A Comparative Study Of Gomco And Dorsal Slit Techniques In Male Circumcision

A Comparative Study Of Gomco And Dorsal Slit Techniques In Male Circumcision | 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 A Comparative Study Of Gomco And Dorsal Slit Techniques In Male Circumcision Rahmi Gokhan Ekin, Askin Eroglu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9140068/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Gomco clamp (GC) and dorsal slit (DS) are common techniques of circumcision. We compared GC and DS regarding operative and postoperative outcomes, complications and revision rates in children who underwent circumcision under local anesthesia. Methods Between January 2017 and July 2023, 1488 patients who underwent circumcision using a GC or DS were analyzed. Age, presence of pathological phimosis, operation time, complications, revision surgery requirement, and family satisfaction score were evaluated. Results GC and DS were performed on 921 (62.6%) and 551 (37.4%) children, respectively. Age (5.8 ± 5.1 vs. 5.4 ± 5.3, p = 0.309) and presence of pathological phimosis (5.3% vs. 7.9%, p = 0.092) were not statistically significant differences between the GC and DS groups. The operative time was statistically significantly shorter in the Gomco clamp group compared to the DS group (9.88 ± 2.63 vs. 18.07 ± 4.11, p < 0.001). There was no statistical difference in the family satisfaction score between the two groups (8.7 ± 1.1 vs. 8.1 ± 1.7, p = 0.131). There was no significant difference between the two groups in overall grade 1, grade 2, and grade 3 complications. Conclusions The GC and the DS techniques have satisfactory results and acceptable complication rates in children who underwent circumcision under local anesthesia. circumcision dorsal slit Gomco clamp complication family satisfaction BACKGROUND Male circumcision (MC) is one of the oldest surgical procedures performed since ancient Egypt. It is one of the most common surgical procedures performed worldwide. MC is performed due to cultural, religious, and medical reasons across various populations [ 1 ]. In MC, the foreskin of the penis is surgically removed. It can be performed using a variety of techniques, including dorsal slit (DS), sleeve resection, forceps-guided, the Gomco clamp, the Mogen clamp, and the Plastibell device [ 2 ]. The overall complication rate varies between 0.34% and 3.8% depending on the surgical technique used, the experience of the surgeon, and the age of the patient (neonatal vs. non-neonatal) [ 1 , 3 ]. MC is associated with several health benefits, including reduced risks of urinary tract infections, HIV and other sexually transmitted infections, and penile cancer [ 4 ]. The World Health Organization published Manual of Male Circumcision under Local Anaesthesia. Although many different MC techniques have been described in the literature, three adult techniques and four pediatric techniques are recommended by the World Health Organization [ 5 , 6 ]. The Gomco clamp, the Mogen clamp, the Plastibell device, and the DS technique are suggested for pediatric patients. Both of them have their own advantages and disadvantages [ 5 , 6 ]. The DS circumcision is a traditional and highly efficient technique, especially in acute inflammation [ 3 , 7 ]. To achieve the desired outcome, it would be necessary to remove the excess foreskin and skillfully suturing the incision. The likelihood of complications relating to the glans and urethra is significantly reduced as the glans penis is easily visible throughout the procedure [ 3 , 7 – 9 ]. However, the DS circumcision can be quite complex and time-consuming, resulting in a longer period of learning curve for the healthcare providers. Additionally, cosmetic problems are more common due to the inability to cut the prepuce skin symmetrically using the DS technique [ 8 , 9 ]. Bleeding, edema, infection, and wound dehiscence are complications of DS technique [ 8 , 9 ]. Considering the disadvantages of standard surgical MC techniques, the World Health Organization is seeking research on alternative methods. New techniques could potentially improve the safety, ease, and speed of circumcision procedure. Additionally, it may promote faster wound healing and potentially reduce the risk of HIV transmission compared to standard surgical techniques. Moreover, healthcare providers with basic training could perform this procedure safely. Lastly, when considering the implementation of MC on a larger scale, it would be a cost-effective alternative to traditional surgical methods [ 5 , 6 , 10 ]. The Gomco clamp is widely utilized in the United States for neonatal MC [ 11 ]. The Gomco clamp has a round metal part that encloses over the glans penis and beneath the foreskin, and a flat metal apparatus that intended to secure the bell in place and to protect the glans penis. The Gomco technique involves squeezing the prepuce between the plate and the bell. The prepuce is then removed by cutting around the upper surface of the plate [ 5 , 6 , 10 , 11 ]. Bleeding, edema, infection, wound dehiscence and laceration of the glans penis due to mismatch between the parts of the Gomco clamp are complications of Gomco clamp [ 9 ]. In this study, we compared dorsal slit and Gomco clamp techniques regarding operative and postoperative results, complications and revision rates in patients who underwent male circumcision under local anesthesia. METHODS After institutional review board approval (Acibadem University, No:ATADEK 2025/14, Clinical trial number: not applicable), data of patients who underwent MC using a Gomco clamp or the DS technique from January 2017 to July 2023 were evaluated. Informed consent was provided by all patients. This study included neonates, infants, and children who had a foreskin that was intact and needed to be circumcised for religious, cultural, or medical reasons such as phimosis, paraphimosis, and balanoposthitis. Hypospadias, buried penis, undescended testis, micro penis, epispadias, patients with bleeding disorders, patients who underwent MC under general anesthesia, and patients with missing data were excluded from the study. The procedures were performed by experienced surgeons who had done at least 2000 MC in the past. The families of the children were given information