An overview of circumcision and a modification that prevents glans injuries and cosmetic problems in circumcisions made with the guillotine technique

An overview of circumcision and a modification that prevents glans injuries and cosmetic problems in circumcisions made with the guillotine technique | 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 An overview of circumcision and a modification that prevents glans injuries and cosmetic problems in circumcisions made with the guillotine technique Kahraman Topsakal This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4159055/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 Purpose: Despite being an age old practice, there is ongoing research and development to improve the procedure in order to enhance its safety, efficacy and client satisfaction. The Guillotine technique, which is one of the most common methods, has been criticised for possible glans injuries and nonpleasing cosmetic results especially when an inexperienced person tries it out. This research paper introduces the Modified Guillotine Technique (MGT) designed to address these issues. Methods: This retrospective study involved analysing 2853 circumcisions performed between 2006 and January 2022 using MGT on males aged between one month and fourteen years. Safety, efficiency of wound healing through cosmetic outcomes by indirect means, pain management of MGT were examined here. Results: MGT was used in different age groups without any significant increase in operative time compared to the traditional Guillotine technique thus showing perpetuation of efficiency. It is important to note that there were no reports of gland injuries, while complications rates did not differ significantly from those obtainable with other methods thus emphasising on safety and efficacy of MGT. Conclusion: The modified Guillotine technique represents a major leap forward in circumcision practice by combining the effectiveness of the Guillotine method with an improved safety profile and cosmetic outcomes. By significantly reducing the risks associated with glanular injury, but with the maintenance of procedural time and the addition of new complications, MGT offers a viable option for routine circumcisions worldwide. Circumcision modified guillotine technique (MGT) cosmetic outcomes glans injuries Figures Figure 1 Figure 2 Figure 3 Introduction Circumcision is an ancient practice that humans have done since the beginning of time, and involves a surgery in which foreskin is removed from the male penis. The main reasons behind this custom include religion, culture, or medicine ( 1 ). Although it is an old method, it has kept on evolving both its techniques and results, prompting continuous investigations to improve the procedure regarding patient contentment, safety and efficiency ( 2 ). This study aims to address the constraints associated with the Guillotine technique, which is one of the most widely implemented methods for circumcision and outline an alternative strategy to reduce risks involved with such a method ( 3 ). Although Guillotine is widely used because it can be done resulting into its popularity to many patients who are looking forward to undergo circumcision procedures; it has also been criticised due to its implications. These may involve injuries in the glans as well as poor cosmetic results, especially if performed by inexperienced surgeons ( 4 ). The presence of these challenges requires the development of more advanced procedure that maintains the advantages of Guillotine while greatly reducing the risks linked to it ( 5 ). By introducing the modified guillotine technique (MGT), with the intention of avoiding glans injuries and improving cosmetic outcomes, our research contributes to the overall goal of safer, faster circumcision with improved aaesthetic appeal ( 6 ). Our study fills a significant void in terms of lack of standardised and simple low risk approaches that could be globally adopted. This gap is especially important considering that circumcision is practised worldwide having health effects on men’s lives. The invention of MGT and its testing in a large cohort provide a unique opportunity to make progress in circumcision practice ( 8 ). The aim of this research was not only to analyse glans injury prevention as well as complication rates, but also set a new benchmark for circumcisions carried out through safe means ( 9 ). Furthermore, our study places itself ahead among other studies conducted in urology and pediatric surgery due to operational time, recovery, and cosmetics improvement aspects of MGT ( 10 ). Our comparison of MGT with standard techniques for circumcision exposes not only the potential advantages but also important lessons on how to carry out this procedure effectively ( 11 ). In conclusion, the goals that this study intends to achieve are; to give a comprehensive insight into the historical and contemporary significance of circumcision; propose an innovative modification to the Guillotine technique, which is widely adopted; critically evaluate the safety, efficiency, and cosmetic aspects of such modified methods as well as advocate for its adoption in regular circumcisions with the aim of reducing risks associated with traditional approaches. Hopefully, through this research, we will be able to improve surgical safety and patient satisfaction that will ultimately influence circumcision practice globally. Methods The study is a retrospective review of circumcisions performed between 2006 and 2022 in men aged from one month to fourteen years (mean age: seven years). The research encompassed a total of 2,000 eight hundred and fifty three circumcisions performed by the same surgeon using the modified guillotine technique. The patients were chosen based on the availability of complete medical records with operative details and follow-up information. Exclusion criteria included patients with congenital penile abnormalities or those who underwent circumcision for medical reasons, such as phimosis, which was not amenable to the standard guillotine technique. This study used male circumcision performed using the Modified Guillotine Technique (MGT) as an inclusion criterion to investigate its effects in males aged between 1 month and 14 years of age. The excluded criteria comprised anyone suffering from known bleeding disorders, with any congenital abnormalities of the penis or any condition that the clinical team thought was contraindicative to carry circumcision under the protocol being studied. For ethical standards and the protection of participant rights, our study protocol was approved by the local institutional review board (IRB), which is responsible for ensuring compliance with these standards. Our ethical guidelines adhered to all procedures detailed in the Declaration of Helsinki, having been acquired prior to the beginning of our research from approval documents. We made sure informed consent was an essential part of our compliance with ethics. Before participating, guardians of all minors involved in this investigation were given full explanations on what it entailed such as its objectives, risks/benefits associated with the modified guillotine technique, and their freedom to withdraw their children any time without fear of facing consequences. These parents/guardians then signed written informed consents indicating their comprehension and wilful acceptance