring is removed after 5–7 days(21). In one meta-anal- ysis including 18 randomized clinical studies, Huang et al. reported a complication rate of 1.27% in 2589 pa- tients circumcised using Shang rings(20). The Gomco method uses a metal clamp with a bell-shaped tip, and Amir et al. reported a complication rate of 1.9% in their study of 1000 patients(22). Ozen et al. reported that 13 newborns who were circumcised using the Gomco tech- nique developed meatal stenoses. Meatoplasties were used to treat these patients(7). The dorsal slit, guillotine, and sleeve methods are de- fined as open circumcision surgical techniques. For the dorsal slit method, a vertical incision is made in the for- ward direction; then, an appropriate amount of mucosa is selected with the foreskin and removed by cutting the tissue around the penis with scissors. Following he- mostasis, the remaining skin and mucosa are stitched together. In the sleeve technique, the incision on the foreskin is done circularly with a scalpel, and the mu- cosal boundaries are excised. The skin is cut in the form of a band and then removed. This process is followed by hemostasis and stitching. Buwembo et al. reported a complication rate of 0.6% in their dorsal slit study of 2471 patients, and a complication rate of 1.4% in their sleeve study of 2681 patients(23). The application of mo- nopolar diathermy runs the potential risk of coagulation due to the electrical current at the penile base(28). Previ- ous studies have revealed serious complications, such as penile ablation, necrosis, and gangrene(29). Shen et al. compared two disposable circumcision suture devices (Langhe and Daming). Complications such as bleeding, manual staple removal, and infections are frequently observed when using these devices(30). The relatively small cohort size, retrospective design, and lack of standardization among the surgical tech- niques of the operating surgeons are the limitations of this research study of the thermocautery-assisted cir- cumcision method. CONCLUSIONS The results of this study show that thermocautery-as- sisted method is a safe, practical, reliable, and efficient technique for performing male circumcisions. ACKNOWLEDGEMENTS The authors wish to thank Prof. Dr. Salih Çetinkursun and Mehmet Ali Çagrı Tuncer for the critical review of this manuscript. The authors received no financial support for the research, authorship, and/or publication of this article. 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