Circumcision with Thermocautery after Local Anesthesia in Males: A Retrospective Single-center Study with 1821 Patients Mehmet Uysal1*, Ahmet Şanlı2 Purpose: This study aimed to examine the short and long-term complications of thermocautery-assisted circumci- sions with local anesthesia done in a sterile environment in operating room conditions, accompanied by literature. Materials and Methods: The participants who consecutively underwent thermocautery-assisted circumcision with local anesthesia from June 2018 to May 2019 were included in the study. They were one month-17 years old, same ethnic origin, in same location. The age groups were compared in terms of complications. Results: The participant age and surgical duration means were 4.89 ± 2.08 (30 days-17 years) years old and 7.484 ± 1.524 (5-20 minutes) minutes, respectively. Complications were observed in fifty-three participants or 2.9% of the whole observation set. The participants under intervals of one six months and over 6 years of age had signif- icantly lower complication rates when compared to the other participants, and this comparison was statistically significant (P = 0.001). Conclusion: The study results demonstrated that circumcision with thermocautery after local anesthesia is a vi- able, reliable, and effective method. It can be assumed that circumcisions in males especially may be effective in 1-6 months, and over 6 years of age. Parents choose this method because it is more appropriate and eliminates the risk of general anesthesia. Keywords: circumcision; children; local anesthesia; complication; thermocautery INTRODUCTION Circumcision is the surgical removal of the skin covering the tip of the penis (prepuce)(1). It is com- monly conducted in neonates, infants, and males for religious, cultural, and medical reasons. An estimated one in three males worldwide is circumcised, with near- ly universal coverage in some surroundings. In 2011, an estimate by an independent researcher found global male circumcision prevalence to be 37–40 %.(2,3). The increased risk for urinary tract infection (UTI) in uncir- cumcised boys is highest with an incidence rate of 1% for boys less than 2 years of age. They found the single risk factor of lack of circumcision to confer a 23.3% lifetime chance of UTI.(4). Apart from medical reasons, circumcision is performed to protect against sexually transmitted diseases, and mostly for traditional and re- ligious reasons(5,6). Complications related to the factors such as anatomical anomalies, clinical comorbidity, surgical methods used, and age of patients are seen in 1-4% of all circumcision procedures(7,8). Circumcision methods are classified into 3 main groups according to Kaplan and Baskin: open surgery (Sleeve method, Dorsal Slit, and excision, Guillotine method), Sheldon method (such as Mogen clamp, circumcision shield), and special circumcision clamps(9,10). Thermocautery has also been proven to be a cheap and practical circumcision method, and it has become more popular. This study aims to examine the types and frequency of complications of circumcision by using 1Karaman Training and Research Hospital, Pediatric Surgery, Karaman, Turkey. 2Karaman Training and Research Hospital, Urology, Karaman, Turkey. *Correspondence: Department of Pediatric Surgery, Karaman Training and Research Hospital, 70200,Karaman, TURKEY. Tel: 90338 2263266 E-mail:drmyzuysal3@gmail.com. Received March 2021 & Accepted October 2021 thermocautery with local anesthesia and conveying our experiences. MATERIALS AND METHODS Study population This study was conducted by ethics committee approv- al obtained from Karamanoğlu Mehmetbey University Faculty of Medicine (issue 01/date 27.01.2021). It was started with 2245 participants registered for cir- cumcision in our hospital's database, but 1821 partic- ipants coming for control on the 10th day, 1st month, and 1st year after circumcision were included. The data of patients circumcised by a pediatric sur- gery specialist doctor between June 2018 and May 2019 were retrospectively retrieved and included in the study at the Karaman Training and Educational Hospi- tal Pediatric Surgery Clinic in Turkey. All participants were living in Karaman, Turkey and all of them were of the same ethnic origin. Candidates aged one month-17 years who underwent circumcision with local anesthe- sia were included in this cross-sectional retrospective study. Participants who had comorbid diseases, such as undescended testis were excluded. In addition, consent