Thermocautery for Infantile Circumcision in High-Volume Hospitals: A Retrospective Analysis of Over 1,500 Cases

Thermocautery for Infantile Circumcision in High-Volume Hospitals: A Retrospective Analysis of Over 1,500 Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Thermocautery for Infantile Circumcision in High-Volume Hospitals: A Retrospective Analysis of Over 1,500 Cases Mohamed Elawdy, Ehab Eltohamy, Khalid Al-Balushi, Hatem Alsaidy, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8146582/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Apr, 2026 Read the published version in World Journal of Urology → Version 1 posted 9 You are reading this latest preprint version Abstract Objectives: We share our experience with thermocautery (TC) used in over 1500 cases. There is a lack of data regarding this technique, and the recent WHO manual for infantile circumcision (IC) included only three devices: Mogen, Gomco, and Plastibell, with limited reports on other techniques. Methods: This retrospective study was conducted where IC was a routine procedure in our locality. The most common reasons for patient cancellation were buried penis, excess suprapubic fat, and obesity. No routine preoperative workup was performed. The technique followed the basic surgical principles of IC, with the skin being cut using a digital thermocautery device along a long surgical clamp. Two stitches were placed at 6 and 12 o’clock using 4/0 absorbable sutures. Results: A total of 1650 patients underwent the procedure during the study period. The mean age was 130 ± 15 days old. The entire procedure took 360 ± 30 seconds. No major perioperative surgical or anesthetic complications were observed. Eleven patients experienced early postoperative bleeding (7/1000), with only three requiring re-suturing under local anesthesia. Five patients required redo-circumcision, and three developed meatal stenosis, which was treated with meatoplasty. Conclusion: For hospitals that regularly perform IC, the thermocautery method offers a simple, convenient, and time-efficient approach. It can be performed outside the main operating room and is cost-effective. This method is nearly bloodless and has the lowest incidence of bleeding compared to other techniques. The occurrence of other complications falls within the range of those observed with other surgical methods. Circumcision neonatal circumcision infantile circumcision circumcision methods thermocautery Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Although circumcision has been reported to lower the incidence of urinary tract infections, sexually transmitted diseases, and penile cancer [ 1 – 3 ], it remains a cultural practice in many societies. The known risks and benefits of the procedure can be discussed with parents so that they can make informed decisions based on their medical advice. In 2010, the WHO published the “Manual for Early Infant Male Circumcision under Local Anesthesia,” which included the pre-qualification of the Mogen, Gomco, and Plastibell devices for IC. This report included only three devices because it accounted for the available research reports, with few reports on other techniques [ 4 ]. The burden is higher in hospitals that perform IC as a routine procedure under local anesthesia with a long list, and in such situations, the feasibility, procedure time, complications, and cost should all be considered. Subsequently, neither the Gomco nor Plastibell procedures, which take an average of 10 minutes or more, are suitable for busy hospitals [ 5 , 6 ]. These hospitals require a technique that is simpler, faster, and more economical. A few studies have been published on the thermocautery (TC) technique, which reported that TC had a lower complication rate and that the thermocautery-supported method can be a very safe and fast circumcision method [ 7 , 8 ]. Our hospital performs IC with 8–12 cases under local anesthesia daily. In this study, we aimed to introduce our experience with circumcision using TC in more than 1500 cases performed by a single urologist. We describe our technique with a long-term follow-up. Patients and Methods After obtaining Institutional Review Board approval (MOH, 144/2023), a retrospective study was conducted between January 2018 and December 2024. The study population included infants below one year of age. All infants who underwent IC were first seen at the one-day surgery unit and were not examined before. The exclusion criteria included infants with known major health conditions and those with obese or buried penises. Infants with undescended testicles and glandular hypospadias with an intact prepuce were enrolled for circumcision. Preoperative evaluation A brief medical history was obtained, and focused general and genital examinations were performed. No preoperative laboratory tests were performed. A brief patient education leaflet was provided to all mothers/parents before signing the consent form. The leaflet included simple information about the procedure, postoperative care, and possible complications that might require urgent medical attention. Digital thermocautery device (RB Medical Engineering, Herefordshire, UK). Grade 2–3 was used in our technique for this age, and sterilization depended on red-hot sterilization of the loop. The surgical method: Lidocaine spray was used in the examination room and administered when the patient was eligible for circumcision. The infant was placed in a supine position and restrained using an infant holder. After sterilization with povidone-iodine, 2 ml of 2% lidocaine was injected preoperatively, and 1 ml was injected at 6 o’clock on both sides to induce circumferential penile ring block. A mosquito clamp was used for gentle preputial dilation, and the preputial skin was retracted backward to expose the entire glans penis. All smegma was cleaned completely with moisturized gauze, the frenulum at 12 o’clock was dissected and cut by thermocautery, setting #2 (Fig. 1) , and the preputial skin was returned. Two mosquito clamps were used to grasp the foreskin at 6 and 12 o’clock, and long forceps were placed on the preputial skin (Fig. 2). Thermocautery was used to incise the skin over the forceps (Fig. 3) . To avoid any possible injuries to the glans penis, the long forceps were placed most distally and advanced proximally in a semi-closed position, which did not permit any possible entrapment of the glans penis between the jaws of the forceps. While the forceps were