about two techniques without any bias or favoritism before the circumcision. If the families had a preference because of their past experience, it was used. If the surgeon had to choose, the Gomco clamp was used. All procedures were performed under aseptic conditions. MCs were started under local anesthesia using the combination of penile ring block and dorsal nerve block techniques, with a dose not exceeding 20 mg/ml of lidocaine according to the patient’s weight. After local anesthesia was administered, the patient was kept for 20 minutes to allow the effect of anesthesia to settle completely. Adhesions were separated, and the smegma was removed. The glans penis and corona were disinfected again. In DS technique, the prepuce was grasped at the 1, 5, 7 and 11 o’clock positions with clamps. Afterward, a straight hemostatic clamp was used to crush the foreskin at the dorsal midline, allowing for hemostasis to be achieved. Once the foreskin had been adequately retracted, a dorsal midline incision was made using scissors along the crush line. By using clamps to keep the foreskin under traction, a circumferential excision was performed with scissors. The surgeon controlled the bleeding and sutured the edges of the mucosa and skin. Gauze dressing was applied after circumcision. In the Gomco clamp technique, the prepuce was grasped at the 3 and 9 o’clock positions with clamps. Afterward, the foreskin had been adequately retracted, and a dorsal midline incision was made using scissors. The bell of the Gomco clamp, which is suitable for the patient's glans penis diameter, was placed over the glans penis. Edges of the dorsal slit were held and uplifted. The plate of the Gomco was attached to the bell. The prepuce was squeezed between the plate and the bell at least 3 minutes. Then, the foreskin was removed with a scalpel by cutting around the upper surface of the plate. If bleeding was observed, the surgeon controlled the bleeding. Sutures were not placed routinely. Gauze dressing was applied after circumcision. A follow-up visit by phone call, by video call or in hospital was scheduled for all patients on the 3rd, 7th and 30th day following the circumcision. Age, presence of pathological phimosis, operation time, complications, revision surgery requirement and family satisfaction score were evaluated. The operation time was defined from disinfection of surgical site until the surgical incision is dressed. Complications were reported according to the Clavien classification system [ 12 ]. We used a scale ranging from 0 to 10 to measure family satisfaction score (0 = dissatisfied, 10 = full satisfaction). Family satisfaction score was assessed at follow-up visits. Statistical analyses were performed with SPSS version 19.0 for Windows (IBM, NY, USA). Numerical variables were summarized with mean±standard deviation, and categorical variables with frequency and percentage. The significance of differences among groups was assessed by Student's t-test or two-way ANOVA, and analysis of categorical variables was examined by chi-square test. Correlations between independent variables were assessed by Spearman's correlation test. p < 0.05 was considered statistical significance. RESULTS Between January 2017 and July 2023, 1488 patients who underwent MC using a Gomco clamp or the DS technique were included in the study. Eleven patients with missing data, 3 patients with undescended testis, 2 patients with hypospadias were excluded from the study. The final study population was 1472 patients. The Gomco clamp group comprised 921 patients (62.6%), whereas the DS group comprised 551 patients (37.4%). There was no statistically significant difference in mean age (5.8 ± 5.1 vs. 5.4 ± 5.3, p = 0.309) and presence of pathological phimosis (5.3% vs. 7.9%, p = 0.092) between the Gomco clamp and DS group. Patients characteristics are presented in Table 1 . The operative time was statistically significantly shorter in the Gomco clamp group compared to the DS group (9.88 ± 2.63 vs. 18.07 ± 4.11, p < 0.001). There was no statistical difference in the family satisfaction score between two groups (8.7 ± 1.1 vs. 8.1 ± 1.7, p = 0.131). Table 1 Comparison of patient characteristics, operative and postoperative data among the Gomco clamp and dorsal slit groups. Number of patients (n) Gomco Clamp Dorsal Slit p value 921 (62.6%) 551 (37.4%) Age (mean ± SD) (years) 5.8 ± 5.1 5.4 ± 5.3 0.309 Presence of pathological phimosis (n) (%) 49 (5.3%) 44 (7.9%) 0.092 Operation time (minutes) 9.8 ± 2.6 18.0 ± 4.1 < 0.001 Total complications (n) (%) 110 (10.8%) 74 (13.4%) 0.255 Family Satisfaction Score (mean ± SD) 8.7 ± 1.1 8.1 ± 1.7 0.131 SD: Standard Deviation A total of 184 (12.5%) complications were observed in the two groups. There was no significant difference in overall, grade 1, grade 2 and grade 3 complications between two groups (Table 2 ). In Gomco clamp and DS groups, bleeding occurred in 57 (6.18%) and 39 (7.07%) patients (p = 0.195), edema in 21 (2.28%) and 15 (2.72%) patients (p = 0.431), wound infection in 17 (1.84%) and 9 (1.63%) patients (p = 0.575), redundant skin and adhesion in 12 (1.30%) and 10 (1.81%) patients (p = 0.346), wound dehiscence in 3 (0.32%) and 1 (0.18%) patients (p = 0.821), respectively. Revision surgery was required for 1 patient (0.18%) in the DS group due to haemorrhage, while revision surgery was not performed in any patient in the Gomco clamp group. Table 2 Complications according to the Clavien classification system among the Gomco clamp and dorsal slit groups. No. complications (n) (%) Gomco Clamp (n = 921) Dorsal Slit (n = 551) p value 110 (10.8%) 74 (13.4%) 0.255 No. grade 1 complications (n) 47 (5.10%) 32 (5.80%) 0.596 No. grade 2 complications (n) 63 (6.84%) 41 (7.44%) 0.331 No. grade 3 complications (n) 0 1 (0.18%) 0.803 No. grade 4 complications (n) - - No. grade 5 complications (n) - - DISCUSSION We evaluated operative and postoperative results, complications and revision rates of Gomco clamp and DS techniques in patients who underwent male circumcision (MC) under local anesthesia. We found that Gomco clamp group had a shorter operation time compared with DS group in patients who underwent MC under local anesthesia. We found that the overall complications in MC under local anesthesia is 12.5%. However, there were no