into the project. Modified Guillotine Technique The modified guillotine technique was applied scrupulously as follows: Preparation: From the top of the sulcus coronarius prepuce was cleaned free using clamps fixed at six and twelve o’clock positions to get enough exposure and tension (Fig. 1 ). Initial incision: The glans were retracted towards the body by the surgeon using a non-dominant hand with the assistance of a nurse holding the clamps. Positioning of the straight clamp on the prepuce just about 3-4mm from the glans, which is adjustable for safety margin depending on preputial length. Subsequent to placing a clamp, an incision was made immediately below it to separate the mucosa and the skin, facilitating skin traction. Second incision: After a slight traction returned the skin back to its original position, a second line of incision was marked along the penile skin where impressions were left by clamps that had been used before. The skin was suspended and over this line was placed taking into account angulation of the glans. The second cut took place underneath the clamp to achieve the desired cosmetic outcome ( Fig. 2 ). Mucosal tissue excision and Suturing: followed by meticulous control of excess bleeding mucosal tissue removed before suturing and tying intermittent stitches on both the skin and mucosa that secured the integrity and aesthetic appearance (Fig. 3 ). These two studies focus on circumcision using the modified guillotine technique (MGT). The main interests of the study were safety, efficiency, healing, cosmetic outcomes, and indirectly pain management. The primary outcome was glans injury, while wound infection, haematoma, and wound breakage were secondary outcomes. The MGT procedure took shorter durations both in preparation and in operation to demonstrate an improvement over traditional methods of circumcision. The duration of healing after surgery allowed conclusions to be drawn about its efficacy during postoperative recovery periods. Through parental feedback and clinical evaluations, we could tell if the method was capable of providing cosmetically beautiful results safely. The research did not look at direct pain assessments such as the Visual Analogue Scale, but it implies that there are no glans injuries associated with MGT which suggests that indirectly there might be relief from pain, hence a more comfortable postoperative period for patients. EVENDOL is given to children below six ( 6 ) years of age. EVENDOL scores can vary between 0–15 with a therapy threshold at 4/15 (Table 1 ). Table 1 EVENDOL score Behavioral expression Sign absent Sign weak or transient Sign moderate or present about half the time Sign strong or present almost all the time Vocal or verbal expression Cries and/or screams and/or moans. 0 1 2 3 Facial expression Furrowed forehead and/or frown, furrowed brow 0 1 2 3 and/or tense mouth Movements Restlessness, agitation and/or rigidity 0 1 2 3 Postures Antalgic posture and/or protection of the painful area and/or immobility 0 1 2 3 Interaction with the environment Can be comforted and/or interested in playing 0 1 2 3 and/or interacts with people SPSS software version 26.0 in windows was used to analyse the data for univariate, bivariate, and stratified analysis. Contingency tables were constructed for qualitative variables with Pearson’s χ2 test or Fisher’s exact test used wherever necessary when requirements of the previous test were not met. The Anova test was performed for multiple comparisons of quantitative variables. The P-value of 0.05 showed significant differences. Results A retrospective review of 2853 circumcisions with modified guillotine technique was done across different age groups; ≤1 year (1643 patients, 57.51%), 1 to 6 years (857 patients, 29.9%), and > 6 years old (353 participants, 12.5%). This analysis aimed to emphasise the improvements in operative efficiency, lower complication rates, and better cosmetic outcomes that are particularly important for avoiding glans injuries. Operative and Healing Times Analysis Figure 2 provided a detailed report on healing periods and duration of the procedure during preparation along specific age cohorts. The mean for the operation time preparation was established at 9.8 minutes with an SD of approximately 2.8 minutes, indicating a relatively uniform preparation phase across varying age groups but the time taken during surgery and the period taken to complete healing showed variations, where the mean duration of operation took approximately about six minutes (SD = 1.4) while the mean time taken to heal was around seven days (SD = 2.2). This indicates variability because the operative times had an average of about 6.0(± 1.4) minutes while the healing durations had an average of about 7.5(± 2) days between the patients operated during this period thus necessitating an individualised approach for managing circumcision that takes into account whether any patient could have some physiological differences due to their age (Table 2 ). Table 2 Age, Operative, and Healing Times Parameter Estimated Data Age (years) ≤ 1 1643 participants (57.51%) 1–6 857 participants (29.9%) > 6 353 participants (12.5%) Mean ± SD (range) 23 ± 25 (0–120) Median (IQR) 7 (4–35) Operative Time Preparation (min) Mean ± SD (range) 9.8 ± 2.8 ( 5 – 16 ) Operative Time (min) Mean ± SD (range) 6.6 ± 1.4 ( 4 – 10 ) Healing Time (days) Mean ± SD (range) 7.5 ± 2.2 ( 4 – 15 ) Table 3 Postoperative Adverse Events Postoperative Adverse Events Outcome Count (Percentage) Infection Positive 86 (3.0%) Negative 2767 (97.0%) Hematoma Positive 57 (2.0%) Negative 2796 (98.0%) Edema Positive 71 (2.5%) Negative 2782 (97.5%) Wound Dehiscence Positive 29 (1.0%) Negative 2824 (99.0%) Bleeding Positive 14 (0.5%) Negative 2839 (99.5%) Penile Injury Positive 0 (0%) Negative 2853 (100%) More or Less Skin Removal Positive 0 (0%) Negative 2853 (100%) Postoperative adverse events The study carefully recorded postoperative adverse events to evaluate the safety profile of the modified guillotine technique (Table III). These included infection, haematoma, edema, wound dehiscence, among others, such as bleeding, penile injury, and skin tags removal concerns. It is important to note that infection and haematoma rates were low across all age groups: among these, more than 97% of the cases remained without infections, while roughly all the cases avoided haemorrhage, including one event where fatality occurred after a very long duration of operation. Edema occurred slightly more frequently at 2.5% and wound dehiscence was rare at 1.0%. Most importantly, there were no cases of penile injuries or cases of excision of the wrong skin indicating how safe and accurate the alteration to the traditional method is. Parental satisfaction and Pain Assessment Among parents of all age brackets, more than 98% expressed satisfaction, indicating that improved technique had fulfilled its purpose in terms of the experiences of the patients and caregivers. Although people over 6 years cannot be evaluated using VAS and older than 6 years of age do not have EVENDOL scores, this high rate indicates that the procedure was performed successfully with tolerable postoperative pain (Table 4 ). Table 4 Age Groups’ Differences Regarding Parental Satisfaction, VAS Score, and EVENDOL Score Measure ≤ 1 years (1643 participants) 1–6 years (857 participants) > 6 years (353 participants) P value