forms were obtained from the legal representatives of the patients for the use of the medical images. The pa- tients were recorded by local voluntary agencies before the date of circumcision. All patients were examined before surgical intervention. All operations were car- ried out by one pediatric surgery specialist. As a local PEDIATRIC UROLOGY Urology Journal/Vol 19 No. 3/ May-June 2022/ pp. 221-227. [DOI:10.22037/uj.v19i.6748] anesthetic, 20 mg /ml lidocaine HCl and 0.025 mg/ml adrenaline and bupivacaine 5 mg /ml were used togeth- er. The penile block was imposed on the radix and cir- cumference of the penis; 2–5 ml of local anesthetic was used according to the patients’ age, and weight. Regu- larly, the penis was cleaned with batticon and covered with a sterile surgical cover. Approximately 10 minutes after the injection of local anesthesia, the prepuce was retracted to prevent glans injury. The prepuce was held using two clamps placed obliquely at an angle close to 15-20°, with its ventral part facing upwards. Thus, the meatus and frenulum were protected from injury. The guillotine technique was used in all circumcisions per- formed with thermocautery included in our study. In this method, after the prepuce is suspended with clamps, the surgeon pulls the glans down with the thumb and in- dex finger of one hand and places the flat clamp on the prepuce in the other hand so that it is above the glans. The prepuce is cut with a scalpel over the clamp. Then, the mucosa is held with clamps and the excess is ex- cised. The skin and mucous membranes of participants were sutured all around with separate sutures (Figure 2-3). In this method, it should be ensured that the glans remain under the clamp. Otherwise, there may be seri- ous glans injuries(1). The skin of participants was held and stabilized on the anterior and posterior sides by the clamp and preputial tissue was cut just above the clamp (Figure 2) using a thermocautery device (Thermo-Med QX 2100; Thermo Medical, Adana, Turkey (Figure 4). The settings of the thermocautery device were estab- lished according to the participant’s age: 500°C was used for patients under 2 years of age; 550-650°C was used for patients of 2-10 years of age,, and 700–750°C was used for patients older than 10 years of age. After bleeding was controlled, mucosal coherence in patients under 2 years of age was provided with two 5/0 absorb- able sutures at 3,6,9 and 12 o’clock positions. A 4/0 absorbable suture was used in participants aged 2-10 years of age, with four sutures at 3, 6, 9, and 12 o’clock positions. Finally, in patients older than 10 years of age, 3/0 ab- sorbable suture was used with six sutures positioned at 2, 4, 6, 8,10, and 12 o’clock. The wound was then dressed with a nitrofurazone-containing bandage. Par- ticipants were observed for 2 hours postoperatively and analgesics were prescribed before discharge. The first follow-up was performed by the operating team, and 10 days after the operation, the wound dressing was re- moved in the Pediatric Surgery Outpatient Clinic, and a return to daily life was recommended. Afterward, the participants and their parents were ad- vised to continue their daily life routines. Possible Complication Clavien-Dindo classification Perioperative Bleeding (n:2 ) 3a Early postoperative (< 10 days) Bleeding (n:12 ) 3a Infection (n:8 ) 2 Convulsion (n:7) 2 Inability to urinate (n:1) 2 Late postoperative (> 10 days) Trapped penis (n:2) 3a Meatal stenosis (n:5) 2 Epidermal granuloma and inclusion cyst (n:4) 3a Adhesion of mucosa or skin to glans (n:6) 3a Glans skin bridge (n:1) 3a Sekonder phimosis (n:4) 2 Urethral fistula (n:1) 3b Table 1. Thermocautery circumcision complication rates Circumcision with thermocautery-Uysal et.al. Figure 1. Complication rates in circumcised children by age group. Pediatric Urology 222 complications were explained to participants and par- ents, and we asked them to visit the hospital if they de- veloped any symptoms, such as penile bleeding, discol- oration, or shape changes. In these cases, participants were evaluated, followed, and treated by the first author of this article. There were not given oral antibiotics to use prophylac- tically or at home. We recommended ibuprofen to chil- dren as an analgesic after 1-year-old, and paracetamol before 1 year of age. The perioperative complications group included bleeding during the cir¬cumcision or the hospital stay. The early post¬operative complica- tions group included complications