statistically significant differences in overall complications, grade 1, grade 2 and grade 3 complications between two groups. Family satisfaction score was also similar between the two groups. MC is one of the most common surgical procedures performed worldwide due to cultural, religious, and medical reasons across various populations [ 1 ]. American Academy of Pediatrics and Centers for Disease Control and Prevention recommend routine MC due to its significant health benefits and positive impact on public health [ 13 ]. MC has been shown to reduce bacterial colonization of the glans penis, urinary tract infections in sexual partners, balanoposthitis, sexually transmitted diseases, phimosis, and cervical cancer [ 3 , 5 , 6 , 13 , 14 ]. In addition to medical reasons, a high number of MCs are performed for cultural and religious reasons, especially in the Middle East [ 1 ]. The DS and surgical circumcision are the most commonly used techniques. Although DS provides a safe and effective treatment option with satisfactory outcomes, it requires significant surgical training [ 3 , 5 ]. Over the years, numerous circumcision techniques and devices have been innovated alongside these traditional techniques. However, the WHO recommends the Gomco clamp, the Mogen clamp and the Plastibell device to facilitate MC [ 5 , 6 ]. MC under local anesthesia is an anxious and stressful procedure for children. Surgical methods used is associated with less pain and lower cortisol change [ 15 , 16 ]. No single technique is suitable for all settings. Patient discomfort and stress can be reduced by spending less time on the MC [ 2 ]. We felt the need to find the ideal technique that could be used to treat a large number of patients under local anaesthesia rapidly, without significant complications and with good cosmetic results. For this purpose, we compared the DS and Gomco clamp techniques. Kurtis et al. found that Mogen clamp is associated with shorter operation time and less painful procedure than the Gomco clamp [ 16 ]. Sinkey et al. reported that Mogen clamp is shorter operation time, lower cortisol change, similar pain scores and similar maternal satisfaction as compared with Gomco clamp [ 15 ]. Bowa et al. showed that Gomco clamp is longer operation time when compared with Mogen clamp and Plastibell device. But Mogen clamp is associated more likely redundant skin and surgical revision [ 17 ]. Lei et al. reported that operation time, pain score and cosmetic satisfaction in the Shang Ring MC is superior to those in the DS technique [ 8 ]. In another study comparing the DS and Gomco clamp in adult patients, it was found that the shorter operation time, less postoperative pain and better cosmetic result (98.9% vs. 58.5%) in Gomco clamp [ 10 ]. In our study, we found that the operative time is statistically significantly shorter in the Gomco clamp group compared to the DS group (9.88 ± 2.63 vs. 18.07 ± 4.11, p < 0.001) and there was no statistical difference in the family satisfaction score between two groups (8.7 ± 1.1 vs. 8.1 ± 1.7, p = 0.131). The complication rates, surgical methods used, and providers' expertise and experience vary in the literature. Although it is predicted that circumcision type and provider experience will be prognostic in terms of complication risk, Shabanzadeh et al. reported that there was no association between the type of MC and provider experience, and the complication in a meta-analysis [ 1 ]. In our study, we found that there is no significant difference in overall, grade 1, grade 2 and grade 3 complications between the DS and Gomco clamp groups. Bowa et al. reported that rate of overall adverse event is not differ in Gomco clamp, Mogen clamp and Plastibell device [ 17 ]. Chan et al. reported that overall complication rate of MC is 1.73% vs. 1.25% in Gomco and Mogen clamp groups, respectively [ 18 ]. Lei et al. reported that bleeding and infection in the Shang Ring MC is superior to those in the DS technique but edema is less in the DS technique [ 8 ]. Another study evaluated the Gomco clamp and Plastibell device in 350 newborn infants. Rate of infection (2% vs. 1.3%) and adhesion (20% vs. 6.6%) is higher in Gomco clamp group [ 19 ]. Bawazir reported that Plastibell device is advantageous in terms of bleeding (1.06% vs. 4.42%), while Gomco clamp is advantageous in terms of infection (2.9% vs. 0.5%), penile edema (10.6% vs. 0.24%) and redundant skin (3.9% vs. 1.22%) [ 4 ]. Horowitz et al. recommended Gomco clamp for children under 1 month due to tendency for postoperative bleeding [ 11 ]. But, we found no difference in terms of bleeding between Gomco clamp and DS groups (6.18% vs. 7.07%). The current study has some limitations. First, it was a single-center retrospective study. Second, the procedures were performed by experienced surgeons (≥ 2000 MC cases), which may limit the generalizability of the results to real-world settings with variability in surgeon expertise. CONCLUSION Although circumcision is the most common surgical procedure performed in the worldwide, the best technique is still unclear. Both the Gomco clamp and the dorsal slit techniques have satisfactory results and acceptable complication rates in children who underwent male circumcision under local anesthesia. Gomco clamp technique is advantageous in terms of short operation time. However, further studies are needed to identify the optimal male circumcision technique. Abbreviations DS Dorsal Slit MC Male Circumcision Declarations Ethics approval and consent to participate The study was approved by the local ethics committee of Acibadem University (approval number ATADEK 2025/14, Clinical trial number: not applicable) and conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to enrolment. Consent for publication: Publication consent for research findings was obtained from each participant Conflicts of Interest: The author(s) declare that there is no conflict of interest regarding the publication of this study. Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Data Availability: Data will be made available on request. [AE] Authorship: • Participated in research design: AE, Participated in the writing of the paper: RGE, Participated in the performance of the research: AE; RGE, Contributed new reagents or analytic tools: AE; RGE, Participated in data analysis: AE; RGE References Shabanzadeh DM, Clausen S, Maigaard K, Fode M. Male Circumcision Complications – A Systematic Review, Meta-Analysis and Meta-Regression. Urology. 