Statistical test VAS first hour (1–3 / 4–6 / 7–9) N/A N/A 12% / 69% / 19% - - VAS second hour (1–3 / 4–6 / 7–9) N/A N/A 19% / 61% / 22% - - VAS 24 h (1–3 / 4–6 / 7–9) N/A N/A 84% / 11% / 5% - - EVENDOL first hour (4–5 / 6–10 / 11–15) 5% / 83% / 12% 6% / 82% / 12% N/A 0.65 For 4–5 χ 2 = 0.72 EVENDOL second hour (4–5 / 6–10 / 11–15) 87% / 8% / 5% 74% / 21% / 5% N/A 0.60 For 4–5: χ 2 = 4.96 Satisfaction (Yes / No) 98.5% / 1.5% 99% / 1% 98% / 2% 0.70 - Operative and Healing Times Analysis of operative times showed an obvious pattern towards extended preparation and surgical durations as patient ages increased. For example, young subjects (≤ 1 year) experienced the shortest preparation time (M = 8.0; SD = 1.5) while the shortest surgery time was observed among infants in that category (M = 6.0; SD = 0.8), revealing a less complicated anatomical situation that may require faster surgical maneuvers for them compared to other groups. On the other hand, older children over six years of age had longest times for preparation (mean = 14.5 minutes; SD = 0.6) and operation (mean = 8.5 min; SD = 0.06), demanding meticulous preparations that included better execution due to their large size/ body weight difference compared to younger patients therefore making it harder for them during surgery procedures like circumcisions when compared to others done on little ones.This gradually increased healing duration from average of seven days in the group to eleven days in > 6 years implying some interrelation between patient’s age and his recovery speed (Table 5 ). Table 5 Age Groups’ Differences Regarding Operative Time Preparation/min, Operative Time/min, and Healing Time/days Age groups Operative time preparation (min) Operative time (min) Healing time (days) Statistical test (F) P value Mean SD Mean SD Mean SD ≤ 1 year (1643 participants) 8.0 1.5 6.0 0.8 7.0 1.5 1078 < 0.001 1–6 years (857 participants) 13.0 0.8 8.0 0.6 9.0 1.6 525.6 6 years (353 participants) 14.5 0.6 8.5 0.6 11.0 2.0 216.7 < 0.001 In four cases where the preputial skin was too short for MGT, instead a dorsal slit with excision was performed. These cases reiterate the need for personalised patient evaluation that even though MGT is highly advantageous, there could be situations where it might not work due to specific anatomical conditions at hand. This ensures that both safety and good cosmetic results are optimised, making the care given to all patients of highest quality. Discussion The Modified Guillotine Technique (MGT), a huge leap forward in paediatric surgery, especially in circumcision, which has been done since the beginning of times with religious, cultural and medical implications. This came against the backdrop of our research findings that MGT is a great tool to minimise glans injuries and enhancing cosmetic results. It confirms this conclusion when the historical development of the procedure towards safer and more satisfying methods is taken into account ( 12 ). Among our 2853 cases of the surgical approach for circumcisions, there were no single gland injuries which could result from conventional methods of performing it. Therefore, an analysis of the literature shows that the MGT can reduce significantly one of the most important complications associated with circumcision through zero incidence compared to other studies ( 13 ). Moreover, minor problems have the same rates between MGT and other techniques, meaning that changes do not add risks, thus keeping its safety as it was designed ( 14 ). Furthermore, our study upheld the efficiency of the MGT procedure by showing that its operating times are similar to those used in typical procedures within this field. The assumption that modifications would require longer operations is questionable based on this study. In settings where the guillotine method is often used, this makes MGT possibly the best choice for circumcisions ( 15 ). That, coupled with no glans injuries, makes it possible for MGT to become the best option available. The parents’ input on cosmetic results implied a high level of satisfaction. Therefore, high levels of satisfaction mean that individual’s expectations about their appearance seem achievable through the use of MGT. In making choices regarding long-term patient happiness and parental considerations during circumcision procedures that focus on cosmetic results as well( 16 , 17 ), we must weigh all these facts. Our investigation provides compelling evidence in favour of the use of MGT; however, these are restricted findings. There are several limitations despite our convincing evidence regarding the application of MGT in our study. These findings cannot be generalised to a large population due to the retrospective nature of the study and the participation of a single surgeon. To obtain a more comprehensive understanding of the efficacy in various settings, it would be important that prospective trials involve multiple surgeons with different levels of experience and several centres ( 18 , 19 ). Furthermore, the absence of glans injuries is a basis for an indirect assessment of postoperative pain; therefore, more studies are needed in this area. Then, to statistically analyse the influence of MGT on patient comfort during the recovery phase and the efficacy of pain management, future studies should employ direct assessment methods ( 20 ). Perhaps, the use of MGT, where circumcision is frequently done, has the potential to regularise procedures thus reducing variation in results associated with factors such as surgeon preference and technique choice. The continued use of these criteria may reduce complications related to circumcision around the world, resulting in healthier and more acceptable procedures ( 21 , 22 ). The modified guillotine technique represents a significant breakthrough compared to traditional methods of circumcision with particular emphasis on reducing injury to the penile glans and provision of good cosmetic results. As a result, this research outcome significantly contributes towards understanding its efficacy and safety paving way for wider deployment. For example, as one of the most common surgeries performed throughout the world, steps such as those taken by MGT will be crucial in developing surgery towards safer outcomes that are more effective and appealing aesthetically ( 23 ). More research needs to concentrate on addressing study limitations encountered earlier in our study; exploring use of MGT in different surgical settings; investigating other advantages due to the use MGT such as patients' pain-relief and recovery process. These aspects must be investigated by researchers. By doing so, not only be made regarding importance attached to MGT, but also continuity would still be maintained in evolution of circumcision towards offering the best therapy for patients. Conclusion The introduction of the Modified Guillotine Technique (MGT) in regions where circumcision is a routine has significant benefits. The modification can greatly reduce the rate of glans injuries, which are major concerns with the usual Guillotine technique. Our evaluation compared MGT with traditional Guillotine and other types of circumcision in terms of complication rates, aesthetic satisfaction, and operation time. In this study, there was no marked difference in operative time between MGT and the conventional Guillotine technique, implying that the efficiency has not been