advanced proximally, counter-traction was performed using the left index and thumb fingers to retract the skin distally. No glans injury was reported using this technique. Our standards were to take only two surgical stitches for skin-mucosa integrity at 6 and 12 o’clock using 4/0 absorbable suture material (sometimes 5/0) (Fig. 4) . Extra stitches at 3 and 9 o’clock were taken if the skin was slightly protracted forward. In some instances, when the skin and mucous membranes were well adhered together, no sutures were used. Thermocautery was also used to control mild bleeding, especially from the glans mucous membrane or skin edges. Compression gauze was routinely used to control mild oozing in all cases. A thin film of antibiotic cream (gentamicin) was applied all around before placing a compression gauze to facilitate the later removal of the gauze. All mothers were asked to wait for 10–15 minutes after the procedure. Postoperative instructions All mothers were instructed to keep the gauze on for 48 h unless it fell off on its own. The gauze was gently removed using warm water. No routine antibiotics were administered, but paracetamol drops were provided as needed. Mothers were instructed to attend the nearest healthcare facility in cases of severe bleeding, acute urine retention, fever, or any unusual symptoms or signs. A routine follow-up visit was scheduled at one month postoperatively. In cases where no postoperative complications were observed, mothers were informed to attend the clinic if they observed any problems in the penis or urinary stream. Results Of the 1980 patients who showed up for circumcision, 1650 patients who were operated on during the study period, all of whom were performed by a single surgeon (EMM). Buried penis/excess suprapubic fat was the most common cause of postponement (90%) associated with or without general obesity. Other causes included fever, upper respiratory tract infections, and acute illnesses. The mean age was 130 ± 15 days. The mean operating time was 360 ± 30 s. Intraoperatively, no major perioperative surgical complications, such as glans amputation, glans necrosis, significant hematoma, or excessive removal of the foreskin, were recorded. No anesthetic complications were observed after lidocaine injection. Early postoperative complications A total of 11 (7/1000) patients visited the ER on the same day as their procedure for noticeable bleeding; eight had minor bleeding and were treated with compression gauze, while 3 them had slipped sutures with significant bleeding that required re-suturing under local anesthesia. Intermediate complications Twenty-seven visits (nearly 1.6%) were recorded with redundant skin covering part of the glans penis with adhesions between the preputial skin and glans. Inconspicuous/buried penis or obesity were the main causes in 24 (88%) patients. All patients were initially treated with preputial dilation and skin retraction. However, 15 of them returned with parents' dissatisfaction, 5 required redo-circumcision (3/1000), and the remaining were assured that with aging, all would be well Long-term follow-up Three patients had meatal stenosis (15, 22, and 33 months) post-circumcision, and meatoplasty was performed. Moreover, two patients had mild penile rotation that did not require surgical correction. Discussion Circumcision is a surgical procedure performed on children of all ages for medical or traditional reasons in many countries worldwide. There are many ways of application, ranging from the classical surgical method without the use of any device to different methods using different apparatuses. Gomco clamp, the Mogen clamp, and the Plastibell device were the most common methods used and reported in the literature. The choice of technique should be guided by the operator’s training and comfort [ 9 ]. Reports on these instruments were from countries that use them to perform circumcision only when it is medically indicated, as in cases of phimosis or vesicoureteral reflux in males, or when requested by parents. However, the matter has different aspects in countries where IC is performed routinely on male children for ritual and religious reasons. It is impossible to determine which of these methods is the best or most reliable. Each surgeon is naturally most successful with their own method. One of the most common complications of circumcision is bleeding. Today, bleeding control during the procedure can be achieved using thermocautery, which applies low-grade electricity. Initially, the Gomco clamp, Mogen clamp, and Plastibell device were tried at our hospital; however, the main problematic issue was the time. For example, the Gomco clamp is a complicated device, and the procedure takes 10 minutes or more on average [ 4 ], with a mean time of 12.8 minutes [ 5 ]. Plastibell takes a similar time, and it is a disposable device that is costly. The average time for the Plastibell to fall off is 6 days [ 6 ], with many unnecessary visits and calls daily to the ER and health care centers regarding the ring. A more convenient method was required that would be practical not only to run 8–12 IC daily but also to be performed outside the main operating theatre with the lowest rate of postoperative-related visits. Since the release of the initial studies on thermocautery (TC), where it was reported that this method can be easily used in both the operating theatre and designated circumcision rooms with a lower complication rate, we started implementing this method (TC). The method follows the basic principles of circumcision, releasing the adhesion between the skin and mucous membrane, and then cutting the frenulum and part of the foreskin. This is superior to cutting over a clamp using a scalpel, where the use of a thermocautery device to cut the skin dramatically minimizes the incidence of bleeding. Bleeding is the most common intraoperative and intermediate postoperative complication reported in many studies, irrespective of the device used. We recorded less than 2/1000 cases of active bleeding that required the application of sutures. Even if the whole number is calculated, which is 7/1000 and includes cases that required compression only, it is noticeably less than the incidence in the published series, 2.5% by Siroosbakht et al. [ 10 ]. In another study comprising 2,062 male patients comparing thermocautery, plastic clamping, and surgical circumcision techniques, the authors reported 11/2000 cases of bleeding that