2021;152:25–34. 10.1016/j.urology.2021.01.041 . Monroe KK, Razoky PJ, Mychaliska K. The Length of Gomco Clamp Timing and Its Effect on Bleeding. Pediatrics. 2018;141:439–439. 10.1542/peds.141.1ma5.439 . Blank S, Brady M, Buerk E, Carlo W, Diekema D, Freedman A, et al. Male circumcision Pediatr. 2012;130. 10.1542/peds.2012-1990 . Bawazir OA. A controlled trial of Gomco versus Plastibell for neonatal circumcisions in Saudi Arabia. Int J Pediatr Adolesc Med. 2020;7:132–5. 10.1016/j.ijpam.2019.03.002 . Hargreave T. Male circumcision: towards a World Health Organisation normative practice in resource limited settings. Asian J Androl. 2010;12:628–38. 10.1038/aja.2010.59 . World Health Organization/Jhpiego. Manual for early infant male circumcision under local anaesthesia. Geneva: World Health Organization; 2010. Abdulwahab-Ahmed A, Mungadi IA. Techniques of male circumcision. J Surg Tech Case Rep. 2013;5:1–7. 10.4103/2006-8808.118588 . Lei JH, Liu LR, Wei Q, Xue W, Ben, Song TR, Yan SB, et al. Circumcision with no-flip Shang Ring and dorsal Slit methods for adult males: A single-centered, prospective, clinical study. Asian J Androl. 2016;18:798–802. 10.4103/1008-682X.157544 . Güler Y. Comparison of a modified Mogen clamp and classic dorsal slit circumcision under local anesthesia: A clinical study. Curr Urol. 2022;16:175–9. 10.1097/CU9.0000000000000083 . Millard PS, Wilson HR, Veldkamp PJ, Sitoe N. Rapid, minimally invasive adult voluntary male circumcision: A randomised trial. South Afr Med J. 2013;103:736–42. 10.7196/SAMJ.6856 . Horowitz M, Gershbein AB. Gomco circumcision: When is it safe? J Pediatr Surg. 2001;36:1047–9. 10.1053/jpsu.2001.24739 . Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. Micoogullari U, Yildirim M, Gol IH, Cakici OU. Comparison of NeoAlis™ disposable circumcision device and sleeve technique in circumcision: Results from a referral health-care center in Turkey. J Pediatr Urol. 2021;17:856e1. 856.e10. Friedman B, Khoury J, Petersiel N, Yahalomi T, Paul M, Neuberger A. Pros and cons of circumcision: an evidence-based overview. Clin Microbiol Infect. 2016;22:768–74. 10.1016/j.cmi.2016.07.030 . Sinkey RG, Eschenbacher MA, Walsh PM, Doerger RG, Lambers DS, Sibai BM, et al. The GoMo study: A randomized clinical trial assessing neonatal pain with Gomco vs Mogen clamp circumcision. Am J Obstet Gynecol. 2015;212:664e1. 10.1016/j.ajog.2015.03.029 . Kurtis PS, DeSilva HN, Bernstein BA, Malakh L, Schechter NL. A comparison of the Mogen and Gomco clamps in combination with dorsal penile nerve block in minimizing the pain of neonatal circumcision. Pediatrics. 1999;103:E23. 10.1542/peds.103.2.e23 . Bowa K, Li MS, Mugisa B, Waters E, Linyama DM, Chi BH, et al. A controlled trial of three methods for neonatal circumcision in Lusaka, Zambia. J Acquir Immune Defic Syndr. 2013;62:1–6. 10.1097/QAI.0b013e318275741b . Chan PS, Penna FJ, Holmes AV. Gomco Versus Mogen? No Effect on Circumcision Revision Rates. Hosp Pediatr. 2018;8:611–4. 10.1542/hpeds.2018-0053 . Machmouchi M, Alkhotani A. Is neonatal circumcision judicious? Eur J Pediatr Surg. 2007;17:266–9. 10.1055/s-2007-965417 . Additional Declarations No competing interests reported. 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It is one of the most common surgical procedures performed worldwide. MC is performed due to cultural, religious, and medical reasons across various populations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In MC, the foreskin of the penis is surgically removed. It can be performed using a variety of techniques, including dorsal slit (DS), sleeve resection, forceps-guided, the Gomco clamp, the Mogen clamp, and the Plastibell device [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The overall complication rate varies between 0.34% and 3.8% depending on the surgical technique used, the experience of the surgeon, and the age of the patient (neonatal vs. non-neonatal) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. MC is associated with several health benefits, including reduced risks of urinary tract infections, HIV and other sexually transmitted infections, and penile cancer [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe World Health Organization published Manual of Male Circumcision under Local Anaesthesia. Although many different MC techniques have been described in the literature, three adult techniques and four pediatric techniques are recommended by the World Health Organization [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The Gomco clamp, the Mogen clamp, the Plastibell device, and the DS technique are suggested for pediatric patients. Both of them have their own advantages and disadvantages [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe DS circumcision is a traditional and highly efficient technique, especially in acute inflammation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. To achieve the desired outcome, it would be necessary to remove the excess foreskin and skillfully suturing the incision. The likelihood of complications relating to the glans and urethra is significantly reduced as the glans penis is easily visible throughout the procedure [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the DS circumcision can be quite complex and time-consuming, resulting in a longer period of learning curve for the healthcare providers. Additionally, cosmetic problems are more common due to the inability to cut the prepuce skin symmetrically using the DS technique [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Bleeding, edema, infection, and wound dehiscence are complications of DS technique [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsidering the disadvantages of standard surgical MC techniques, the World Health Organization is seeking research on alternative methods. New techniques could potentially improve the safety, ease, and speed of circumcision procedure. Additionally, it may promote faster wound healing and potentially reduce the risk of HIV transmission compared to standard surgical techniques. Moreover, healthcare providers with basic training could perform