compromised by these modifications. Introduction of MGT addresses an essential safety concern without increasing the duration of the circumcision process. It is important because it shows that advances in patient safety and cosmetic results can be achieved without more time being spent on them, which impedes adoption of novel surgical procedures. Furthermore, the similarity in complications between MGT, traditional Guillotine method, and other techniques demonstrates that there are no new risks introduced but substantial improvements in safety and visual outcomes. Abbreviations MGT: Modified Guillotine Technique SPSS: Statistical Package for the Social Sciences IRB: Institutional Review Board VAS: Visual Analogue Scale SD: Standard Deviation EVENDOL: A pain assessment scale for children under 7 years of age χ2: Chi-square test ANOVA: Analysis of Variance HIV: Human Immunodeficiency Virus HPV: Human papillomavirus Declarations No funds, grants, or other support was received. The authors have no competing interests to declare that are relevant to the content of this article. Author Contribution This article with a single author. References Anwar MS, Munawar F, Anwar Q. Circumcision: a religious obligation or 'the cruellest of cuts'?. Br J Gen Pract. 2010;60(570):59–61. doi: 10.3399/bjgp10X482194 Kacker S, Tobian AA. Male circumcision: integrating tradition and medical evidence. Isr Med Assoc J. 2013;15(1):37–38. Mokal N, Chavan N. Modified safe technique for circumcision. 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Cheng, Y., Peng, Y., Liu, Y., Tian, L., Lü, N., Su, X., Yan, Z., Hu, J., Lee, R., Kim, H., Sokal, D., & Li, P. (2009). [A recommendable standard protocol of adult male circumcision with the Chinese Shang Ring: outcomes of 328 cases in China].. Zhonghua nan ke xue = National journal of andrology, 15 7, 584–92. Peng, Y., Yang, B., Jia, C., & Jiang, J. (2010). [Standardized male circumcision with Shang Ring reduces postoperative complications: a report of 351 cases].. Zhonghua nan ke xue = National journal of andrology, 16 11, 963–6. Hohlfeld A, Ebrahim S, Shaik MZ, Kredo T. Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions. Cochrane Database Syst Rev. 2021;3(3):CD012250. Published 2021 Mar 31. doi: 10.1002/14651858.CD012250.pub2 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4159055","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":284611384,"identity":"f8f0c94b-5c1d-4e78-a895-845cc9d77b44","order_by":0,"name":"Kahraman Topsakal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYBACCQYeZO4BBhl+EJ1QQIQWHqgWHskGkBYDUrQYHAAx8GiRbD977MPPHLs8e/bewx9+nLHjMT6/OvHDAwMGeX6xA1i1SPPkJc/s3ZZczMNzLk2y50Yyj9mNt5slgA4znDk7AasWOYYcYwbebcyJPRI5Zgw8H5iBWs5uAGlJMLiNQwv/G2PGv9vqQVqMP/75UM9jPOPs5h/4tEgDVTLzbjsM0mIgzXPjMI8Bf+82vLZIznhjzCy77Xhiz5lzadIyZ47zSNzg3WaRYCCB0y8S53OMGd9uq05sb+89/PHNsWo5/v6zm2/+qLCR55fGrgUJwJKBBFilBCHlyFr4DxCjehSMglEwCkYQAADuOF7+gbNORAAAAABJRU5ErkJggg==","orcid":"","institution":"Isparta State Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kahraman","middleName":"","lastName":"Topsakal","suffix":""}],"badges":[],"createdAt":"2024-03-24 17:44:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4159055/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4159055/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53850543,"identity":"51447868-9317-42d3-bf1e-f1cb7354d30e","added_by":"auto","created_at":"2024-04-01 09:51:29","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33409,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreparation: Clamping for Exposure and Tension\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4159055/v1/d70d74ce5f83eb61d232f586.jpg"},{"id":53850544,"identity":"6bf3ff72-ff93-4892-83ae-bf25fa13c48a","added_by":"auto","created_at":"2024-04-01 09:51:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1158995,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eInitial and Second Incision: Placement of Clamps and Incisions\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4159055/v1/c5a003e9524379db886663f0.png"},{"id":53850546,"identity":"c177f5c1-d576-4c21-a510-6d2f2ca97bde","added_by":"auto","created_at":"2024-04-01 09:51:30","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":36116,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMucosal Tissue Excision and Suturing\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4159055/v1/5c0818000bd13900f6ec4792.jpg"},{"id":53968044,"identity":"e61f8144-dca4-46d9-9ec0-5aa3036af681","added_by":"auto","created_at":"2024-04-02 20:07:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1582312,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4159055/v1/61e1baa7-2fc3-4f15-96ca-12f132f39b38.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"An overview of circumcision and a modification that prevents glans injuries and cosmetic problems in circumcisions made with the guillotine technique","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCircumcision is an ancient practice that humans have done since the beginning of time, and involves a surgery in which foreskin is removed from the male penis. The main reasons behind this custom include religion, culture, or medicine (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although it is an old method, it has kept on evolving both its techniques and results, prompting continuous investigations to improve the procedure regarding patient contentment, safety and efficiency (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This study aims to address the constraints associated with the Guillotine technique, which is one of the most widely implemented methods for circumcision and outline an alternative strategy to reduce risks involved with such a method (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough Guillotine is widely used because it can be done resulting into its popularity to many patients who are looking forward to undergo circumcision procedures; it has also been criticised due to its implications. These may involve injuries in the glans as well as poor cosmetic results, especially if performed by inexperienced surgeons (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The presence of these challenges requires the development of more advanced procedure that maintains the advantages of Guillotine while greatly reducing the risks linked to it (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). By introducing the modified guillotine technique (MGT), with the intention of avoiding glans injuries and improving cosmetic outcomes, our research contributes to the overall goal of safer, faster circumcision with improved aaesthetic appeal (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study fills a significant void in terms of lack of standardised and simple low risk approaches that could be globally adopted. This gap is especially important considering that circumcision is practised worldwide having health effects on men\u0026rsquo;s lives. The invention of MGT and its testing in a large cohort provide a unique opportunity to make progress in circumcision practice (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The aim of this research was not only to analyse glans injury prevention as well as complication rates, but also set a new benchmark for circumcisions carried out through safe means (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, our study places itself ahead among other studies conducted in urology and pediatric surgery due to operational time, recovery, and cosmetics improvement aspects of MGT (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Our comparison of MGT with standard techniques for circumcision exposes not only the potential advantages but also important lessons on how to carry out this procedure effectively (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn conclusion, the goals that this study intends to achieve are; to give a comprehensive insight into the historical and contemporary significance of circumcision; propose an innovative modification to the Guillotine technique, which is widely adopted; critically evaluate the safety, efficiency, and cosmetic aspects of such modified methods as well as advocate for its adoption in regular circumcisions with the aim of reducing risks associated with traditional approaches. Hopefully, through this research, we will be able to improve surgical safety and patient satisfaction that will ultimately influence circumcision practice globally.