34 Original article

Comparison of thermal cautery-assisted circumcision with

the conventional technique
Musa Saracoglu, Hakan Ozturk, Tarik Zengin and Huseyin S. Kerman

Department of Urology, School of Medicine, Objective

Sifa University, Izmir, Turkey
Correspondence to Hakan Öztürk, MD, Basmane
Hospital of Sifa University, Fevzipasa Boulevard No:
172/2, 35240, Basmane, Konak, Izmir, Turkey
Tel: + 90 232 446 0880; fax: + 90 232 446 0770;
e-mail: drhakanozturk@yahoo.com.tr
Received 4 February 2014
Accepted 23 February 2014
Human Andrology 2014, 4:34–37
Circumcision is one of the most common surgical procedures performed worldwide.
The World Health Organization has begun to recommend circumcision on the basis
of studies indicating its effects in protection against AIDS. Different circumcision
techniques have been defined, but the search for a rapid technique with low
complication rates still continues. In this study, thermal cautery-assisted circumcision
has been compared with the classical technique.
Patients and methods
A total of 110 patients were randomized into two groups, and the duration of the
surgical procedure, number of sutures, number of vessels coagulated, frenulotomy,
and the need for winding after the procedure were noted. The results were compared
statistically; a P-value less than 0.05 was considered significant.
Results
In the thermal cautery group, duration, the number of vessels coagulated, and the
number of patients who required winding after surgery were significantly lower. For the
number of vessels coagulated and the need for winding, the P-value was less than
0.001; for the duration of surgery, the P-value was 0.002. There was no significant
difference in the frenulotomy ratio and number of sutures.
Conclusion
Bipolar thermal cautery-assisted circumcision is a reliable technique that results in less
bleeding and shorter operation time.

Keywords:
cautery, circumcision, male

Hum Androl 4:34–37

& 2014 Human Andrology
2090-6048

tions. The present study aimed to compare bipolar

Introduction
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 indicat-
ing 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 per-
formed 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 complica-
2090-6048 & 2014 Human Andrology
thermal cautery-assisted circumcision technique, consid-
ered 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 rando-
mized 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
DOI: 10.1097/01.XHA.0000439147.28288.fe

Copyright © Human Andrology. Unauthorized reproduction of this article is prohibited.


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 separat-
ing the prepuce from the glans penis after administering
antisepsis. The frenulum was inspected and the frenu-
lotomy 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 circumci-
sion 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 circum-
cision (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 w2-analysis (whichever was appropriate) considering
Table 1 Comparison of surgical parameters between the groups
Classical surgery group (n = 55) Bipolar thermal cautery group (n = 55) P-value
Number of patients undergoing frenulotomy (%)
Number of vessels coagulated [median (minimum–maximum)]
Number of sutures (mean ± SD)
Duration of procedure (mean ± SD)
Number of patients with bandage (%)
Copyright © Human Andrology. Unauthorized reproduction of this article is prohibited.
Thermal cautery-assisted circumcision Saracoglu et al. 35
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.
Results
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
29 (52.7) 25 (45.5) 0.567
7.0 (4–12) 0.0 (0–4) o0.001
8.8 ± 0.93 6.7 ± 1.16 o0.001
813 ± 138 309 ± 93 o0.001
52 (94.5%) 2 (3.6%) o0.001
36 Human Andrology
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 occur-
rence of late complications.
Discussion
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 circumci-
sion 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 B200 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 circum-
cised [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 complica-
tions 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 circumci-
Copyright © Human Andrology. Unauthorized reproduction of this article is prohibited.
sion 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 techni-
ques 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 circum-
cision 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 circumci-
sion and for a better cosmetic result, although circumci-
sion 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 bleed-
ing, wound infection, hyperesthesia of the glans, lacera-
tion 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.
Conclusion
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.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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