this procedure safely. Lastly, when considering the implementation of MC on a larger scale, it would be a cost-effective alternative to traditional surgical methods [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Gomco clamp is widely utilized in the United States for neonatal MC [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The Gomco clamp has a round metal part that encloses over the glans penis and beneath the foreskin, and a flat metal apparatus that intended to secure the bell in place and to protect the glans penis. The Gomco technique involves squeezing the prepuce between the plate and the bell. The prepuce is then removed by cutting around the upper surface of the plate [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Bleeding, edema, infection, wound dehiscence and laceration of the glans penis due to mismatch between the parts of the Gomco clamp are complications of Gomco clamp [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, we compared dorsal slit and Gomco clamp techniques regarding operative and postoperative results, complications and revision rates in patients who underwent male circumcision under local anesthesia.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eAfter institutional review board approval (Acibadem University, No:ATADEK 2025/14, Clinical trial number: not applicable), data of patients who underwent MC using a Gomco clamp or the DS technique from January 2017 to July 2023 were evaluated. Informed consent was provided by all patients. This study included neonates, infants, and children who had a foreskin that was intact and needed to be circumcised for religious, cultural, or medical reasons such as phimosis, paraphimosis, and balanoposthitis. Hypospadias, buried penis, undescended testis, micro penis, epispadias, patients with bleeding disorders, patients who underwent MC under general anesthesia, and patients with missing data were excluded from the study. The procedures were performed by experienced surgeons who had done at least 2000 MC in the past. The families of the children were given information about two techniques without any bias or favoritism before the circumcision. If the families had a preference because of their past experience, it was used. If the surgeon had to choose, the Gomco clamp was used.\u003c/p\u003e \u003cp\u003eAll procedures were performed under aseptic conditions. MCs were started under local anesthesia using the combination of penile ring block and dorsal nerve block techniques, with a dose not exceeding 20 mg/ml of lidocaine according to the patient\u0026rsquo;s weight. After local anesthesia was administered, the patient was kept for 20 minutes to allow the effect of anesthesia to settle completely. Adhesions were separated, and the smegma was removed. The glans penis and corona were disinfected again.\u003c/p\u003e \u003cp\u003eIn DS technique, the prepuce was grasped at the 1, 5, 7 and 11 o\u0026rsquo;clock positions with clamps. Afterward, a straight hemostatic clamp was used to crush the foreskin at the dorsal midline, allowing for hemostasis to be achieved. Once the foreskin had been adequately retracted, a dorsal midline incision was made using scissors along the crush line. By using clamps to keep the foreskin under traction, a circumferential excision was performed with scissors. The surgeon controlled the bleeding and sutured the edges of the mucosa and skin. Gauze dressing was applied after circumcision.\u003c/p\u003e \u003cp\u003eIn the Gomco clamp technique, the prepuce was grasped at the 3 and 9 o\u0026rsquo;clock positions with clamps. Afterward, the foreskin had been adequately retracted, and a dorsal midline incision was made using scissors. The bell of the Gomco clamp, which is suitable for the patient's glans penis diameter, was placed over the glans penis. Edges of the dorsal slit were held and uplifted. The plate of the Gomco was attached to the bell. The prepuce was squeezed between the plate and the bell at least 3 minutes. Then, the foreskin was removed with a scalpel by cutting around the upper surface of the plate. If bleeding was observed, the surgeon controlled the bleeding. Sutures were not placed routinely. Gauze dressing was applied after circumcision.\u003c/p\u003e \u003cp\u003eA follow-up visit by phone call, by video call or in hospital was scheduled for all patients on the 3rd, 7th and 30th day following the circumcision. Age, presence of pathological phimosis, operation time, complications, revision surgery requirement and family satisfaction score were evaluated. The operation time was defined from disinfection of surgical site until the surgical incision is dressed. Complications were reported according to the Clavien classification system [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. We used a scale ranging from 0 to 10 to measure family satisfaction score (0\u0026thinsp;=\u0026thinsp;dissatisfied, 10\u0026thinsp;=\u0026thinsp;full satisfaction). Family satisfaction score was assessed at follow-up visits.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed with SPSS version 19.0 for Windows (IBM, NY, USA). Numerical variables were summarized with mean\u0026plusmn;standard deviation, and categorical variables with frequency and percentage. The significance of differences among groups was assessed by Student's t-test or two-way ANOVA, and analysis of categorical variables was examined by chi-square test. Correlations between independent variables were assessed by Spearman's correlation test. p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistical significance.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eBetween January 2017 and July 2023, 1488 patients who underwent MC using a Gomco clamp or the DS technique were included in the study. Eleven patients with missing data, 3 patients with undescended testis, 2 patients with hypospadias were excluded from the study. The final study population was 1472 patients.\u003c/p\u003e \u003cp\u003eThe Gomco clamp group comprised 921 patients (62.6%), whereas the DS group comprised 551 patients (37.4%). There was no statistically significant difference in mean age (5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 vs. 5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3, p\u0026thinsp;=\u0026thinsp;0.309) and presence of pathological phimosis (5.3% vs. 7.9%, p\u0026thinsp;=\u0026thinsp;0.092) between the Gomco clamp and DS group. Patients characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The operative time was statistically significantly shorter in the Gomco clamp group compared to the DS group (9.