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ORIGINAL ARTICLE
Year : 2023 | Volume
: 34
| Issue : 1 | Page : 28-32
Comparison of Holmium: YAG laser circumcision with conventional circumcision in adult male
Chih-Chun Kuo, Chia-Hao Kuei, Chun-Hou Liao, Yu-Hua Lin
Division of Urology, Department of Surgery, Cardinal Tien Hospital, New Taipei City, Taiwan
Correspondence Address:
Dr. Yu-Hua Lin
Department of Surgery, Division of Urology, Cardinal Tien Hospital, New Taipei City
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_169_21
Purpose: To evaluate the use of the Holmium: Yttrium-aluminum-garnet (YAG) laser versus the conventional dorsal-slit procedure for adult male circumcision. Materials and Methods: From January 2020 to December 2020, 60 adult men diagnosed with as having phimosis and received circumcision were enrolled. Patients received either Holmium: YAG laser circumcision or conventional circumcision. In this study, we assessed the difference between the groups. Results: Although the operative time and blood loss decreased more in the Holmium: YAG laser circumcision group than in the conventional circumcision group (P < 0.001), a longer short-term delay in wound healing was observed in the laser circumcision group than in the conventional circumcision during the follow-up course (20.0% vs. 3.3%, P = 0.04). Our results also demonstrated no significant difference between the two groups in pain control, postoperative prepuce edema, prepuce redundancy, infection, or hematoma occurrence (P > 0.05). Microscopy findings of the resected prepuce in the Holmium: YAG laser circumcision group demonstrated a high percentage of coagulated small capillaries near the cutting edge. Conclusion: The holmium laser seems to be a concrete and feasible option for circumcision. Although patients undergoing holmium laser circumcision benefit from less blood loss and a rapid surgery compared to the conventional procedure, there is a higher risk of poor wound healing in short-term follow-up.
Keywords: Circumcision, Holmium, male, male circumcision
Adult male circumcision has been performed for centuries and has been demonstrated to decrease the risk of sexually transmitted infections, such as the human immunodeficiency virus (HIV), human papillomavirus (HPV), and herpes simplex virus infections.[1],[2]
Various circumcision methods have been established. Currently, the dorsal-slit procedure is most widely used worldwide. Although all the techniques have good long-term results, there is a continuous need to improve the safety and efficacy of the circumcision procedure. Laser circumcision is a relatively new technique. Aynaud et al. first reported the use of a CO2 laser in 1995,[3] but this method was not widely applied until the last decade. Although the CO2 laser had promising results,[3],[4] its cost is prohibitive for most urological institutions.
The Holmium: Yttrium-aluminum-garnet (YAG) laser is a pulsed laser with a wavelength of 2140 nm. It is well-known for its efficacy as an intracorporeal lithotripter for urolithiasis and had been used for a wide range of soft tissue treatments, including the ablation of urothelial tumors and incisions of strictures over the urinary tract,[5] thermokeratoplasty for hyperopia and astigmatism in the cornea,[6] and endoscopic treatment of tracheal stenosis.[7] As the Holmium: YAG laser is common in most urology departments for urolithiasis and urothelial lesions, adapting it for circumcision will significantly decrease the cost of setting up and maintaining the CO2 laser. However, no previous study has evaluated the feasibility of performing circumcision using a Holmium: YAG laser. Therefore, our study aimed to evaluate the use of a Holmium: YAG laser compared to the conventional dorsal-slit procedure for performing adult male circumcision.
Materials and MethodsPatients
We retrospectively reviewed patient records from January to December 2020 after excluding patients with active balanoposthitis, active genital infections, sexually transmitted diseases, anatomical abnormalities of the penis, acute-stage paraphimosis, or trauma. Adult male patients who were diagnosed with phimosis were eligible for enrollment. Patients chose to receive either conventional circumcision or Holmium: YAG laser circumcision after they were informed about the differences and costs of the methods. We then enrolled consecutive patients receiving laser circumcision or conventional circumcision into each group. The enrollment was terminated as soon as each group had 30 patients.