required active management; 8, 2, and 1 were after open, clamp, and thermocautery methods, respectively [ 7 ]. In the same study, the operative times were 14.3 ± 2.9, 5 ± 1.3, and 4 ± 1 min for the classical surgical technique, thermocautery, and clamp-guided technique, respectively (P = 0.000). There is an agreement in the literature that the average time for the clamp method is 5 min, while all other techniques are 10 min or longer [ 4 ], [ 5 , 7 ]. Electrocautery and thermocautery operate on different principles. The thermocautery device supplies electrical energy by converting it into heat energy instead of passing it through the tissue. It also provides coagulation during circumcision. This method combines the advantage of using a clamp to save time compared to the open method and using thermal injury to cut the skin and minimize bleeding. Additionally, the use of electric cautery with metal instruments during circumcision can result in catastrophic loss of the penis. In another study that included a large number of patients undergoing circumcision, the authors used a Thermo-Med TM 806 cautery device. Authors concluded that it is a safe procedure and a good option when circumcisions cannot be performed in a hospital setting[ 11 ]. In another study involving a considerable number of children, the authors concluded that in countries where circumcision is routinely performed, developing faster and safer methods is of utmost importance. To this end, we prefer thermocautery, which can meet patient needs quickly and safely [ 8 ]. In our series, the most common long-term complication was redundant skin. Initially, 27 patients were treated with mild preputial dilation and skin retraction; however, 5 of these required redo circumcision, while the remaining patients were reassured. Preputial adhesions often resulted either from inadequate lysis of natural adhesions before circumcision or from distal migration of the skin due to a prominent suprapubic fat pad. Our findings align with those of Williams et al., who reported that 63% of patients presenting for circumcision revision had prominent suprapubic fat pads [ 12 ]. It is worth mentioning that 50% of the cases involving redundant skin occurred during the first year of the study, which was due to the long waiting list. After the first year, this incidence was reported, and the quality management meeting recommended that the decision to proceed should be left to the doctors without any external pressure. The contraindications for this procedure are similar to those for other procedures. We scheduled children with undescended testicles and glandular hypospadias with an intact prepuce. Although Jimoh et al. reported postponing children with distal hypospadias, their report was unclear about whether these cases involved distal or glandular hypospadias with an intact prepuce [ 6 ]. We recorded fewer than 1.5 cases of meatal stenosis per 1,000, which contradicts the assumption that thermocautery leads to tissue necrosis and a higher incidence of meatal stenosis. Ammar et al. reported a 4% incidence of meatal stenosis in a series of 150 circumcision cases [ 13 ]. This incidence is too low to justify prophylactic measures, such as applying petroleum jelly to the glans, as recommended by Omole et al. [ 14 ]. The main limitation of our study is its retrospective design; however, it was necessary to include this substantial number of patients with long-term follow-up. Additionally, we classified patients who missed their routine scheduled visits as having no complications, as it was not feasible to contact such a large number of patients for follow-up. We believe that each surgical method and procedure has its own advantages and disadvantages, and the choice depends on both the physician and the hospital facilities. In low-volume centers that perform circumcisions only when medically indicated, several different methods may be chosen. However, circumcision using thermocautery could be a good time-saving option for high-volume hospitals. Conclusion For hospitals that perform infant circumcisions daily for ritual and religious purposes, the thermocautery method is more convenient, can be conducted outside the main operating rooms, and is the most economical option. Additionally, it is a simple technique with the shortest surgical time, which is a priority for busy hospitals. The incidence of intermediate and long-term complications is comparable to that of other surgical methods. Declarations Generative AI in Scientific Writing: Contributors Mohamed Mohamed Elawdy 1 [email protected] Idea, proposal, writing Ehab Eltohamy 2 [email protected] Data collections Khalid Al-Balushi 1 [email protected] Writing Hatem Alsaidy 3 [email protected] Reviewing Talib Almaqbali 3 [email protected] Reviewing Department(s) and institution(s) Urology 1 Pediatric surgery 2 , General surgery 3 departments, Sohar Hospital, Ministry of Health, Sultanate of Oman Funding: None Ethical approval: IRB was obtained Conflict of interest: No Authors’ contributions: Mentioned above with authors’ information Corresponding Author: Mohamed M. Elawdy , MD, MSc., ECFMG certified Specialist (A) in Urology, Sohar Hospital, Ministry of Health, Oman Phone: 0096891441050 [email protected] References Nelson CP, Dunn R, Wan J, Wei JT (2005) The increasing incidence of newborn circumcision: Data from the nationwide inpatient sample. J Urol 173(3):978–981 Morris BJ, Katelaris A, Blumenthal NJ, Hajoona M, Sheen AC, Schrieber L et al Evidence-based circumcision policy for Australia. J Mens Health [Internet]. 2022 [cited 2024 May 10];18(6). Available from: http://www.ncbi.nlm.nih.gov/pubmed/36034719 Li G, Li Q, Fu WJ, Hong BF, Luo J, Xu FQ et al (2010) Modified one-cut circumcision technique by clamp: Reports of 2000 cases. Chin Med J (Engl) 123(19):2732–2735 Manual for early infant male circumcision under local anaesthesia (2010) ; Available from: https://iris.who.int/bitstream/handle/10665/44478/9789241500753_eng.pdf?sequence=1&isAllowed=y Millard PS, Wilson HR, Veldkamp PJ, Sitoe N (2013) Rapid, minimally invasive adult voluntary male circumcision: A randomised trial. South Afr Med J 103(10):736–742 Jimoh BM, Odunayo IS, Chinwe I, Akinfolarin OO, Oluwafemi A, Olusanmi EJ (2016) Plastibell circumcision of 2,276 male infants: A multi-centre study. Pan Afr Med J. ;23 Tuncer AA, Erten EEA Examination of short and long term complications of thermocautery, plastic clamping, and surgical circumcision techniques. Pak J Med Sci [Internet]. 