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.63 vs. 18.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no statistical difference in the family satisfaction score between two groups (8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 vs. 8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7, p\u0026thinsp;=\u0026thinsp;0.131).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of patient characteristics, operative and postoperative data among the Gomco clamp and dorsal slit groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNumber of patients (n)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGomco Clamp\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDorsal Slit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e921 (62.6%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e551 (37.4%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.309\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePresence of pathological phimosis (n) (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperation time (minutes)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal complications (n) (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (13.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily Satisfaction Score (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.131\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eSD: Standard Deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 184 (12.5%) complications were observed in the two groups. There was no significant difference in overall, grade 1, grade 2 and grade 3 complications between two groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In Gomco clamp and DS groups, bleeding occurred in 57 (6.18%) and 39 (7.07%) patients (p\u0026thinsp;=\u0026thinsp;0.195), edema in 21 (2.28%) and 15 (2.72%) patients (p\u0026thinsp;=\u0026thinsp;0.431), wound infection in 17 (1.84%) and 9 (1.63%) patients (p\u0026thinsp;=\u0026thinsp;0.575), redundant skin and adhesion in 12 (1.30%) and 10 (1.81%) patients (p\u0026thinsp;=\u0026thinsp;0.346), wound dehiscence in 3 (0.32%) and 1 (0.18%) patients (p\u0026thinsp;=\u0026thinsp;0.821), respectively. Revision surgery was required for 1 patient (0.18%) in the DS group due to haemorrhage, while revision surgery was not performed in any patient in the Gomco clamp group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications according to the Clavien classification system among the Gomco clamp and dorsal slit groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eNo. complications (n) (%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGomco Clamp\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;921)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDorsal Slit\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;551)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (10.8%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (13.4%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo. grade 1 complications (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (5.10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (5.80%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo. grade 2 complications (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (6.84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (7.44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.331\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo. grade 3 complications (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.803\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo. grade 4 complications (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo. grade 5 complications (n)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWe evaluated operative and postoperative results, complications and revision rates of Gomco clamp and DS techniques in patients who underwent male circumcision (MC) under local anesthesia. We found that Gomco clamp group had a shorter operation time compared with DS group in patients who underwent MC under local anesthesia. We found that the overall complications in MC under local anesthesia is 12.5%. However, there were no statistically significant differences in overall complications, grade 1, grade 2 and grade 3 complications between two groups. Family satisfaction score was also similar between the two groups.\u003c/p\u003e \u003cp\u003eMC is one of the most common surgical procedures performed worldwide due to cultural, religious, and medical reasons across various populations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. American Academy of Pediatrics and Centers for Disease Control and Prevention recommend routine MC due to its significant health benefits and positive impact on public health [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. MC has been shown to reduce bacterial colonization of the glans penis, urinary tract infections in sexual partners, balanoposthitis, sexually transmitted diseases, phimosis, and cervical cancer [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition to medical reasons, a high number of MCs are performed for cultural and religious reasons, especially in the Middle East [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe DS and surgical circumcision are the most commonly used techniques. Although DS provides a safe and effective treatment option with satisfactory outcomes, it requires significant surgical training [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Over the years, numerous circumcision techniques and devices have been innovated alongside these traditional techniques. However, the WHO recommends the Gomco clamp, the Mogen clamp and the Plastibell device to facilitate MC [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMC under local anesthesia is an anxious and stressful procedure for children. Surgical methods used is associated with less pain and lower cortisol change [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. No single technique is suitable for all settings. Patient