Introduction

Phimosis is a clinical condition in which the prepuce cannot retract over the glans, with a prevalence of around 3.4% among adult males; Adult phimosis is typically considered pathological, often resulting from lichen sclerosis, chronic balanoposthitis, or it may be idiopathic [1]. While the etiology of penile cancer is multifactorial including chronic inflammation, smoking, and persistent human papillomavirus infection, phimosis remains a significant risk factor for its development [2]. Additionally, paraphimosis secondary to a phimotic band can lead to devastating consequences, including tissue necrosis and gangrene [3].

Circumcision is the primary treatment for pathological phimosis, while preputioplasty is an effective alternative in selected cases [4, 5]. Various methods of circumcision have been reported, each with its benefits and complication risks [6, 7]. Complication rates depend on factors, including anatomic abnormalities, medical comorbidities, surgical technique, and patient age [8]. In clinical practice, circumcision for phimosis often adopts the dorsal slit method as the primary goal is to expose the glans penis [9, 10]. Although this procedure is relatively quick, safe, and effective, it has obvious shortcomings, such as bleeding, subcutaneous hematoma, persistent edema, significant pain, and unsatisfactory postoperative appearance [8, 11, 12]. Accordingly, more effective and safer methods of circumcision are needed to avoid these complications.

Here, we describe a novel circumcision technique called the modified dorsal slit-guillotine-sleeve (DGS) technique, specifically designed for adult phimosis. It combines three existing techniques—dorsal slit, guillotine, and sleeve—with specific modifications. Based on the hypothesis that the novel technique provides better safety and patient satisfaction with penile appearance, we performed a single-center retrospective trial for adult males with phimosis to compare short term complication rates and patient satisfaction between the dorsal slit and modified DGS techniques.

Materials and methods

Study design

This single‐center retrospective comparative study was conducted following the Helsinki Declaration and was registered as a Chinese clinical trial (ChiCTR2400084358). The study’s approval was obtained from the Ethical Committee of Peking Union Medical College Hospital (PUMCH; approval no. I-24PJ0959).

Subjects

Adult males with phimosis who underwent circumcision at PUMCH between March 1, 2018 and March 1, 2024 were recruited for this study by study staff via telephone. After receiving detailed explanations regarding the benefits, risks, and procedural differences of each method, patients were allowed to choose the surgical technique according to their personal preferences. The reasons for ineligibility are detailed in Fig. 1. Upon signing informed consent forms at the scheduled clinic, patients can be followed up immediately.

Fig. 1
Fig. 1The alternative text for this image may have been generated using AI.
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Flowchart of cohort selection.

The inclusion criteria were as follows: (1) patients aged 18 and above; (2) patients diagnosed with phimosis; (3) patients who underwent circumcision at PUMCH.

The exclusion criteria included the following: (1) presence of malignant pathology in the resected foreskin lesion; (2) patients unable to understand the study conditions and objectives; (3) patients with incomplete clinical data; (4) patients circumcised using techniques other than the dorsal slit or modified DGS technique.

Data collection

At the clinic, participants were physically examined by staff and completed a brief questionnaire about satisfaction with penile appearance. Additionally, medical data were collected through the hospital information system, including the patient’s age, diagnosis, medical history, circumcision techniques, surgical duration, postoperative pathological results, and complications recorded during outpatient follow-up.

Surgical procedures

The patients underwent the same preoperative preparation: oral antibiotics administered on the surgery day, supine position, routine skin preparation, routine field disinfection with povidone-iodine, and spreading of a towel with 10 mL of 1% lidocaine block anesthesia of the penile dorsal nerve.

After circumcision, the patients’ cutting edge was wrapped with vaseline-coated gauze, and the outer layer was properly bandaged with elastic bandages. Dressing removal was scheduled 24–48 h after circumcision following confirmation of no bleeding. Intercourse should be avoided for four weeks after circumcision to prevent wound breakdown.

Dorsal slit technique

In the dorsal slit technique, the preputial orifice is first lifted with hemostatic forceps at the 3 and 9 o’clock positions to align the penis perpendicularly. A dorsal midline incision is then made in the prepuce using scissors until full retraction is achieved. Next, the adhesions between the glans penis and prepuce are carefully separated. The prepuce is freed up to 0.5–0.8 cm from the corona, and a circumferential incision is made around the glans, extending to the frenulum while preserving approximately 1 cm of frenulum tissue. Electrocoagulation is used to achieve hemostasis, and the two circular skin incisions are aligned. Finally, the full thickness of the foreskin, including both the skin and dartos fascia, is sutured together using 4–0 Coated Vicryl® Plus suture (Ethicon, Somerville, NJ, USA).

Modified DGS technique

Modified dorsal slit technique

Mosquito forceps are applied at the 12 o’clock position of the prepuce, aligning them with the shaft of the penis. A dorsal incision is made between the forceps, which breaks the fibrotic ring and exposes the glans penis. The adhesions between the prepuce and the glans are then carefully separated until the prepuce is fully freed (Fig. 2A).

Fig. 2: Steps of the modified DGS procedure.
Fig. 2: Steps of the modified DGS procedure.The alternative text for this image may have been generated using AI.
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A Modified dorsal slit technique. B Marking the incision of the inner plate of the prepuce. C Marking the incision of the outer plate of the prepuce. D Modified guillotine technique. E Modified sleeve technique. F Separation of the inner plate and serosa. G Trimming of the inner plate. H Restoration of Dartos fascia continuity. I Skin suturing.