2017 Nov 15 [cited 2024 May 10];33(6):1418–23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29492070 Akyüz O, Bodakçi MN, Tefekli AH Thermal cautery-assisted circumcision and principles of its use to decrease complication rates. J Pediatr Urol [Internet]. 2019 Apr 1 [cited 2025 Jul 23];15(2):186 .e1-186.e8 . Available from: https://pubmed.ncbi.nlm.nih.gov/30770302/ Zeitler M, Rayala B (2021) Neonatal Circumcision. Prim Care - Clin Office Pract 48(4):597–611 Siroosbakht S, Rezakhaniha B A comprehensive comparison of the early and late complications of surgical circumcision in neonates and children: A cohort study. Health Sci Rep [Internet]. 2022 Nov 1 [cited 2024 May 10];5(6):e939. Available from: http://www.ncbi.nlm.nih.gov/pubmed/36425897 Arslan D, Kalkan M, Yazgan H, Ünüvar U, Şahin C (2013) Collective circumcision performed in Sudan: evaluation in terms of early complications and alternative practice. Urology [Internet]. [cited 2024 May 12];81(4):864–8. Available from: https://pubmed.ncbi.nlm.nih.gov/23465159/ Williams CP, Richardson BG, Bukowski TP (2000) Importance of identifying the inconspicuous penis: Prevention of circumcision complications. Urology 56(1):140–142 Abid AF, Hussein NS Meatal stenosis posttraditional neonatal circumcision-cross-sectional study. Urol Ann [Internet]. 2021 Jan 1 [cited 2024 May 10];13(1):62–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/33897167 Omole F, Smith W, Carter-Wicker K (2020) Newborn Circumcision Techniques. Am Fam Physician 101(11):680–685 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Apr, 2026 Read the published version in World Journal of Urology → Version 1 posted Editorial decision: Revision requested 16 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviews received at journal 31 Jan, 2026 Reviewers agreed at journal 19 Jan, 2026 Reviewers agreed at journal 17 Jan, 2026 Reviewers invited by journal 24 Nov, 2025 Editor assigned by journal 21 Nov, 2025 Submission checks completed at journal 21 Nov, 2025 First submitted to journal 18 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8146582","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":550214868,"identity":"0a0fba7f-0292-46b1-a85f-36818f40a370","order_by":0,"name":"Mohamed 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10:05:26","extension":"xml","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":40776,"visible":true,"origin":"","legend":"","description":"","filename":"cfdbbbb8a8634ad6b6721395178b53c81structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8146582/v1/6c08a4d3f7b4a0ff0eda5d63.xml"},{"id":97141877,"identity":"270ee818-18b2-4992-86da-7deca913ac34","added_by":"auto","created_at":"2025-12-01 10:07:08","extension":"html","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":48202,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8146582/v1/2bd502194e9a211073182723.html"},{"id":97140628,"identity":"125f6396-d49e-42b1-b030-1afbaa9b1a14","added_by":"auto","created_at":"2025-12-01 10:05:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1639428,"visible":true,"origin":"","legend":"\u003cp\u003eSeparation and cutting of the frenulum by thermocautery\u003c/p\u003e","description":"","filename":"1Separationandcuttingofthefrenulumbythermocautery.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8146582/v1/e23c900453d932cfd7432c62.jpg"},{"id":97127080,"identity":"13a42226-f830-4d6e-8f9b-840dc884ce2a","added_by":"auto","created_at":"2025-12-01 08:26:27","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2902209,"visible":true,"origin":"","legend":"\u003cp\u003ePutting 2 mosquito clamps at 6 and 12 o’clock and putting a surgical clamp over the preputial skin\u003c/p\u003e","description":"","filename":"2Putting2mosquitoclampsat6and12oclockandputtingasurgicalclampoverthepreputialskin.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8146582/v1/82b7c61e0ae2c86e4a3164d9.jpg"},{"id":97127094,"identity":"f76c3518-718f-4ce3-80be-1c3c7b8746c9","added_by":"auto","created_at":"2025-12-01 08:26:28","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":8376901,"visible":true,"origin":"","legend":"\u003cp\u003eCutting the excess skin using thermocautery\u003c/p\u003e","description":"","filename":"3Cuttingtheexcessskinusingthermocautery.png","url":"https://assets-eu.researchsquare.com/files/rs-8146582/v1/bdbda64f027c938224271003.png"},{"id":97140824,"identity":"2db47441-1d63-41a4-b292-5c09b7f05e5b","added_by":"auto","created_at":"2025-12-01 10:05:50","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":2232665,"visible":true,"origin":"","legend":"\u003cp\u003eTwo sutures at 6 and 12 o’clock using 4/0 absorbable sutures\u003c/p\u003e","description":"","filename":"4Twosuturesat6and12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8146582/v1/cc6dc3f429769e489ddd213b.jpg"},{"id":107350704,"identity":"9049c156-9fc1-4a95-8d6a-5bfafee499ef","added_by":"auto","created_at":"2026-04-20 16:00:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":17137032,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8146582/v1/09d0bdba-6193-4908-8fd4-08d61d4b5234.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Thermocautery for Infantile Circumcision in High-Volume Hospitals: A Retrospective Analysis of Over 1,500 Cases","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAlthough circumcision has been reported to lower the incidence of urinary tract infections, sexually transmitted diseases, and penile cancer [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], it remains a cultural practice in many societies. The known risks and benefits of the procedure can be discussed with parents so that they can make informed decisions based on their medical advice.\u003c/p\u003e\u003cp\u003eIn 2010, the WHO published the \u0026ldquo;Manual for Early Infant Male Circumcision under Local Anesthesia,\u0026rdquo; which included the pre-qualification of the Mogen, Gomco, and Plastibell devices for IC. This report included only three devices because it accounted for the available research reports, with few reports on other techniques [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe burden is higher in hospitals that perform IC as a routine procedure under local anesthesia with a long list, and in such situations, the feasibility, procedure time, complications, and cost should all be considered. Subsequently, neither the Gomco nor Plastibell procedures, which take an average of 10 minutes or more, are suitable for busy hospitals [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese hospitals require a technique that is simpler, faster, and more economical. A few studies have been published on the thermocautery (TC) technique, which reported that TC had a lower complication rate and that the thermocautery-supported method can be a very safe and fast circumcision method [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur hospital performs IC with 8\u0026ndash;12 cases under local anesthesia daily. In this study, we aimed to introduce our experience with circumcision using TC in more than 1500 cases performed by a single urologist. We describe our technique with a long-term follow-up.