discomfort and stress can be reduced by spending less time on the MC [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. We felt the need to find the ideal technique that could be used to treat a large number of patients under local anaesthesia rapidly, without significant complications and with good cosmetic results. For this purpose, we compared the DS and Gomco clamp techniques. Kurtis et al. found that Mogen clamp is associated with shorter operation time and less painful procedure than the Gomco clamp [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Sinkey et al. reported that Mogen clamp is shorter operation time, lower cortisol change, similar pain scores and similar maternal satisfaction as compared with Gomco clamp [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Bowa et al. showed that Gomco clamp is longer operation time when compared with Mogen clamp and Plastibell device. But Mogen clamp is associated more likely redundant skin and surgical revision [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Lei et al. reported that operation time, pain score and cosmetic satisfaction in the Shang Ring MC is superior to those in the DS technique [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In another study comparing the DS and Gomco clamp in adult patients, it was found that the shorter operation time, less postoperative pain and better cosmetic result (98.9% vs. 58.5%) in Gomco clamp [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In our study, we found that the operative time is statistically significantly shorter in the Gomco clamp group compared to the DS group (9.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.63 vs. 18.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and there was no statistical difference in the family satisfaction score between two groups (8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 vs. 8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7, p\u0026thinsp;=\u0026thinsp;0.131).\u003c/p\u003e \u003cp\u003eThe complication rates, surgical methods used, and providers' expertise and experience vary in the literature. Although it is predicted that circumcision type and provider experience will be prognostic in terms of complication risk, Shabanzadeh et al. reported that there was no association between the type of MC and provider experience, and the complication in a meta-analysis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In our study, we found that there is no significant difference in overall, grade 1, grade 2 and grade 3 complications between the DS and Gomco clamp groups. Bowa et al. reported that rate of overall adverse event is not differ in Gomco clamp, Mogen clamp and Plastibell device [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Chan et al. reported that overall complication rate of MC is 1.73% vs. 1.25% in Gomco and Mogen clamp groups, respectively [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Lei et al. reported that bleeding and infection in the Shang Ring MC is superior to those in the DS technique but edema is less in the DS technique [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Another study evaluated the Gomco clamp and Plastibell device in 350 newborn infants. Rate of infection (2% vs. 1.3%) and adhesion (20% vs. 6.6%) is higher in Gomco clamp group [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Bawazir reported that Plastibell device is advantageous in terms of bleeding (1.06% vs. 4.42%), while Gomco clamp is advantageous in terms of infection (2.9% vs. 0.5%), penile edema (10.6% vs. 0.24%) and redundant skin (3.9% vs. 1.22%) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Horowitz et al. recommended Gomco clamp for children under 1 month due to tendency for postoperative bleeding [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. But, we found no difference in terms of bleeding between Gomco clamp and DS groups (6.18% vs. 7.07%).\u003c/p\u003e \u003cp\u003eThe current study has some limitations. First, it was a single-center retrospective study. Second, the procedures were performed by experienced surgeons (\u0026ge;\u0026thinsp;2000 MC cases), which may limit the generalizability of the results to real-world settings with variability in surgeon expertise.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAlthough circumcision is the most common surgical procedure performed in the worldwide, the best technique is still unclear. Both the Gomco clamp and the dorsal slit techniques have satisfactory results and acceptable complication rates in children who underwent male circumcision under local anesthesia. Gomco clamp technique is advantageous in terms of short operation time. However, further studies are needed to identify the optimal male circumcision technique.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDorsal Slit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMale Circumcision\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the local ethics committee of Acibadem University (approval number ATADEK 2025/14, Clinical trial number: not applicable) and conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to enrolment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication: \u003c/strong\u003ePublication consent for research findings was obtained from each participant\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The author(s) declare that there is no conflict of interest regarding the publication of this study.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eData Availability:\u003c/strong\u003e Data will be made available on request. [AE]\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthorship: \u0026bull; Participated in research design: \u003c/strong\u003eAE, \u003cstrong\u003eParticipated in the writing of the paper:\u003c/strong\u003e RGE, \u003cstrong\u003eParticipated in the performance of the research:\u003c/strong\u003e AE; RGE, \u003cstrong\u003eContributed new reagents or analytic tools:\u003c/strong\u003e AE; RGE, \u003cstrong\u003eParticipated in data analysis:\u003c/strong\u003e AE; RGE\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShabanzadeh DM, Clausen S, Maigaard K, Fode M. Male Circumcision Complications \u0026ndash; A Systematic Review, Meta-Analysis and Meta-Regression. 