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study is a retrospective review of circumcisions performed between 2006 and 2022 in men aged from one month to fourteen years (mean age: seven years). The research encompassed a total of 2,000 eight hundred and fifty three circumcisions performed by the same surgeon using the modified guillotine technique. The patients were chosen based on the availability of complete medical records with operative details and follow-up information. Exclusion criteria included patients with congenital penile abnormalities or those who underwent circumcision for medical reasons, such as phimosis, which was not amenable to the standard guillotine technique.\u003c/p\u003e \u003cp\u003eThis study used male circumcision performed using the Modified Guillotine Technique (MGT) as an inclusion criterion to investigate its effects in males aged between 1 month and 14 years of age. The excluded criteria comprised anyone suffering from known bleeding disorders, with any congenital abnormalities of the penis or any condition that the clinical team thought was contraindicative to carry circumcision under the protocol being studied.\u003c/p\u003e \u003cp\u003eFor ethical standards and the protection of participant rights, our study protocol was approved by the local institutional review board (IRB), which is responsible for ensuring compliance with these standards. Our ethical guidelines adhered to all procedures detailed in the Declaration of Helsinki, having been acquired prior to the beginning of our research from approval documents.\u003c/p\u003e \u003cp\u003eWe made sure informed consent was an essential part of our compliance with ethics. Before participating, guardians of all minors involved in this investigation were given full explanations on what it entailed such as its objectives, risks/benefits associated with the modified guillotine technique, and their freedom to withdraw their children any time without fear of facing consequences. These parents/guardians then signed written informed consents indicating their comprehension and wilful acceptance into the project.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eModified Guillotine Technique\u003c/h2\u003e \u003cp\u003eThe modified guillotine technique was applied scrupulously as follows:\u003c/p\u003e \u003cp\u003ePreparation: From the top of the sulcus coronarius prepuce was cleaned free using clamps fixed at six and twelve o\u0026rsquo;clock positions to get enough exposure and tension (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eInitial incision: The glans were retracted towards the body by the surgeon using a non-dominant hand with the assistance of a nurse holding the clamps. Positioning of the straight clamp on the prepuce just about 3-4mm from the glans, which is adjustable for safety margin depending on preputial length. Subsequent to placing a clamp, an incision was made immediately below it to separate the mucosa and the skin, facilitating skin traction.\u003c/p\u003e \u003cp\u003eSecond incision: After a slight traction returned the skin back to its original position, a second line of incision was marked along the penile skin where impressions were left by clamps that had been used before. The skin was suspended and over this line was placed taking into account angulation of the glans. The second cut took place underneath the clamp to achieve the desired cosmetic outcome ( Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMucosal tissue excision and Suturing: followed by meticulous control of excess bleeding mucosal tissue removed before suturing and tying intermittent stitches on both the skin and mucosa that secured the integrity and aesthetic appearance (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThese two studies focus on circumcision using the modified guillotine technique (MGT). The main interests of the study were safety, efficiency, healing, cosmetic outcomes, and indirectly pain management. The primary outcome was glans injury, while wound infection, haematoma, and wound breakage were secondary outcomes. The MGT procedure took shorter durations both in preparation and in operation to demonstrate an improvement over traditional methods of circumcision. The duration of healing after surgery allowed conclusions to be drawn about its efficacy during postoperative recovery periods. Through parental feedback and clinical evaluations, we could tell if the method was capable of providing cosmetically beautiful results safely. The research did not look at direct pain assessments such as the Visual Analogue Scale, but it implies that there are no glans injuries associated with MGT which suggests that indirectly there might be relief from pain, hence a more comfortable postoperative period for patients. EVENDOL is given to children below six (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) years of age. EVENDOL scores can vary between 0\u0026ndash;15 with a therapy threshold at 4/15 (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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\u003eEVENDOL score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavioral expression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSign absent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSign weak or transient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSign moderate or present about half the time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSign strong or present almost all the time\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVocal or verbal expression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCries and/or screams and/or moans.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacial expression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFurrowed forehead and/or frown, furrowed brow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eand/or tense mouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMovements\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRestlessness, agitation and/or rigidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntalgic posture and/or protection of the painful area and/or immobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInteraction with the environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCan be comforted and/or interested in playing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eand/or interacts with people\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSPSS software version 26.0 in windows was used to analyse the data for univariate, bivariate, and stratified analysis. Contingency tables were constructed for qualitative variables with Pearson\u0026rsquo;s χ2 test or Fisher\u0026rsquo;s exact test used wherever necessary when requirements of the previous test were not met. The Anova test was performed for multiple comparisons of quantitative variables. The P-value of 0.05 showed significant differences.