Circumcision is one of the most common urological procedures. Although circumcision is considered a minor procedure, patients carry a risk of complications, including local edema, local tenderness, hematoma, infection, wound dehiscence, and scarring [7,8,9]. The Holmium YAG laser has been reported to be effective for the treatment of soft tissue pathologies, such as Holmium laser enucleation of the prostate (HoLEP), upper tract urothelial carcinomas, and urinary strictures. The Holmium YAG laser has a short destruction length in the tissue due to strong absorption of water molecules around 2140 nm. A penetration depth of 0.4 mm was reported, which allows coagulation and a vaporation-incision. It is considered suitable for an alternative laser technique for circumcision. Nonetheless, to our knowledge, there has been no evaluations of the efficacy and safety of Holmium laser circumcision. We first reported that there is a shorter operative time, less postoperative pain, less blood loss, and fewer complications among patients who underwent circumcision with Holmium YAG laser. These findings support it as a good choice for laser circumcision. Currently, carbon oxide lasers are widely used for circumcision due to its advantages. First, a CO2 laser provides good incision and hemostasis ability because small vessels can be cauterized under a high-power setting. Second, the effectiveness of the incision is much better with a CO2 laser compared to the conventional scalpel method. Third, patients feel less postoperative pain compared to those treated with the conventional method, which increased the comfort of the patients. Several studies have supported these theses. Xu et al. stated that there were shorter operative times, less blood loss, and a lower postoperative complication rate in the laser group compared to the conventional group . Mungnirandr et al. reported similar conclusions as well . They found that the CO2 laser and tissue glue method were a good procedure with a significantly shorter operative time, lower proportion of tissue with local irritation, and good cosmetic appearance. Gorgulu et al. also stated that the combined CO2 laser and cyanoacrylate procedure not only decreased the operating time markedly, but also eliminated the disadvantages . As for the Nd-YAG laser used in circumcision, George Vaos completed a trial with patients who underwent the guillotine circumcision procedure with a Nd-YAG laser (setting of 15–30 W and pulse duration of 0.2–0.5 s) or conventional scalpel electrocoagulation . He found fewer early and late complications in the Nd-YAG laser group but spent more time in the Nd-YAG laser group than in the conventional group.
To the best of our knowledge, the present study is the first to evaluate the efficacy and safety of circumcision using the Holmium YAG laser. A shorter operative time, less postoperative pain, less blood loss, and fewer complications were found. However, the cost of CO2 lasers is expensive for patients and medical providers. The cost of a laser device is about Singapore dollars $105,000 (approximately equal to USD $75,124). The maintenance charges are Singapore dollars $5000 (approximately equal to USD $3577) every year, and the predictable lifespan for each device is 10 years. Thus, the machine costs comprise Singapore dollars $15,500 (approximately equal to USD $11,089) per year . In a local hospital or clinic, there are estimated to be one hundred circumcisions per year, which makes the cost of the device per circumcision Singapore dollars $155.0 (approximately equal to USD $110.89). Hence, the cost of a Holmium YAG laser per use is just USD $66.20. Although this cost is more than the conventional scalpel method, the above finding is useful information for small capacity hospitals or clinics, and the Holmium YAG laser can be an alternative choice for laser circumcisions.
Another important issue widely discussed is the potential for sub-clinical injury by electrosurgery on the penis. Some studies have shown that conventional monopolar electrocoagulation may cause electrical burns, penile tissue damage, and necrosis [13,14,15,16,17]. Tsai et al. conducted an experiment that demonstrated the electrical field strength of the whole penis shaft was 9.03 V/cm. They found heat generated from the penis is four times that of other body parts, which may contribute to erectile tissue damage by heat . They also suggested since they use less power (W) and less time, bipolar electrosurgery, ligation to achieve hemostasis, and new laser technologies, including CO2, Nd-YAG or Holmium YAG laser, are superior methods.