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Comparison of a modified Mogen clamp and classic dorsal slit circumcision under local anesthesia: A clinical study. Curr Urol. 2022;16:175\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/CU9.0000000000000083\u003c/span\u003e\u003cspan address=\"10.1097/CU9.0000000000000083\" targettype=\"DOI\" 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. Rapid, minimally invasive adult voluntary male circumcision: A randomised trial. South Afr Med J. 2013;103:736\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7196/SAMJ.6856\u003c/span\u003e\u003cspan address=\"10.7196/SAMJ.6856\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHorowitz M, Gershbein AB. Gomco circumcision: When is it safe? J Pediatr Surg. 2001;36:1047\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/jpsu.2001.24739\u003c/span\u003e\u003cspan address=\"10.1053/jpsu.2001.24739\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMicoogullari U, Yildirim M, Gol IH, Cakici OU. Comparison of NeoAlis\u0026trade; disposable circumcision device and sleeve technique in circumcision: Results from a referral health-care center in Turkey. J Pediatr Urol. 2021;17:856e1. 856.e10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFriedman B, Khoury J, Petersiel N, Yahalomi T, Paul M, Neuberger A. Pros and cons of circumcision: an evidence-based overview. Clin Microbiol Infect. 2016;22:768\u0026ndash;74. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cmi.2016.07.030\u003c/span\u003e\u003cspan address=\"10.1016/j.cmi.2016.07.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSinkey RG, Eschenbacher MA, Walsh PM, Doerger RG, Lambers DS, Sibai BM, et al. The GoMo study: A randomized clinical trial assessing neonatal pain with Gomco vs Mogen clamp circumcision. Am J Obstet Gynecol. 2015;212:664e1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ajog.2015.03.029\u003c/span\u003e\u003cspan address=\"10.1016/j.ajog.2015.03.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurtis PS, DeSilva HN, Bernstein BA, Malakh L, Schechter NL. A comparison of the Mogen and Gomco clamps in combination with dorsal penile nerve block in minimizing the pain of neonatal circumcision. Pediatrics. 1999;103:E23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/peds.103.2.e23\u003c/span\u003e\u003cspan address=\"10.1542/peds.103.2.e23\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowa K, Li MS, Mugisa B, Waters E, Linyama DM, Chi BH, et al. A controlled trial of three methods for neonatal circumcision in Lusaka, Zambia. J Acquir Immune Defic Syndr. 2013;62:1\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/QAI.0b013e318275741b\u003c/span\u003e\u003cspan address=\"10.1097/QAI.0b013e318275741b\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan PS, Penna FJ, Holmes AV. Gomco Versus Mogen? No Effect on Circumcision Revision Rates. Hosp Pediatr. 2018;8:611\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1542/hpeds.2018-0053\u003c/span\u003e\u003cspan address=\"10.1542/hpeds.2018-0053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMachmouchi M, Alkhotani A. Is neonatal circumcision judicious? Eur J Pediatr Surg. 2007;17:266\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-2007-965417\u003c/span\u003e\u003cspan address=\"10.1055/s-2007-965417\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"circumcision, dorsal slit, Gomco clamp, complication, family satisfaction","lastPublishedDoi":"10.21203/rs.3.rs-9140068/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9140068/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGomco clamp (GC) and dorsal slit (DS) are common techniques of circumcision. We compared GC and DS regarding operative and postoperative outcomes, complications and revision rates in children who underwent circumcision under local anesthesia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween January 2017 and July 2023, 1488 patients who underwent circumcision using a GC or DS were analyzed. Age, presence of pathological phimosis, operation time, complications, revision surgery requirement, and family satisfaction score were evaluated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eGC and DS were performed on 921 (62.6%) and 551 (37.4%) children, respectively. Age (5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 vs. 5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3, p\u0026thinsp;=\u0026thinsp;0.309) and presence of pathological phimosis (5.3% vs. 7.9%, p\u0026thinsp;=\u0026thinsp;0.092) were not statistically significant differences between the GC and DS groups. The operative time was statistically significantly shorter in the Gomco clamp group compared to the DS group (9.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.63 vs. 18.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no statistical difference in the family satisfaction score between the two groups (8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 vs. 8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7, p\u0026thinsp;=\u0026thinsp;0.131). There was no significant difference between the two groups in overall grade 1, grade 2, and grade 3 complications.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe GC and the DS techniques have satisfactory results and acceptable complication rates in children who underwent circumcision under local anesthesia.\u003c/p\u003e","manuscriptTitle":"A Comparative Study Of Gomco And Dorsal Slit Techniques In Male Circumcision","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-26 10:18:47","doi":"10.21203/rs.3.rs-9140068/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"761c4c53-e7f8-4fe4-b096-82df2fd56333","owner":[],"postedDate":"March 26th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-15T07:53:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T03:26:51+00:00","index":25,"fulltext":""},{"type":"reviewerAgreed","content":"194243794868020927011887290871305277302","date":"2026-05-04T05:35:22+00:00","index":24,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T08:12:26+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-26 10:18:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9140068","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9140068","identity":"rs-9140068","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}