Operative technique
All procedures were performed using a penile-ring regional block and penile root nerve block anesthesia with 1% lidocaine. Circumcision was performed by the same urologist who was well trained and experienced with circumcision practices. The laser circumcision procedure was a modification of the “Cutting method,” and all patients in the conventional group received a dorsal slit for circumcision. Detailed procedure steps explained as follows.
Laser group
For this group, we used a Multipulse Holmium: YAG laser (Medilas H20; Dornier MedTech, Munich, Germany) with a wavelength of 800 nm at a continuous power setting of 800 mJ. The laser energy was delivered to the prepuce in the contact mode using a delivery system consisting of a reusable optical fiber that focused the light beam onto a spot with a diameter <0.3 mm. We performed the laser circumcision using the following steps:
Step 1. After confirming adequate anesthesia, the fat pad around the base of the penis was compressed firmly to the pubic symphysis [Figure 1]a. The location of the glans beneath the prepuce was identified, and the distal end of the foreskin was stretched. After pulling the prepuce forward as much as possible, a Doyen intestinal clamp was fixed just above the glans [Figure 1]bStep 2. The prepuce was resected using the Holmium: YAG laser via a contact technique [Figure 1]c and [Figure 1]d. The incision line was made oblique to the ventral side of the preputial skin, about 0.5 cm more elongated than the dorsal sideStep 3. After achieving hemostasis with electrocauterization, the cut edges of the foreskin and preputial tissue were approximated with interrupted 4–0 absorbable sutures [Figure 1]eStep 4. The surgical wound was covered with Vaseline gauze and draped with an elastic bandage, which was removed 24 h postoperatively [Figure 1]f.
Figure 1: Surgical procedures for Holmium: YAG laser circumcision: (a) Localize the glans level beneath prepuce after compressing the fat pad around penile root firmly to the pubic symphysis. (b) Pulling the prepuce forward as much as possible and use Doyen's intestinal clamp for foreskin fixation just above the glans. (c) Resecting prepuce with Holmium: YAG laser just along the intestinal clamp edge. (d) The prepuce status after Holmium: YAG laser resection. (e) Cut edge suture with few interrupted absorbable suture. (f) The incision was covered by a Vaseline gauze and an elastic bandage. YAG: Yttrium-aluminum-garnetConventional group
After the incision was completed, dissecting scissors and artery forceps were used, and the conventional dorsal-slit method of circumcision was performed. Monopolar electrocoagulation was used to achieve hemostasis. The cut edges of the skin and preputial tissue were approximated with interrupted 4–0 absorbable sutures. A Vaseline gauze and elastic bandages were also applied to cover the incision, and they were removed 24 h postoperatively.
Follow-up and data collection
Operating time and intraoperative blood loss were recorded. The operating time was defined as the duration from draping until complete suturing of the wound. We recorded the blood loss by subtracting the dry weight of the gauzes from the blood-soaked weight of the gauzes. Postoperatively, all patients were discharged to their homes on the same day. They received an oral antibiotic for 3 days to prevent infection. All patients were advised to apply 3% tetracycline topical ointment on the operative site daily for 1-week after removing the dressings and to avoid intercourse and masturbation for 6 weeks postoperatively to prevent failure of the wound healing process.
Patients were followed up at the hospital 1-day, 1-week, 2 weeks, and 1-month postoperatively. During the follow-up period, patients with any complaint were encouraged to visit the hospital. Regarding pain assessment, participants were asked to rate their postoperative pain at 1-day and 7 days postoperatively using a visual analog scale that displays numbers and words describing levels of pain from 0 (no pain) to 10 (worst pain possible). Side effects were closely monitored during the postoperative period. Postoperative bleeding or hematoma was defined as bleeding or development of a hematoma during the postoperative course after the removal of the wound dressing. Edema was defined as an edematous change in the prepuce near the sutured wound or foreskin on postoperative day 7. Infection was defined as a wound presenting with purulent discharge and local inflammatory signs with erythema or progressive local heat. Delayed wound healing was defined as a poor wound healing status without complete closure on postoperative day 7.
