Although circumcision has been recommended for religious, social and legal reasons, there is a hypothesis that the use of electric devices may be hazardous for the neurovascular compartment of the genital organs, such as the peripheral NR complex [11, 12]. In our research, we aimed to investigate if preputium cutting in circumcision using modern surgical methods plays an important role in preputial excision injuries. Aydin et al. have reported that genital organs innervating pudendal nerve/taste rosea circuitry injuries may be responsible for disorgasmia causing by disruption of the erectile/ejaculatory/somatosensitive feedback networks [11, 12]. Circumcised patients may suffer from some neurourological or psychosexual disorders because pudendal nerve network injuries could result in disorgasmia as reported by Aydin et al. [4]. Circumcision is used to treat phimosis and recurrent balanitis and reduce the risk of urinary tract infection in boys less than 1 year old with concomitant urinary tract abnormalities and is performed for religious, cultural and societal preferences.
Pudendal, pelvic and hypogastric nerves consist of somatic and autonomic fibres that innervate penile tissues and produce orgasmic sensations [3].
Understanding the anatomy of the penile neurovascular network in rabbits is necessary. Thus, we examined the branching patterns of their penile vessels. The internal pudendal artery and ischiatic arch are the primary sources, which are divided into two branches, that is the deep and dorsal penile arteries at the ischiatic arch level. The deep penile artery passes through the tunica albuginea and forms the arterial web of corpus cavernosum penis; on the other hand, the dorsal penile artery is divided into three small branches between the subischiocavernosus muscles, while two small branches form an arterial network around the preputium, the dorsolateral surface of the penis and the glans. Moreover, the caudal branch of the prostatic artery sends some branches to penile circulation [2]. During circumcision surgery, the dissected nerves, arteries and veins are mostly pudendal nerves and dorsal penile arteries; therefore, we examined the pudendal nerve ganglia at the bilateral third sacral root ganglia level.
Simple surgical circumcision is still the most commonly used method in male children worldwide [13]. Therefore, circumcision during infancy merely for the nonretractile prepuce is unwarranted, which is the cornerstone for the modern anticircumcision movements [1]. Circumcision is advised for the treatment of phimosis or balanitis [14], although electrocautery damage can be prevented via the tunica albuginea of intracavernous sinusoid insult, which plays an essential role in fulfilling the venoocclusive mechanism [6].
The basic procedure of circumcision is to remove the preputium without causing complications. Although the essential circumcision technique is surgical circumcision, some surgeons use monopolar cautery or thermocautery ablation. Nevertheless, monopolar-bipolar electrocautery devices are also used for postoperative bleeding control. Using bipolar scissors is a safe operation method [15]. Recently, using the Colorado MicroDissection Needle is recommended for easy tissue dissection and separation without complications [16].
Electrical accidents can lead to SC injury complicated by motor, sensory and autonomic dysfunctions. The direct current and heating effect of electric devices can result in neurovascular and SC damage [17].
In circumcision surgery, postoperative bleeding complications occur frequently [5]. If bleeding is potentially dangerous, then electric devices should be used; however, they frequently result in skin bridges and neurovascular complications [18]. Postcircumcision electrocautery penile ablation injuries could lead to vascular injury-related ischaemic insults and scar formation [19]; such pathologies would be more frequent if electric devices are used. Gangrene of the glans penis is the most dangerous complication of electrocautery following circumcision [20]. It is also well-known that electrocauterisation may result in the development of thrombosis [11] and neuronal degeneration in DRG [12]. According to Peng et al., using the Ultracision Harmonic Scalpel in circumcision is a safe method because of its simplicity and lower complication rates [21]. To avoid the hazardous electric current in bipolar scissors, circumcision is advised, since it is more effective and safer than the standard scalpel techniques in terms of morbidity [22]. Electrocautery is more commonly used in separating the prepuce from the glans in newborn circumcision; however, the glans is superficially injured and if the shaft skin or part of the circumcision wound adheres to this, it may cause epithelialisation and growth, causing a skin bridge [23, 24]. The authors recommended that high-voltage electrocautery should not be employed in such circumstances. Since there is no retrograde injury in cautery in bipolar, the damage is less. The same mechanism is also valid for thermocoutery [25]. We think this is the reason why we suffer more damage in monopolar cautery and less damage in others.
Both the literature and our research suggest that the circumcision process should be further investigated in future studies.
Clinical implications of the study
Sensory innervation of the penile tissues affects wound healing through the immunoregulatory and circulation modulation of nerve endings [26]. Wound healing could be challenging in the presence of neural injuries. Although circumcision may be useful in preventing harboured uropathogenic flora infections [27], using electrical devices induces neural circuitry pathologies such as nonhealing wound and circumcision area infections. Moreover, we demonstrated that electrical device usage might cause penile tissue innervating somatosensitive nerves and their ganglia injury. The following complications should be attributed to neural network collapse following circumcision: penile adhesion, skin bridges, meatal stenosis, redundant foreskin, recurrent phimosis, buried penis and penile rotation [28], residual foreskin, meatal stenosis, granuloma [29] and postcircumcision necrosis [30]. According to our clinical experiences, the granuloma is frequently developed from cauterised nerve endings [12]. For that reason, high-voltage electrical devices should not be used unless necessary.
Limitations
This was an animal study; as a result, its findings may not be generalisable to humans. If we used local anaesthetics some resembling complications like electrocautery could be possible. Lack of sham group may be another limitation; however, the surgical circumcision group may be considered a sham group. Surgical circumcision methods were compared in this study, but Gomco, plastibell and clamp methods were not included in the study, which is one of the limitations of our study. If the vascular injury is mild, satellite neural and endothelial cells can be regenerated with neovascularisation and collaterals to develop. If apoptotic neurodegeneration has begun, the neurodegeneration is irreversible. However, since this study was short, no evaluation was made regarding whether neuronal degeneration was reversible or irreversible, which is one of the limitations of our study.