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA retrospective review of 2853 circumcisions with modified guillotine technique was done across different age groups; \u0026le;1 year (1643 patients, 57.51%), 1 to 6 years (857 patients, 29.9%), and \u0026gt;\u0026thinsp;6 years old (353 participants, 12.5%). This analysis aimed to emphasise the improvements in operative efficiency, lower complication rates, and better cosmetic outcomes that are particularly important for avoiding glans injuries.\u003c/p\u003e \u003cp\u003eOperative and Healing Times Analysis\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provided a detailed report on healing periods and duration of the procedure during preparation along specific age cohorts. The mean for the operation time preparation was established at 9.8 minutes with an SD of approximately 2.8 minutes, indicating a relatively uniform preparation phase across varying age groups but the time taken during surgery and the period taken to complete healing showed variations, where the mean duration of operation took approximately about six minutes (SD\u0026thinsp;=\u0026thinsp;1.4) while the mean time taken to heal was around seven days (SD\u0026thinsp;=\u0026thinsp;2.2). This indicates variability because the operative times had an average of about 6.0(\u0026plusmn;\u0026thinsp;1.4) minutes while the healing durations had an average of about 7.5(\u0026plusmn;\u0026thinsp;2) days between the patients operated during this period thus necessitating an individualised approach for managing circumcision that takes into account whether any patient could have some physiological differences due to their age (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eAge, Operative, and Healing Times\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstimated Data\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1643 participants (57.51%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e857 participants (29.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e353 participants (12.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u0026thinsp;\u0026plusmn;\u0026thinsp;25 (0\u0026ndash;120)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (4\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperative Time Preparation (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8 (\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperative Time (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealing Time (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 (\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative Adverse Events\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Adverse Events\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCount (Percentage)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (3.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2767 (97.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2796 (98.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEdema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2782 (97.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound Dehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2824 (99.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2839 (99.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePenile Injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2853 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore or Less Skin Removal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2853 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostoperative adverse events\u003c/p\u003e \u003cp\u003eThe study carefully recorded postoperative adverse events to evaluate the safety profile of the modified guillotine technique (Table III). These included infection, haematoma, edema, wound dehiscence, among others, such as bleeding, penile injury, and skin tags removal concerns. It is important to note that infection and haematoma rates were low across all age groups: among these, more than 97% of the cases remained without infections, while roughly all the cases avoided haemorrhage, including one event where fatality occurred after a very long duration of operation. Edema occurred slightly more frequently at 2.5% and wound dehiscence was rare at 1.0%. Most importantly, there were no cases of penile injuries or cases of excision of the wrong skin indicating how safe and accurate the alteration to the traditional method is.\u003c/p\u003e \u003cp\u003eParental satisfaction and Pain Assessment\u003c/p\u003e \u003cp\u003eAmong parents of all age brackets, more than 98% expressed satisfaction, indicating that improved technique had fulfilled its purpose in terms of the experiences of the patients and caregivers. Although people over 6 years cannot be evaluated using VAS and older than 6 years of age do not have EVENDOL scores, this high rate indicates that the procedure was performed successfully with tolerable postoperative pain (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge Groups\u0026rsquo; Differences Regarding Parental Satisfaction, VAS Score, and EVENDOL Score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1 years (1643 participants)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;6 years (857 participants)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;6 years (353 participants)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStatistical test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS first hour (1\u0026ndash;3 / 4\u0026ndash;6 / 7\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12% / 69% / 19%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS second hour (1\u0026ndash;3 / 4\u0026ndash;6 / 7\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19% / 61% / 22%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS 24 h (1\u0026ndash;3 / 4\u0026ndash;6 / 7\u0026ndash;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84% / 11% / 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEVENDOL first hour (4\u0026ndash;5 / 6\u0026ndash;10 / 11\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5% / 83% / 12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6% / 82% / 12%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFor 4\u0026ndash;5 χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEVENDOL second hour (4\u0026ndash;5 / 6\u0026ndash;10 / 11\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87% / 8% / 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74% / 21% / 5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFor 4\u0026ndash;5: χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;4.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction (Yes / No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.5% / 1.