Statistical analysis
Statistical analysis was performed using the Statistical Package for the Social Sciences for Windows (version 22.0; SPSS Inc., Chicago, IL). Continuous data are presented as means ± standard deviations. The t-test and Chi-square tests were used to compare the data between groups. All P values were two-sided, and a P < 0.05 was considered statistically significant.
Registration and ethical considerations
This study was approved by the Institutional Review Board and Ethics Committee of Cardinal Tien Hospital (Approval number: CTH-110-3-5-048). For this type of study, formal consent is not required. This report does not contain any studies of animals.
ResultsA comparison of the clinical data is displayed in [Table 1]. The laser and conventional groups had a similar age distribution (32.17 ± 10.77 vs. 29.60 ± 12.63 years, P = 0.40). The operative time was shorter in the laser group by more than 10 min (13.5 ± 1.8 min vs. 27.1 ± 2.5 min, P < 0.001), with less blood loss (0 ± 0 g vs. 6.76 ± 0.58 g, P < 0.001). There was no significant difference in pain control between the laser and conventional groups on postoperative day-1 (2.10 ± 1.24 vs. 2.20 ± 0.93; P = 0.73) and day 7 (1.07 ± 0.25 vs. 1.13 ± 0.35; P = 0.40).
Short-term postoperative prepuce edema was most commonly observed on postoperative day 7, with an incidence rate up to 43.3%. A slightly higher portion of patients in the conventional group (50%) had complications, but the difference was significant (P = 0.4). All patients that complained of edema over the prepuce recovered gradually by 1-month postoperatively, and none required surgical treatment. Postoperative bleeding or hematoma was observed in 3.3% of all patients and only in the conventional group. These patients were treated with compressive management; a second operation was not required for hemorrhage control. The incidence of short-term dehiscence of the sutured wound, which was associated with incomplete healing on postoperative day 7, was 11.7%; most of these patients (Six of Seven patients) were in the laser group. No patient required a second operation or suturing or had late complications, such as adhesion, secondary phimosis, or scar formation. In both groups, excellent cosmetic results were noted at the follow-up visits, and no secondary operations were performed because of an unacceptable appearance.
A coagulation effect was noted over the cutting edge of the prepuce in the laser group under microscopic examination. Compared to the conventional group, the irradiated skin tissue in the laser group showed thermal damage, epidermal ablation, and a coagulation zone [Figure 2]. Total loss of the stratum corneum and gradual thinning of the epidermis occurred. Histologic findings included loss of hair, disappearance of hair follicles, and inflammation of all damaged areas. In the dermis, the majority of the collagen fibers were coagulated, which led to darker and slightly bushed appearance. Collagen shrinkage with coagulated arterioles, venules, or capillaries was found on microscopic examination.