emerging during the first ten days after discharge from the hospital. The long-term complications group included those compli- cations occurring ten or more days after discharge from the hospital. Statistical analysis The observation set, which consisted of those patients circumcised using the thermocautery-assisted meth- od, 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 number of participants included in the study ac- cording to age groups was as follows; 30 days-6 months 630 (34.6%), 6-12 months 358 (19.7%), 1-3 years 152 (8.3%),3-6 years 54 (3%), 6-17 years 627 (34.4%). The mean age of the participants was 4.89 ± 2.08 years old (range: 50 days–17 years old). The average surgical du- ration was 7.48 ± 1.52 minutes (range: 5-20 min¬utes). The complication rates for the age groups of partici- pants included in the study were as follows; 30 days- 6 months 2 (0.3%), 6-12 months 17 (4.7%), 1-3 years 22 (14.4%), 3-6 years 10 (18.5%), 6-17 years 2 (0.3%) (Figure 1). Complications were observed in fifty-three participants or 2.9% of the whole dataset. The compli- cations of participants were evaluated according to the modified Clavien-Dindo classification method (Table 1). Two (0.11%) of the participants had bleed¬ing from the suture line, which was classified as a pe-rioperative complication. The bleedings of them were stopped im- mediately via cauterization. Twenty-eight (1,54%) of the participants who underwent circumcision had post- operative early complications. Eight (0.44%) infections and twelve (0.66%) bleeding cases were classified as early postoperative early complications. The infection was treated with antibiotics and dressing. Due to a ligated artery, a four-year-old participant had frenular artery bleeding on the first day after the cir- cumcision and it was controlled after taking to the oper- ating room. Five of all participants who developed cir- cumcision bleeding were controlled by stitching under local anesthesia. The ages of them were 11,22 months, 3, 4, and 5.5 years old, respectively. Six of all partici- pants had dorsal vein bleeding that was treated via vein ligation. The ages of them were 10,16,18,22 months, and 3, and 4 years old, respectively. Seven (0.38%) of all patients evolved convulsions due to local anesthesia. The ages of them were 8, 9, 10, 10 months, and three of them were one year old, respec- tively. Four of these convulsions were as nystagmus form and 3 were as the tonic-clonic form. The reason Figure 2. Surgical step of thermocautery circumcision. Figure 3. 1st-month control after circumcision Circumcision with thermocautery-Uysal et.al. Vol 19 No 3 May-June 2022 223 for the high number of convulsions under 1 year of age may be an allergy to bupivacaine. All convulsions were followed by rectal diazepam (0.5 mg/kg) for 24 hours. In one case (0.05 %) a 2.5-year-old participant could not urinate for the first 8 hours after local anesthesia, but this participant urinated spontaneously without a urinary catheter. Twenty-three (1,26%) of the participants who under- went circumcision had late complications. The penises of two participants were trapped and they were sur- gically circumcised again. A total of five participants whose ages were 7,10,12,17,21 months during the cir- cumcision required urethral dilatations after one month because of meatal stenosis. A one-year-old participant developed meatitis ten days after the circumcision, while a two-year-old participant had the same issue one month after the circumcision. Both children were med- ically treated. Epidermal granüloma and inclusion cysts in the dorsal or ventral part of the penis were removed from the su- ture line with local anesthesia in 4 (0.22%) cases. The ages of these children were 4,9,14 months, and 2.5 years, respectively. After circumcision, six of 7 (0.38%) cases were opened by simply retracting, while the skin bridge in one case was cut with a scalpel. Although we coagulated the ves- sels by holding them one by one, we saw ecchymotic changes in the skin in one case after circumcision, and lacerations due to a burn at the edge of the skin during the procedure in 3 cases. Finally, one participant had a glans-skin bridge complication six months after the circumcision, and he was treated surgically. Secondary phimosis was detected in 4 (0.21%) of our cases and they were treated by circumcision revision. The ages of them were 10, 14 months, and 1.5, and 2 years, respectively. Urethral injury and fistula occurred in a 4-year-old pa- tient with an