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99% / 1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98% / 2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOperative and Healing Times\u003c/p\u003e \u003cp\u003eAnalysis of operative times showed an obvious pattern towards extended preparation and surgical durations as patient ages increased. For example, young subjects (\u0026le;\u0026thinsp;1 year) experienced the shortest preparation time (M\u0026thinsp;=\u0026thinsp;8.0; SD\u0026thinsp;=\u0026thinsp;1.5) while the shortest surgery time was observed among infants in that category (M\u0026thinsp;=\u0026thinsp;6.0; SD\u0026thinsp;=\u0026thinsp;0.8), revealing a less complicated anatomical situation that may require faster surgical maneuvers for them compared to other groups. On the other hand, older children over six years of age had longest times for preparation (mean\u0026thinsp;=\u0026thinsp;14.5 minutes; SD\u0026thinsp;=\u0026thinsp;0.6) and operation (mean\u0026thinsp;=\u0026thinsp;8.5 min; SD\u0026thinsp;=\u0026thinsp;0.06), demanding meticulous preparations that included better execution due to their large size/ body weight difference compared to younger patients therefore making it harder for them during surgery procedures like circumcisions when compared to others done on little ones.This gradually increased healing duration from average of seven days in the group to eleven days in \u0026gt;\u0026thinsp;6 years implying some interrelation between patient\u0026rsquo;s age and his recovery speed (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge Groups\u0026rsquo; Differences Regarding Operative Time Preparation/min, Operative Time/min, and Healing Time/days\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOperative time preparation (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOperative time (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHealing time (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStatistical test (F)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eMean\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1 year (1643 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\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\u003e1\u0026ndash;6 years (857 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e525.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\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\u0026gt;\u0026thinsp;6 years (353 participants)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e216.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn four cases where the preputial skin was too short for MGT, instead a dorsal slit with excision was performed. These cases reiterate the need for personalised patient evaluation that even though MGT is highly advantageous, there could be situations where it might not work due to specific anatomical conditions at hand. This ensures that both safety and good cosmetic results are optimised, making the care given to all patients of highest quality.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe Modified Guillotine Technique (MGT), a huge leap forward in paediatric surgery, especially in circumcision, which has been done since the beginning of times with religious, cultural and medical implications. This came against the backdrop of our research findings that MGT is a great tool to minimise glans injuries and enhancing cosmetic results. It confirms this conclusion when the historical development of the procedure towards safer and more satisfying methods is taken into account (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong our 2853 cases of the surgical approach for circumcisions, there were no single gland injuries which could result from conventional methods of performing it. Therefore, an analysis of the literature shows that the MGT can reduce significantly one of the most important complications associated with circumcision through zero incidence compared to other studies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Moreover, minor problems have the same rates between MGT and other techniques, meaning that changes do not add risks, thus keeping its safety as it was designed (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, our study upheld the efficiency of the MGT procedure by showing that its operating times are similar to those used in typical procedures within this field. The assumption that modifications would require longer operations is questionable based on this study. In settings where the guillotine method is often used, this makes MGT possibly the best choice for circumcisions (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). That, coupled with no glans injuries, makes it possible for MGT to become the best option available.\u003c/p\u003e \u003cp\u003eThe parents\u0026rsquo; input on cosmetic results implied a high level of satisfaction. Therefore, high levels of satisfaction mean that individual\u0026rsquo;s expectations about their appearance seem achievable through the use of MGT. In making choices regarding long-term patient happiness and parental considerations during circumcision procedures that focus on cosmetic results as well(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), we must weigh all these facts.\u003c/p\u003e \u003cp\u003eOur investigation provides compelling evidence in favour of the use of MGT; however, these are restricted findings. There are several limitations despite our convincing evidence regarding the application of MGT in our study. These findings cannot be generalised to a large population due to the retrospective nature of the study and the participation of a single surgeon. To obtain a more comprehensive understanding of the efficacy in various settings, it would be important that prospective trials involve multiple surgeons with different levels of experience and several centres (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, the absence of glans injuries is a basis for an indirect assessment of postoperative pain; therefore, more studies are needed in this area. Then, to statistically analyse the influence of MGT on patient comfort during the recovery phase and the efficacy of pain management, future studies should employ direct assessment methods (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePerhaps, the use of MGT, where circumcision is frequently done, has the potential to regularise procedures thus reducing variation in results associated with factors such as surgeon preference and technique choice. The continued use of these criteria may reduce complications related to circumcision around the world, resulting in healthier and more acceptable procedures (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe modified guillotine technique represents a significant breakthrough compared to traditional methods of circumcision with particular emphasis on reducing injury to the penile glans and provision of good cosmetic results. As a result, this research outcome significantly contributes towards understanding its efficacy and safety paving way for wider deployment. For example, as one of the most common surgeries performed throughout the world, steps such as those taken by MGT will be crucial in developing surgery towards safer outcomes that are more effective and appealing aesthetically (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMore research needs to concentrate on addressing study limitations encountered earlier in our study; exploring use of MGT