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eAfter obtaining Institutional Review Board approval (MOH, 144/2023), a retrospective study was conducted between January 2018 and December 2024. The study population included infants below one year of age. All infants who underwent IC were first seen at the one-day surgery unit and were not examined before. The exclusion criteria included infants with known major health conditions and those with obese or buried penises. Infants with undescended testicles and glandular hypospadias with an intact prepuce were enrolled for circumcision.\u003c/p\u003e\u003cp\u003ePreoperative evaluation\u003c/p\u003e\u003cp\u003eA brief medical history was obtained, and focused general and genital examinations were performed. No preoperative laboratory tests were performed. A brief patient education leaflet was provided to all mothers/parents before signing the consent form. The leaflet included simple information about the procedure, postoperative care, and possible complications that might require urgent medical attention.\u003c/p\u003e\u003cp\u003eDigital thermocautery device (RB Medical Engineering, Herefordshire, UK). Grade 2\u0026ndash;3 was used in our technique for this age, and sterilization depended on red-hot sterilization of the loop.\u003c/p\u003e\u003cp\u003eThe surgical method:\u003c/p\u003e\u003cp\u003eLidocaine spray was used in the examination room and administered when the patient was eligible for circumcision. The infant was placed in a supine position and restrained using an infant holder.\u003c/p\u003e\u003cp\u003eAfter sterilization with povidone-iodine, 2 ml of 2% lidocaine was injected preoperatively, and 1 ml was injected at 6 o\u0026rsquo;clock on both sides to induce circumferential penile ring block. A mosquito clamp was used for gentle preputial dilation, and the preputial skin was retracted backward to expose the entire glans penis. All smegma was cleaned completely with moisturized gauze, the frenulum at 12 o\u0026rsquo;clock was dissected and cut by thermocautery, setting #2 \u003cb\u003e(Fig.\u0026nbsp;1)\u003c/b\u003e, and the preputial skin was returned.\u003c/p\u003e\u003cp\u003eTwo mosquito clamps were used to grasp the foreskin at 6 and 12 o\u0026rsquo;clock, and long forceps were placed on the preputial skin \u003cb\u003e(Fig.\u0026nbsp;2).\u003c/b\u003e Thermocautery was used to incise the skin over the forceps \u003cb\u003e(Fig.\u0026nbsp;3)\u003c/b\u003e.\u003c/p\u003e\u003cp\u003eTo avoid any possible injuries to the glans penis, the long forceps were placed most distally and advanced proximally in a semi-closed position, which did not permit any possible entrapment of the glans penis between the jaws of the forceps. While the forceps were advanced proximally, counter-traction was performed using the left index and thumb fingers to retract the skin distally. No glans injury was reported using this technique.\u003c/p\u003e\u003cp\u003eOur standards were to take only two surgical stitches for skin-mucosa integrity at 6 and 12 o\u0026rsquo;clock using 4/0 absorbable suture material (sometimes 5/0) \u003cb\u003e(Fig.\u0026nbsp;4)\u003c/b\u003e. Extra stitches at 3 and 9 o\u0026rsquo;clock were taken if the skin was slightly protracted forward. In some instances, when the skin and mucous membranes were well adhered together, no sutures were used.\u003c/p\u003e\u003cp\u003eThermocautery was also used to control mild bleeding, especially from the glans mucous membrane or skin edges. Compression gauze was routinely used to control mild oozing in all cases. A thin film of antibiotic cream (gentamicin) was applied all around before placing a compression gauze to facilitate the later removal of the gauze. All mothers were asked to wait for 10\u0026ndash;15 minutes after the procedure.\u003c/p\u003e\u003cp\u003ePostoperative instructions\u003c/p\u003e\u003cp\u003eAll mothers were instructed to keep the gauze on for 48 h unless it fell off on its own. The gauze was gently removed using warm water. No routine antibiotics were administered, but paracetamol drops were provided as needed. Mothers were instructed to attend the nearest healthcare facility in cases of severe bleeding, acute urine retention, fever, or any unusual symptoms or signs. A routine follow-up visit was scheduled at one month postoperatively. In cases where no postoperative complications were observed, mothers were informed to attend the clinic if they observed any problems in the penis or urinary stream.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 1980 patients who showed up for circumcision, 1650 patients who were operated on during the study period, all of whom were performed by a single surgeon (EMM). Buried penis/excess suprapubic fat was the most common cause of postponement (90%) associated with or without general obesity. Other causes included fever, upper respiratory tract infections, and acute illnesses. The mean age was 130\u0026thinsp;\u0026plusmn;\u0026thinsp;15 days. The mean operating time was 360\u0026thinsp;\u0026plusmn;\u0026thinsp;30 s.\u003c/p\u003e\u003cp\u003eIntraoperatively, no major perioperative surgical complications, such as glans amputation, glans necrosis, significant hematoma, or excessive removal of the foreskin, were recorded. No anesthetic complications were observed after lidocaine injection.\u003c/p\u003e\n\u003ch3\u003eEarly postoperative complications\u003c/h3\u003e\n\u003cp\u003eA total of 11 (7/1000) patients visited the ER on the same day as their procedure for noticeable bleeding; eight had minor bleeding and were treated with compression gauze, while 3 them had slipped sutures with significant bleeding that required re-suturing under local anesthesia.