urethral ventral chord. About one year lat- er, urethral fistula repair was performed under general anesthesia. Except for four participants, complications were only ob¬served in children older than six months and younger than six years old. The participants who were younger than six months or over 6 years of age had significantly lower complication rates when com- pared to the other patients, and this comparison was sta- tistically significant (P = 0.001). DISCUSSION In this study, the age groups of participants were com- pared in terms of complications. It was also demonstrat- ed that It can be presumed that circumcisions in males especially may be effective in 1-6 months, and over 6 Figure 4. Thermocautery device Circumcision with thermocautery-Uysal et.al. Pediatric Urology 224 Kidney Transplantation 136 years of age Circumcision has been around for centuries. It is done as a routine for all newborn infant males in Muslim countries, reaching almost 100% (if no contraindica- tions), in hospitals in Saudi Arabia. Circumcision con- tinues to be done for a variety of religious, cultural, and medical reasons. The overall prevalence of circumci- sion in the United States is estimated to be about 80% for males, with most of these procedures performed in newborns(12). A recent meta-analysis included 140 journal articles that came to the same conclusion; early infant male cir- cumcision has immediate and lifelong benefits. It was shown to protect against urinary tract infections, phi- mosis, inflammatory skin conditions, candidiasis, vari- ous sexually transmitted diseases (STDs) in both sexes, genital ulcers, and penile, prostate, and cervical cancer (13). Male circumcision has a low incidence of adverse events overall, especially if the procedure was performed dur- ing the first year of life(14). The risk is further decreased and might be prevented, with careful consideration of the penile anatomy and the correct use of surgical equipment by trained clinicians in sterile environments. Although there are different studies of the vari¬ous cir- cumcision 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-as- sisted method with the other circumcision methods in terms of the early and long-term complications. The early complications include bleeding, pain, inadequate skin removal, in¬fection, chordee, iatrogenic hypospa- dias, glanular ne¬crosis, and glanular amputation. The long-term com¬plications include epidermal inclusion cysts, suture sinus, penile adhesions, phimosis, urethro- cutaneous fis¬tula, trapped penis, meatitis, and meatal stenosis(15-17). In addition, hydronephrosis and perma- nent renal damage can be caused by meatal stenosis (18). In our study, we didn’t see hydronephrosis and perma- nent renal damage caused by meatal stenosis. 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(19). It has been shown that the thermocautery technique re- sults in similar wound healing when com¬pared to the scalpel technique(20). According to our observations, the circumcision line usually heals within 5 days before six months and 7 days after six months when using the thermo¬cautery technique. We observed that the wound heal¬ing was extended to 20 days in only two patients in our data set. Their ages are 8 and 10 years old during the circumci- sion. In addition to that knowledge, urinary retention was observed in one patient in our thermocautery-as- sisted 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(21). This pa¬per provides a complete evaluation of the thermo- cau¬tery-assisted circumcision technique with respect to the short- and long-term complications. The patients in our dataset were followed up postoperatively for ten days, one month, and one year. In a study carried out in England, 66519 circumcisions were reported, with a complication rate of 2%(22). In the present study, similar to the literature, the most com- mon early circumcision complication was found to be bleeding (0.77% of 1821 participants). Hospital stay during the circumcision is short outpa- tient surgery and increases patient and parent satisfac- tion(23). We applied local anesthesia to all our patients before circumcision. It was first reported in a study that lidocaine with epinephrine had a protective ef- fect against bupivacaine toxicity and that it increased the asystole dura¬tion and improved hemodynamic parameters. Chiu et al. Added adrenaline to lidocaine and reported that its addition prolongs the duration of anesthesia(24). In our cases, bupivacaine and