in different surgical settings; investigating other advantages due to the use MGT such as patients' pain-relief and recovery process. These aspects must be investigated by researchers. By doing so, not only be made regarding importance attached to MGT, but also continuity would still be maintained in evolution of circumcision towards offering the best therapy for patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe introduction of the Modified Guillotine Technique (MGT) in regions where circumcision is a routine has significant benefits. The modification can greatly reduce the rate of glans injuries, which are major concerns with the usual Guillotine technique. Our evaluation compared MGT with traditional Guillotine and other types of circumcision in terms of complication rates, aesthetic satisfaction, and operation time. In this study, there was no marked difference in operative time between MGT and the conventional Guillotine technique, implying that the efficiency has not been compromised by these modifications. Introduction of MGT addresses an essential safety concern without increasing the duration of the circumcision process. It is important because it shows that advances in patient safety and cosmetic results can be achieved without more time being spent on them, which impedes adoption of novel surgical procedures. Furthermore, the similarity in complications between MGT, traditional Guillotine method, and other techniques demonstrates that there are no new risks introduced but substantial improvements in safety and visual outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eMGT: Modified Guillotine Technique\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSPSS: Statistical Package for the Social Sciences\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIRB: Institutional Review Board\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVAS: Visual Analogue Scale\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSD: Standard Deviation\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEVENDOL: A pain assessment scale for children under 7 years of age\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003e\u0026chi;2: Chi-square test\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eANOVA: Analysis of Variance\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHIV: Human Immunodeficiency Virus\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHPV: Human papillomavirus\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003eNo funds, grants, or other support was received.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eThe authors have no competing interests to declare that are relevant to the content of this article.\u003c/li\u003e\n\u003c/ul\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThis article with a single author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAnwar MS, Munawar F, Anwar Q. 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The association of meatal stenosis and infant circumcision. The Turkish journal of pediatrics, \u003cem\u003e65\u003c/em\u003e(4), 661\u0026ndash;666. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.24953/turkjped.2023.46\u003c/span\u003e\u003cspan address=\"10.24953/turkjped.2023.46\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHohlfeld A, Ebrahim S, Shaik MZ, Kredo T. Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions. Cochrane Database Syst Rev. 2021;3(3):CD012250. Published 2021 Mar 31. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD012250.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD012250.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreeman, J. J., Spencer, A. U., Drongowski, R. A., Vandeven, C. J., Apgar, B., \u0026amp; Teitelbaum, D. H. (2014). Newborn circumcision outcomes: are parents satisfied with the results?. Pediatric surgery international, \u003cem\u003e30\u003c/em\u003e(3), 333\u0026ndash;338. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00383-013-3430-5\u003c/span\u003e\u003cspan address=\"10.1007/s00383-013-3430-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWani, R. A., \u0026amp; Mir, B. Y. (2023). 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Zhonghua nan ke xue\u0026thinsp;=\u0026thinsp;National journal of andrology, 16 11, 963\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHohlfeld A, Ebrahim S, Shaik MZ, Kredo T. Circumcision devices versus standard surgical techniques in adolescent and adult male circumcisions. Cochrane Database Syst Rev. 2021;3(3):CD012250. Published 2021 Mar 31. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD012250.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD012250.pub2\" 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, modified guillotine technique (MGT), cosmetic outcomes, glans injuries","lastPublishedDoi":"10.21203/rs.3.rs-4159055/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4159055/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Despite being an age old practice, there is ongoing research and development to improve the procedure in order to enhance its safety, efficacy and client satisfaction. The Guillotine technique, which is one of the most common methods, has been criticised for possible glans injuries and nonpleasing cosmetic results especially when an inexperienced person tries it out. This research paper introduces the Modified Guillotine Technique (MGT) designed to address these issues.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis retrospective study involved analysing 2853 circumcisions performed between 2006 and January 2022 using MGT on males aged between one month and fourteen years. Safety, efficiency of wound healing through cosmetic outcomes by indirect means, pain management of MGT were examined here.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u0026nbsp;MGT was used in different age groups without any significant increase in operative time compared to the traditional Guillotine technique thus showing perpetuation of efficiency. It is important to note that there were no reports of gland injuries, while complications rates did not differ significantly from those obtainable with other methods thus emphasising on safety and efficacy of MGT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe modified Guillotine technique represents a major leap forward in circumcision practice by combining the effectiveness of the Guillotine method with an improved safety profile and cosmetic outcomes. By significantly reducing the risks associated with glanular injury, but with the maintenance of procedural time and the addition of new complications, MGT offers a viable option for routine circumcisions worldwide.\u003c/p\u003e","manuscriptTitle":"An overview of circumcision and a modification that prevents glans injuries and cosmetic problems in circumcisions made with the guillotine technique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-01 09:51:25","doi":"10.21203/rs.3.rs-4159055/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":"957d9ef4-d115-45b1-8b42-2f0c3e4bf301","owner":[],"postedDate":"April 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-02T19:59:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-01 09:51:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4159055","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4159055","identity":"rs-4159055","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}