Figure 2: Pathological examination of laser circumcised prepuce revealed increased thermal damage and coagulation zone. Cutting edge of prepuce surface showed loss of hair and follicles, and inflammation over thermal damaged areas (arrows). Shrinkage capillaries were presented in subcutaneous layer with coagulated collagen fibers (arrow heads) Discussion Circumcision remains an important operation for phimosis or recurrent balanoposthitis. Recent systematic reviews have demonstrated that circumcised adult men benefit from reduced HIV or HPV infection, and circumcision reduces the risk of other acquired sexually transmitted infections.[1],[2] Circumcised adult men also have decreased penile sensitivity, which may be beneficial for patients who prematurely ejaculate.[8],[9] Although regarded as a simple and minor operation, circumcision is still associated with the risk of complications, including bleeding, infection, fistula, necrosis of the glans, buried penis, penile amputation, or even death.[10],[11] Different modalities have been developed for circumcision in the past few decades, including the disposable suture device, circular stapler, Unicirc, CO2 laser, and other devices.[3],[4],[12],[13],[14],[15]
According to our literature review, no previously published studies have mentioned the use of the Holmium: YAG laser for prepuce circumcision. In the current study, we analyzed the superiority and feasibility of Holmium: YAG laser circumcision compared to conventional circumcision. Although CO2 laser circumcision was developed about two decades earlier, the high cost of setting up and maintaining the CO2 laser equipment prevented the popularization of laser circumcision. In addition, the CO2 laser can only be used in room air for cutaneous lesions, and its nonadaptability for making incisions in the prostate or bladder tumors further limited its widespread adoption. However, the Holmium: YAG laser is routinely used for urolithiasis and is commonly available in the urology department of most hospitals. Several reports have demonstrated the use of the holmium laser with enucleation or incision methods for prostate enlargement, bladder neck contracture, or bladder tumor management.[5] The Holmium: YAG laser enables urologists to work on soft tissue, and the technique is easy to master. If using Holmium: YAG laser for circumcision is proven to be safe and superior to conventional circumcision, its adaptation could significantly lower the cost of laser circumcision as a treatment option for circumcision.
Compared to previous reports on laser circumcision, our study also demonstrated the benefits of less intraoperative bleeding and a shorter operation time. In our study, histologic results showed thermal damage over the cutting edge with coagulated capillary and arterioles. The decrease in operative time seemed to be related to the time saved in achieving hemostasis. However, an increased prevalence of delayed wound healing was observed in the laser group during the short-term follow-ups, as shown in our results. This may be associated with coagulated capillaries and a damaged subcutaneous layer due to the thermal effect of laser cutting. As laser has a damaging effect on skin tissue,[16],[17] this effect could slow down the healing process. A different frequency and energy level may be associated with different effects on the skin. The photodamage induced by a CO2 laser is caused by photothermal effects, which involve burning and vaporizing mechanisms to ablate the epidermis. The burning area literally expands and penetrates deep into the dermis, subsequently causing collagen coagulation.[17] The delayed wound healing seemed to be only a short-term effect because the two groups of patients demonstrated no difference in wound healing at 1-month postoperatively. No increase in scar formation was observed in either group.
Better postoperative pain control was reported with the use of CO2 laser for circumcision compared with conventional circumcision in a previous study.[4] However, Holmium: YAG laser showed no superiority in pain control in our study. Instead, a lower pain score was reported by patients in the conventional group, which might be related to the different operative procedure on circumcision. Xu et al. also reported decreased reversible postoperative edema in the laser group.[4] In our study, the prevalence of postoperative edema was not significantly different between the two groups. Photodamage may be attributed to both decreasing venous and lymphatic return, whereas postoperative edema in the conventional group was most likely related to incomplete hemostasis or subcutaneous tissue damage due to electrosurgery. Hence, no difference in the postoperative edema was found between the groups.
Conventional circumcision may contribute to potential and subclinical injury to erectile tissue caused by electrocauterization during hemostasis. The injury mechanism can be attributed to thermal (electrical current) and nonthermal (mainly electrical field) effects.[18] However, laser circumcision prevents electrosurgical injury. The present study was limited by our noncollection of long-term follow-up data on sexual function and possible erectile dysfunction. Thus, further investigation seems necessary regarding our findings.
ConclusionsOur study demonstrated that the Holmium: YAG laser is a safe and feasible method for performing circumcision in adult men. A decrease in the operative time and less blood loss was observed with the Holmium: YAG laser compared to the conventional circumcision procedure. The potential disadvantage of using the laser is delayed wound healing in a short-term follow-up period. This modified technique has proven to be a useful alternative to the conventional surgical technique.
Financial support and sponsorship
Nil.
Conflicts of interest
Dr. Chun-Hou Liao, an editorial board member at Urological Science, had no role in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
References
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