A rare complication of circumcision due to monopolar cauterization: Penile necrosis

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Introduction

Circumcision is one of the most common surgical practices and complication rate is around 1% [1]. Many methods were described but until recently, electrocauterization was not preferred due to its possible
risks [2]. There are conflicting results at the literature regarding complications of monopolar cauterization during circumcision [2-4].

Differences of approachment might be because of this complication is encountered very rarely. After penile necrosis takes place, it is sensible to use medical treatment and hyperbaric oxygen modalities. However at some cases, it seems that tissue loss is inevitable [3]. Yet, feminizing genitoplasty is a tough decision to make [4].

At this case report, three-years old male patient who had penile necrosis after circumcision with monopolar cauterization is presented. Medical treatment and hyperbaric oxygen treatment was started after application but benefits of these treatment modalities seemed to be limited. After the debridement of the necrotic tissues, penile reconstruction was practiced and skin graft was applied. No serious complication was encountered and patient was discharged 23 days after circumcision.

Case Presentation

Three-year old male patient with no other morbidities was circumcised on an outpatient setting. After being discharged, patient re-applied the same center because of disruption of the circulation of glans penis. At this center, dressing with an antibiotic pomade was applied and local care was advised. However, the patient’s symptoms were not improved and urethra was catheterized with an 8f foley catheter and referred to our hospital. Patient was hospitalized on the fifth day after circumcision. At the bed-side examination, glans and distal one centimeter of penis evaluated as necrotic (Fig 1). But when penis was incised at this level, bleeding occurred. Broad-spectrum intravenous antibiotic (sulbactam-ampicilline and amikasin), local glycerin and bacitracine pomade treatment was started. Patient was consulted to pediatric hematology department. Initial coagulation parameters was normal. Intravenous heparine, dextrane-40, ilioprost and pentoxyphylline treatment was started. Meanwhile, hyperbaric oxygen treatment and hydrotherapy for an hour twice daily started. After 2 days, heparine infusion was stopped and enoxaparine was started. 11th day after the circumcision, debridement was made, considering benefits of medical treatment happened to be limited and demarcation line developed. During debridement, once glans was incised, no bleeding occurred. Necrotic tissues were excised and only proximal half of the penis remained. At this level, bleeding occurred and debridement ended. Urethra catheterized with a 6f foley catheter. Skin fleb was prepared using surrounding tissues and penis was implanted under scrotal skin at the suprapubic region (Fig 2). After the operation, enoxaparine, dextrane-40, ilioprost and pentoxyphylline treatments were stopped. No complication occurred after the debridement. Eight days after the debridement, penile reconstruction was made. Penis isolated from surrounding tissues and degloving was made until penile root was reached. Penopubic ligament was dissected (Fig 3). At the end, five centimeters of penile length was achieved. After this, full-thickness skin graft was harvested from antecubital region. Graft was spread over penis and sutured. Fat tissue at suprapubic region was excised in order to prevent buried penis. After this penile reconstruction was concluded (Fig 4). Wound dressed made with Bactigras, Smith and Nephew. Postoperatively diazepam and ibuprofen treatment was started. Wound dress was removed 3 days after penile reconstruction and grafts evaluated as well-adapted. Hydrotherapy was started. Urethral catheter was removed 12 days after penile reconstruction. Patient urinated with a good calibration through neomeatus at the tip of the penis. He was discharged with local methylprednisolone treatment. On postoperative day 58 after the circumcision, patient re-applied to clinic without any complaints (Fig 5). On examination, a granulation tissue at the ventral site of penis was seen and excised. Cystoscopy was practiced and no pathology was found. The patient still uses Contractubex and local methylprednisolone treatment.

Fig. 1. Necrotic glans and penile skin on admission.

Fig. 2. After debridement, penis was embedded into the suprapubic region.

Fig. 3. Penis dissected through the pubic roots and 5 cm of penile length was achieved.

Fig. 4. Penile reconstruction was completed.

Fig. 5. On postoperative 2nd month, reconstructed penis seems well.

Results and Discussion

Penile necrosis due to monopolar cauterization during circumcision is a rare but serious complication that is hard to manage. In this case, no improvement seen in the necrotic parts despite intense medical treatment, that is being consistent with literature, and debridement necessitated. After the debridement, cavernous bodies dissected, penile reconstruction was made and penile length increased more than twice. Skin defect was closed with an autologous skin graft. Patient discharged 23 days after circumcision without any problem.