\u003c/p\u003e\n\u003ch3\u003eIntermediate complications\u003c/h3\u003e\n\u003cp\u003eTwenty-seven visits (nearly 1.6%) were recorded with redundant skin covering part of the glans penis with adhesions between the preputial skin and glans. Inconspicuous/buried penis or obesity were the main causes in 24 (88%) patients. All patients were initially treated with preputial dilation and skin retraction. However, 15 of them returned with parents' dissatisfaction, 5 required redo-circumcision (3/1000), and the remaining were assured that with aging, all would be well\u003c/p\u003e\n\u003ch3\u003eLong-term follow-up\u003c/h3\u003e\n\u003cp\u003eThree patients had meatal stenosis (15, 22, and 33 months) post-circumcision, and meatoplasty was performed. Moreover, two patients had mild penile rotation that did not require surgical correction.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCircumcision is a surgical procedure performed on children of all ages for medical or traditional reasons in many countries worldwide. There are many ways of application, ranging from the classical surgical method without the use of any device to different methods using different apparatuses. Gomco clamp, the Mogen clamp, and the Plastibell device were the most common methods used and reported in the literature. The choice of technique should be guided by the operator\u0026rsquo;s training and comfort [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eReports on these instruments were from countries that use them to perform circumcision only when it is medically indicated, as in cases of phimosis or vesicoureteral reflux in males, or when requested by parents. However, the matter has different aspects in countries where IC is performed routinely on male children for ritual and religious reasons.\u003c/p\u003e\u003cp\u003eIt is impossible to determine which of these methods is the best or most reliable. Each surgeon is naturally most successful with their own method. One of the most common complications of circumcision is bleeding. Today, bleeding control during the procedure can be achieved using thermocautery, which applies low-grade electricity.\u003c/p\u003e\u003cp\u003eInitially, the Gomco clamp, Mogen clamp, and Plastibell device were tried at our hospital; however, the main problematic issue was the time. For example, the Gomco clamp is a complicated device, and the procedure takes 10 minutes or more on average [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], with a mean time of 12.8 minutes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Plastibell takes a similar time, and it is a disposable device that is costly. The average time for the Plastibell to fall off is 6 days [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], with many unnecessary visits and calls daily to the ER and health care centers regarding the ring. A more convenient method was required that would be practical not only to run 8\u0026ndash;12 IC daily but also to be performed outside the main operating theatre with the lowest rate of postoperative-related visits.\u003c/p\u003e\u003cp\u003eSince the release of the initial studies on thermocautery (TC), where it was reported that this method can be easily used in both the operating theatre and designated circumcision rooms with a lower complication rate, we started implementing this method (TC).\u003c/p\u003e\u003cp\u003eThe method follows the basic principles of circumcision, releasing the adhesion between the skin and mucous membrane, and then cutting the frenulum and part of the foreskin. This is superior to cutting over a clamp using a scalpel, where the use of a thermocautery device to cut the skin dramatically minimizes the incidence of bleeding.\u003c/p\u003e\u003cp\u003eBleeding is the most common intraoperative and intermediate postoperative complication reported in many studies, irrespective of the device used. We recorded less than 2/1000 cases of active bleeding that required the application of sutures. Even if the whole number is calculated, which is 7/1000 and includes cases that required compression only, it is noticeably less than the incidence in the published series, 2.5% by Siroosbakht et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn another study comprising 2,062 male patients comparing thermocautery, plastic clamping, and surgical circumcision techniques, the authors reported 11/2000 cases of bleeding that required active management; 8, 2, and 1 were after open, clamp, and thermocautery methods, respectively [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the same study, the operative times were 14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9, 5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3, and 4\u0026thinsp;\u0026plusmn;\u0026thinsp;1 min for the classical surgical technique, thermocautery, and clamp-guided technique, respectively (P\u0026thinsp;=\u0026thinsp;0.000). There is an agreement in the literature that the average time for the clamp method is 5 min, while all other techniques are 10 min or longer [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eElectrocautery and thermocautery operate on different principles. The thermocautery device supplies electrical energy by converting it into heat energy instead of passing it through the tissue. It also provides coagulation during circumcision. This method combines the advantage of using a clamp to save time compared to the open method and using thermal injury to cut the skin and minimize bleeding. Additionally, the use of electric cautery with metal instruments during circumcision can result in catastrophic loss of the penis.\u003c/p\u003e\u003cp\u003eIn another study that included a large number of patients undergoing circumcision, the authors used a Thermo-Med TM 806 cautery device. Authors concluded that it is a safe procedure and a good option when circumcisions cannot be performed in a hospital setting[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn another study involving a considerable number of children, the authors concluded that in countries where circumcision is routinely performed, developing faster and safer methods is of utmost importance. To this end, we prefer thermocautery, which can meet patient needs quickly and safely [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our series, the most common long-term complication was redundant skin. Initially, 27 patients were treated with mild preputial dilation and skin retraction; however, 5 of these required redo circumcision, while the remaining patients were reassured. Preputial adhesions often resulted either from inadequate lysis of natural adhesions before circumcision or from distal migration of the skin due to a prominent suprapubic fat pad. Our findings align with those of Williams et al., who reported that 63% of patients presenting for circumcision revision had prominent suprapubic fat pads [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt is worth mentioning that 50% of the cases involving redundant skin occurred during the first year of the study, which was due to the long waiting list. After the first year, this incidence was reported, and the quality management meeting recommended that the decision to proceed should be left to the doctors without any external pressure.