lidocaine with epinephrine were given concurrently before the operation, and the most commonly observed problem was mucosal edema, which was seen in one-quarter of the patients. We believe that mucosal edema is a com- monly observed but unheeded complication in thermo- cautery-assisted circumcision. Ngcobo and colleagues(25) reported that 30% of the pa- tients experienced penis swelling on the second day after surgery, which was a slightly higher rate than in our findings; however, the surgical procedure was not made clear. Secondary phimosis can be seen due to fibrosis, which occurs especially after circumcision with cautery in which the electric current is not controlled(26). Second- ary phimosis was detected in 4 (0.21%) of our cases and they were treated with circumcision revision. Urethral injuries often occur in circumcisions per- formed by people with limited experience and are due to urgent stitching due to bleeding during circumcision (26), and their treatment is in the form of primary ure- thral repair. In one case of our circumcision which had a urethral chordee was injured from the urethra (0.05%) during the operation and then we repaired the urethral fistula with general anesthesia over one year. Frenulum injury was observed in 1.57% of patients but was resolved with treatment. Wound recovery, af- ter thermocautery-assisted circumcision, is reported to occur in 1 week(27). Similarly, we observed that healing started on the fourth day after the operation, and total recovery occurred in ten days. The ancillary technique leads to an increase of penis size, is safe and easy to per- form, and does not increase significantly operative time or complication rate of the conventional procedure(28). According to our observations, the circumcision line usually heals within 10 days under 6 months of age when using the thermocautery technique. We observed that the wound healing was extended overe three weeks in five patients in our data set, but their circumcision ages were over one year. This paper provides a com- plete evaluation of the thermocautery-assisted circum- cision technique with respect to the short- and long- term complications. The patients in our dataset were followed up postoperatively for one month to one year. Circumcision with thermocautery-Uysal et.al. Vol 19 No 3 May-June 2022 225 Pediatric Urology 226 Urethral injury and fistula occurred in a 4-year-old pa- tient with a urethral ventral chordee. His urethral plate was very thin and weak, so a urethracutaneous fistula occurred. About one year later, urethral fistula repair was performed under general anesthesia. Prolongation of postoperative discharge time after general anesthesia often causes pain, nausea, and vomiting. No nausea and vomiting were observed in our cases. All our patients were discharged on the day of the operation. Adequate sedation, anxiolysis, and analgesia in circumcision cas- es a safe perioperative process should be planned. Circumcision was not preferred for the first month be- cause there may be additional problems such as neona- tal jaundice and bleeding in newborns under 1 month. Since a newborn baby can establish a cause-effect re- lationship with the events around him at the 6th month and after birth, we recommend more circumcision with the thermocautery method after local anesthesia before the 6th month. CONCLUSIONS The main advantages of this technique can be that it is performed fairly quickly and allows for much more cir- cumcision in all age groups of children in areas where the cost and availability of general anesthesia are pro- hibited. Circumcision with thermocautery after local anesthesia is a viable, reliable, and effective method for circumci- sions in males especially 1-6 months, and over 6 years of age. Parents choose this method because it is more appropriate and eliminates the risk of general anesthe- sia. ACKNOWLEDGMENTS All authors contributed to the study’s conception and design. The study were performed material preparation (Mehmet Uysal), data collection (Mehmet Uysal) and analysis (Mehmet Uysal, Ahmet Şanlı). The first draft of the manuscript was written by (Mehmet Uysal) and all authors commented on previous versions of the man- uscript. All authors read and approved the final manu- script. There is no financial and material support should mention for this study. CONFLICT OF INTEREST All authors have no conflicts of inrest to declare. This study wasn’t supported by any Research Fund REFERENCES 1. Başaklar C. Çocuklarda sık karşılaşılan ürolojik ve jinekolojik hastalıkları. Bebek ve çocukların cerrahi ve ürolojik hastalıkları. Ankara Palme yayıncılık, 2006;69, p.1535- 1570. 