Bipolar cauterization is commonly and safely used during circumcision. However, there are conflicting results about usage of monopolar cauterization during circumcision. Peters et al. reported that they have seen no necrosis or circulatory problem after using monopolar cauterization [2]. Yet, there are a couple of case reports regarding glans necrosis due to monopolar cauterization. In the case reported by Uzun et al. debridement became inevitable despite of hyperbaric oxygen treatment [3]. Gearhart et al. applied feminizing genitoplasty all four of their patients after penile necrosis [4]. Recently, in two separate animal experiments, monopolar and bipolar cauterization during circumcision were compared and it was shown that bipolar cauterization causes localized but deeper burns and monopolar cauterization causes necrosis at distant areas and intravascular coagulation [5,6]. In a systematic review, Altokhais et al. revealed that monopolar cauterization must be avoided during circumcision. In our case, no prominent benefit was seen after intense medical treatment, however after demarcation line developed, debridement and penile reconstruction was made successfully. Urethral stricture, chordee, fistule or erectile dysfunction are thought to be potential late complications. Local steroid and vacuum treatments were started and the patient will be followed regarding these possible complications.

Conclusion

The usage of monopolar cauterization is a risky situation that might even cause organ losses. However, once the complication develops, penile reconstruction via cavernous body dissection and skin graft is an applicable
and satisfactory option.

Ayşe Ertoy

ORCID: 0000-0002-3129-0130

e-mail: ayseertoy@gmail.com

Phone number: 00905056004503

Ankara Şehir Hastanesi Çocuk Hastanesi Çocuk Cerrahisi Anabilim Dalı

06800 Üniversiteler Mahallesi 1604. Cadde No: 9 Çankaya/ANKARA

Hüseyin Tuğrul Tiryaki

ORCID: 0000-0002-9544-1137

e-mail: httiryaki@hotmail.com

Phone number: 00905323728015

Ankara Şehir Hastanesi Çocuk Hastanesi ÇocukÜrolojisi Bilim Dalı

06800 Üniversiteler Mahallesi 1604. Cadde No: 9 Çankaya/ANKARA

Emrah Şenel

e-mail: dremrah2000@yahoo.com

ORCID: 0000-0002-0383-4559

Phone number: 905321940309

Ankara Şehir Hastanesi Çocuk Hastanesi Çocuk Cerrahisi Anabilim Dalı

06800 Üniversiteler Mahallesi 1604. Cadde No: 9 Çankaya/ANKARA

Gökhan Demirtaş

ORCID: 0000-0003-0787-2330

e-mail: drgokhandemirtas@gmail.com

Phone number: 905066340217

Ankara Şehir Hastanesi Çocuk Hastanesi Çocuk
Ürolojisi Bilim Dalı

06800 Üniversiteler Mahallesi 1604. Cadde No: 9
Çankaya/ANKARA

Derya Yayla

ORCID: 0000-0001-7811-5949

e-mail: dryayla@yahoo.com

Phone number: 905053572662

Ankara Şehir Hastanesi Çocuk Hastanesi ÇocukÜrolojisi Bilim Dalı

06800 Üniversiteler Mahallesi 1604. Cadde No: 9 Çankaya/ANKARA

Süleyman Tağcı

ORCID: 0000-0002-5763-8916

e-mail: suleyman_tagci@hotmail.com

Phone number: 905309383522

Ankara Şehir Hastanesi Çocuk Hastanesi Çocuk Ürolojisi Bilim Dalı

06800 Üniversiteler Mahallesi 1604. Cadde No: 9Çankaya/ANKARA

References

1. American Academy of Pediatrics. Report of the task force on circumcision. Pediatrics. 1989; 84: 388-391.
2. Peters KM, Kass EJ. Electrosurgery for routine pediatric penile procedures. J Urology. 1997; 1453-1455.
3. Uzun G, Ozdemir Y, Eroglu M, Mutluoglu M. Electrocautery-induced gangrene of the glans penis in a child following circumcision. BMJ Case Rep. 2012; 2012-007096.
4. Gearhart JP, Rock JA. Total ablation of the penis after circumcision with electrocautery: A method of management and long-term followup. J Urology. 1989; 799-801.
5. Günal DY, Boybeyi O, Atasoy P, Kisa U, Aslan MK, Bakar B, et al. Oxidative and histopathological effects of the application of electrosurgical devices to the penile tissue of rats. J Pediatr Urol. 2020; 16: 39E1-E7.
6. Tuncer AA, Bozkurt MF, Bayraktaroglu A, Koca HB, Dogan I, Çetinkursun S, et al. Examination of histopathological changes of scalpel, monopolar, bipolar, and thermocautery applications in rat experimental circumcision model. Am J Transl Res. 2017; 9: 2306-2313.