\u003c/p\u003e\u003cp\u003eThe contraindications for this procedure are similar to those for other procedures. We scheduled children with undescended testicles and glandular hypospadias with an intact prepuce. Although Jimoh et al. reported postponing children with distal hypospadias, their report was unclear about whether these cases involved distal or glandular hypospadias with an intact prepuce [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe recorded fewer than 1.5 cases of meatal stenosis per 1,000, which contradicts the assumption that thermocautery leads to tissue necrosis and a higher incidence of meatal stenosis. Ammar et al. reported a 4% incidence of meatal stenosis in a series of 150 circumcision cases [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This incidence is too low to justify prophylactic measures, such as applying petroleum jelly to the glans, as recommended by Omole et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe main limitation of our study is its retrospective design; however, it was necessary to include this substantial number of patients with long-term follow-up. Additionally, we classified patients who missed their routine scheduled visits as having no complications, as it was not feasible to contact such a large number of patients for follow-up.\u003c/p\u003e\u003cp\u003eWe believe that each surgical method and procedure has its own advantages and disadvantages, and the choice depends on both the physician and the hospital facilities. In low-volume centers that perform circumcisions only when medically indicated, several different methods may be chosen. However, circumcision using thermocautery could be a good time-saving option for high-volume hospitals.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eFor hospitals that perform infant circumcisions daily for ritual and religious purposes, the thermocautery method is more convenient, can be conducted outside the main operating rooms, and is the most economical option. Additionally, it is a simple technique with the shortest surgical time, which is a priority for busy hospitals. The incidence of intermediate and long-term complications is comparable to that of other surgical methods.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eGenerative AI in Scientific Writing:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eContributors\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eMohamed Mohamed Elawdy\u003csup\u003e1\u003c/sup\u003e [email protected] Idea, proposal, writing\u003c/p\u003e\n\u003cp\u003eEhab Eltohamy \u003csup\u003e2\u003c/sup\u003e [email protected] Data collections\u003c/p\u003e\n\u003cp\u003eKhalid Al-Balushi\u003csup\u003e1\u003c/sup\u003e [email protected] Writing\u003c/p\u003e\n\u003cp\u003eHatem Alsaidy\u003csup\u003e3\u0026nbsp;\u003c/sup\[email protected] \u003csup\u003e\u0026nbsp;\u003c/sup\u003eReviewing\u003c/p\u003e\n\u003cp\u003eTalib Almaqbali\u003csup\u003e3\u0026nbsp;\u003c/sup\u003e [email protected] Reviewing\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDepartment(s) and institution(s)\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eUrology\u003csup\u003e\u0026nbsp;1\u0026nbsp;\u003c/sup\u003ePediatric surgery \u003csup\u003e2\u003c/sup\u003e, General surgery\u003csup\u003e3\u003c/sup\u003e departments, Sohar Hospital, Ministry of Health, Sultanate of Oman\u003c/p\u003e\n\u003cp\u003eFunding: None\u003cbr\u003eEthical approval: IRB was obtained\u003c/p\u003e\n\u003cp\u003eConflict of interest: No\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions: Mentioned above with authors\u0026rsquo; information\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCorresponding Author:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMohamed M. Elawdy\u003c/strong\u003e, MD, MSc., ECFMG certified\u003c/p\u003e\n\u003cp\u003eSpecialist (A) in Urology, Sohar Hospital, Ministry of Health, Oman\u003c/p\u003e\n\u003cp\u003ePhone: 0096891441050\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNelson CP, Dunn R, Wan J, Wei JT (2005) The increasing incidence of newborn circumcision: Data from the nationwide inpatient sample. J Urol 173(3):978\u0026ndash;981\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMorris BJ, Katelaris A, Blumenthal NJ, Hajoona M, Sheen AC, Schrieber L et al Evidence-based circumcision policy for Australia. J Mens Health [Internet]. 2022 [cited 2024 May 10];18(6). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/pubmed/36034719\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/pubmed/36034719\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi G, Li Q, Fu WJ, Hong BF, Luo J, Xu FQ et al (2010) Modified one-cut circumcision technique by clamp: Reports of 2000 cases. Chin Med J (Engl) 123(19):2732\u0026ndash;2735\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eManual for early infant male circumcision under local anaesthesia (2010) ; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/44478/9789241500753_eng.pdf?sequence=1\u0026amp;isAllowed=y\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/44478/9789241500753_eng.pdf?sequence=1\u0026amp;isAllowed=y\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMillard PS, Wilson HR, Veldkamp PJ, Sitoe N (2013) Rapid, minimally invasive adult voluntary male circumcision: A randomised trial. South Afr Med J 103(10):736\u0026ndash;742\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJimoh BM, Odunayo IS, Chinwe I, Akinfolarin OO, Oluwafemi A, Olusanmi EJ (2016) Plastibell circumcision of 2,276 male infants: A multi-centre study. Pan Afr Med J. ;23\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTuncer AA, Erten EEA Examination of short and long term complications of thermocautery, plastic clamping, and surgical circumcision techniques. Pak J Med Sci [Internet]. 