2. Helen AW, Natasha L,Daniel H,Inon S. Complications of circumcision in male neonates, infants and children: a systematic review.BMC Urol. 2010;10:2 3. Morris BJ, Wamai RG, Heneberg EB, et al. Estimation of the country-specific and global prevalence of male circumcision. Popul Health Metr. 2016; 14: 4. 4. Morris BJ, Wiswell TE. Circumcision and lifetime risk of urinary tract infection: a systematic review and meta-analysis. J Urol. 2013 Jun;189(6):2118-24. 5. Elizabeth S, Jean C, Patrick M. Neonatal Circumcision: New Recommendations and Implications for Practice. M. Med. 2014 May- Jun; 111(3): 222-230. 6. Prabhakaran S, Ljuhar D, Coleman R, Nataraja RM: Circumcision in the pediatric patient: a review of indications, technique and complications. J Pediatr Child Health. 2018; 54: 1299-1307. 7. Krill AJ, Palmer LS, Palmer JS. Complications of circumcision. Scientific World J. 2011; 11: 2458-68. 8. Weiss HA, Larke N, Halperin D, Schenker I. Complications of circumcision in male neonates, infants and children: A systematic review. BMC Urol. 2010; 10: 2. 9. Tahmaz ML, Erduran. Sünnet. In: Dayanç M, ed. Güncel Çocuk Ürolojisi. Ankara: Atlas Kitapçılık, 2004; p.281-294. 10. Male circumcision. Task force on circumcision. American Academy of Pediatrics. 2012;130(3):756-785 11. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009; 250: 187-96. 12. Introcaso CE, Xu F, Kilmarx PH, Zaidi A, Markowitz LE. Prevalence of circumcision among men and boys aged 14 to 59 years in the United States, National Health and nutrition examination surveys 2005-2010. Sexually Transmitted Diseases.2013; 40 (7): 521-525 13. Morris BJ, Kennedy SE, Wodak AD et al. Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy. World J of Clinical Pediatrics. 2017; 6(1): 89-102 14. El Bcheraoui C, Zhang X, Cooper CS, Rose CE, Kilmarx PH, Chen RT. Rates of adverse events associated with male circumcision in U.S. medical settings, 2001 to 2010. JAMA Pediatrics. 2014; 168(7): 625-634 15. Krill AJ, Palmer LS, Palmer JS. Complications of circumcision. Scientific World J. 2011; 11:2458-68. 16. Eke N. Major surgical complications from minor urological procedures. J Natl Med. Assoc. 2000; 92: 196-199. 17. Tuncer AA,Değer M. Incidence of complications following Thermocautery- assisted circumcisions.Urol. J. 2018;15(6):359- 364 18. Saeedi P, Ahmadnia H, Akhavan Rezayat A. Evaluation of the effect of meatal stenosis on the urinary tract by using ultrasonography. Urol J. 2017; 14: 3071-4. 19. Lane JE, O'Brien EM, Kent DE. Optimization of thermocautery in excisional dermatologic surgery. Dermatol Surg. 2006; 32: 669-75. 20. Tuncer AA, Bozkurt MF, Bayraktaroğlu A, et al. Examination of histopathological changes of scalpel, monopolar, bipolar, and thermocautery applications in rat experimental circumcision model. Am J Transl Res. 2017; 9(5): 2306-13. Circumcision with thermocautery-Uysal et.al. Vol 19 No 3 May-June 2022 100 21. Saracoglu M, Ozturk H, Zengin T, Kerman HS. Comparison of thermal cautery-assisted circumcision with the conventional technique. Human Androl. 2014; 4: 34-7. 22. Cathcart P, Nuttall M, Meulen JVD, et.al. Trends in pediatric circumcision and its complications in England between 1997 and 2003. Br J Surg 2006; 93: 885–890. 23. Micha G, Samanta E,Damigos D, et.al. Impact of an Anesthesia Discharge Scoring System on Postoperative Monitoring after Circumcision in Children: A Randomized Trial.Eur J Pediatr Surg. 2009 Oct; 19(5): 293-2966 24. Ersöz G,Çatlı D. Turk J The Effects of Lidocaine with Epinephrine on Bupivacaine- Induced Cardiotoxicity.Anaesthesiol Reanim 2018; 46(6): 447-52. 25. Ngcobo S, Wolvaardt JE, Bac M, et al. The quality of voluntary medical male circumcision done by mid-level workers in Tshwane District, South Africa: a retrospective analysis. PLoS One. 2018; 13(1):190795. 26. Balkan E, Kılıç N. Sünnet ve komplikasyonlar. Güncel Pediatri 2005; 2: 22-23. 27. Tuncer AA and Erten EEA. Examination of short and long term complications ofthermocautery, plastic clamping, and surgical circumcision techniques. Pak J Med Sci 2017;33: 1418-1423. 28. Carmine P, Mario F, Antonio G, et.al. Circumferential dissection of deep fascia as ancillary technique in circumcision: is it possible to correct phimosis increasing penis size? BMC Urol. 2021 Feb 3;21(1):15. Circumcision with thermocautery-Uysal et.al. Vol 19 No 3 May-June 2022 227