2017 Nov 15 [cited 2024 May 10];33(6):1418\u0026ndash;23. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/pubmed/29492070\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/pubmed/29492070\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAky\u0026uuml;z O, Bodak\u0026ccedil;i MN, Tefekli AH Thermal cautery-assisted circumcision and principles of its use to decrease complication rates. J Pediatr Urol [Internet]. 2019 Apr 1 [cited 2025 Jul 23];15(2):186\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.e1-186.e8\u003c/span\u003e\u003cspan address=\"http://.e1-186.e8\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Available from: https://pubmed.ncbi.nlm.nih.gov/30770302/\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZeitler M, Rayala B (2021) Neonatal Circumcision. Prim Care - Clin Office Pract 48(4):597\u0026ndash;611\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiroosbakht S, Rezakhaniha B A comprehensive comparison of the early and late complications of surgical circumcision in neonates and children: A cohort study. Health Sci Rep [Internet]. 2022 Nov 1 [cited 2024 May 10];5(6):e939. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/pubmed/36425897\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/pubmed/36425897\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArslan D, Kalkan M, Yazgan H, \u0026Uuml;n\u0026uuml;var U, Şahin C (2013) Collective circumcision performed in Sudan: evaluation in terms of early complications and alternative practice. Urology [Internet]. [cited 2024 May 12];81(4):864\u0026ndash;8. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed.ncbi.nlm.nih.gov/23465159/\u003c/span\u003e\u003cspan address=\"https://pubmed.ncbi.nlm.nih.gov/23465159/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilliams CP, Richardson BG, Bukowski TP (2000) Importance of identifying the inconspicuous penis: Prevention of circumcision complications. Urology 56(1):140\u0026ndash;142\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbid AF, Hussein NS Meatal stenosis posttraditional neonatal circumcision-cross-sectional study. Urol Ann [Internet]. 2021 Jan 1 [cited 2024 May 10];13(1):62\u0026ndash;6. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/pubmed/33897167\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/pubmed/33897167\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOmole F, Smith W, Carter-Wicker K (2020) Newborn Circumcision Techniques. Am Fam Physician 101(11):680\u0026ndash;685\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Circumcision, neonatal circumcision, infantile circumcision, circumcision methods, thermocautery","lastPublishedDoi":"10.21203/rs.3.rs-8146582/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8146582/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjectives:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe share our experience with thermocautery (TC) used in over 1500 cases. There is a lack of data regarding this technique, and the recent WHO manual for infantile circumcision (IC) included only three devices: Mogen, Gomco, and Plastibell, with limited reports on other techniques.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003e This retrospective study was conducted where IC was a routine procedure in our locality. The most common reasons for patient cancellation were buried penis, excess suprapubic fat, and obesity. No routine preoperative workup was performed. The technique followed the basic surgical principles of IC, with the skin being cut using a digital thermocautery device along a long surgical clamp. Two stitches were placed at 6 and 12 o\u0026rsquo;clock using 4/0 absorbable sutures.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of 1650 patients underwent the procedure during the study period. The mean age was 130\u0026thinsp;\u0026plusmn;\u0026thinsp;15 days old. The entire procedure took 360\u0026thinsp;\u0026plusmn;\u0026thinsp;30 seconds. No major perioperative surgical or anesthetic complications were observed. Eleven patients experienced early postoperative bleeding (7/1000), with only three requiring re-suturing under local anesthesia. Five patients required redo-circumcision, and three developed meatal stenosis, which was treated with meatoplasty.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFor hospitals that regularly perform IC, the thermocautery method offers a simple, convenient, and time-efficient approach. It can be performed outside the main operating room and is cost-effective. This method is nearly bloodless and has the lowest incidence of bleeding compared to other techniques. The occurrence of other complications falls within the range of those observed with other surgical methods.\u003c/p\u003e","manuscriptTitle":"Thermocautery for Infantile Circumcision in High-Volume Hospitals: A Retrospective Analysis of Over 1,500 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 08:26:22","doi":"10.21203/rs.3.rs-8146582/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-16T12:10:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T15:55:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-31T08:54:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109298662542995584234808552846667126959","date":"2026-01-19T18:33:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"99281077008390730256407417601787523076","date":"2026-01-17T08:50:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-24T23:37:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-22T00:41:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-21T16:31:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2025-11-18T14:21:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3c647d95-94fa-462d-b5c0-a31cf2396eee","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:00:10+00:00","versionOfRecord":{"articleIdentity":"rs-8146582","link":"https://doi.org/10.1007/s00345-026-06390-5","journal":{"identity":"world-journal-of-urology","isVorOnly":false,"title":"World Journal of Urology"},"publishedOn":"2026-04-14 15:57:03","publishedOnDateReadable":"April 14th, 2026"},"versionCreatedAt":"2025-12-01 08:26:22","video":"","vorDoi":"10.1007/s00345-026-06390-5","vorDoiUrl":"https://doi.org/10.1007/s00345-026-06390-5","workflowStages":[]},"version":"v1","identity":"rs-8146582","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8146582","identity":"rs-8146582","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}