Marking incision lines

For the inner plate, incision lines are marked 0.3 cm from the corona at the 5–7 o’clock positions. A V-shaped incision line is drawn at the frenulum, approximately 1.5 cm from the corona (Fig. 2B). For the outer plate, the penis is stretched, and measurements are taken from the penopubic junction to the corona. The foreskin is then pulled over the glans, and the incision line is marked parallel to the coronal sulcus from the dorsal mark to the frenulum (Fig. 2C).

Modified guillotine technique

The frenulum is secured with an Allis clamp, and the prepuce is lifted vertically. The outer plate is clamped along the marked incision line, and the excess foreskin is excised (Fig. 2D). Any bleeding spots are treated as the clamps are removed.

Modified sleeve technique and inner skin trimming

Mosquito forceps are used to lift the residual inner plate edge at specified points (Fig. 2E), and the dartos fascia is separated from the inner plate (Fig. 2F). The dorsal and lateral edges of the inner plate are trimmed along the marked line, leaving approximately 0.3 cm of skin proximal to the corona (Fig. 2G). The ventral dartos fascia and frenulum are left intact and are not separated.

Restoration

The dartos fascia is sutured at key points between the distal and proximal ends using 4–0 Coated Vicryl ® Plus suture (Ethicon, Somerville, NJ, USA) (Fig. 2H). The proximal penile skin is then sutured to the coronal preputial sleeve with the same suture (Fig. 2I).

For detailed surgical steps, please refer to the supplementary materials.

Outcomes

The primary outcomes of this analysis were (1) the rates and types of complications following circumcision, (2) participants’ satisfaction with penile appearance, and (3) surgical duration. Postoperative complications related to circumcision were defined based on World Health Organization guidelines and findings from previous studies [8, 13]. Complications were followed up on the 7th postoperative day, as most adverse events occur during or shortly after the circumcision procedure. Satisfaction with penile appearance includes overall satisfaction with penis appearance and the frequency of three common complaints: skin color mismatch, hypertrophic scarring, and edema [14]. Participant satisfaction was assessed using a self-designed, non-validated questionnaire. Surgical duration was calculated from the onset of anesthesia to the completion of the circumcision procedure.

Statistical analysis

Statistical analysis was conducted following published guidelines [15]. Continuous variables are presented as mean ± standard deviation and analyzed using Student’s t-test or the Mann–Whitney U test, as appropriate. Categorical variables are presented as numbers and percentages and compared using Pearson’s chi-squared test or Fisher’s exact test, as appropriate. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) software (version 22.0; SPSS Inc., Chicago, IL, USA). A p < 0.05 was considered statistically significant.

Results

Between March 1, 2018 and March 1, 2024, 641 males with phimosis who underwent circumcision at PUMCH were screened. Ultimately, 483 adult males were enrolled, with 332 undergoing the traditional dorsal slit technique and 151 undergoing the modified DGS technique.

The study population was divided into two groups to investigate the primary hypothesis: patients who received the modified DGS technique and those who received the traditional dorsal slit technique (Control). Details on the age distribution, the proportion of diabetes patients, and the follow-up time between the two groups are provided in Table 1. The participants in both groups demonstrated similar demographic profiles. The surgical duration is also presented in Table 1. The mean surgical duration in the modified DGS and control groups was 36.8 ± 11.5 min and 35.2 ± 8.9 min, respectively (p = 0.0964).

Table 1 Clinical data of the participants in this study.
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Table 2 displays the types of non-pain-related complications that occurred a week after circumcision, along with cases for each type, including delayed healing, infection, hematoma, insufficient skin removal, and excess skin removal. Other complications, such as injury to the penis or urethra, micturition and anesthesia-related complications, were assessed but not observed. The overall complication rate was higher in the control group (11.1%) than in the modified DGS group (2.6%, p = 0.0019). The most common complications in the modified DGS and control groups were infection and excess skin removal, respectively. A more detailed analysis of various types of postoperative complications indicated that a significantly higher number of males complained of excessive removal of the prepuce skin in the control group compared to the modified DGS group. Moreover, no significant differences were found between the two groups in delayed healing, infection, hematoma, or insufficient skin removal.

Table 2 Comparison of complication rates between the modified DGS and control groups.
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Table 3 summarizes the satisfaction with penile appearance following circumcision. We found that a significantly lower number of males in the modified DGS group (2.6%) were dissatisfied with the overall appearance of the penis after circumcision than those in the control group (18.1%, p < 0.0001). Furthermore, patients in the modified DGS group complained less frequently about skin color mismatch, hypertrophic scarring, or wound edema than those in the control group (p = 0.0001, 0.0001, and 0.0440, respectively).

Table 3 Comparison of penile appearance satisfaction rates between modified DGS and control groups.
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Discussion

Proper surgical technique based on patients’ age and anatomical considerations is critical to prevent circumcision-related complications [8]. Here, we introduced a novel circumcision technique, the modified DGS technique, specifically for adult phimosis that combines the advantages of three common circumcision methods—dorsal slit, sleeve, and guillotine—and modifies the relevant technical details. We compared the short-term outcomes with those of the traditional dorsal slit technique. Considering the impact of circumcision on patients’ psychological well-being and quality of life [16, 17], we opted to allow patients to choose their surgical method after receiving a detailed explanation, rather than assigning them to groups randomly. While this approach may introduce potential outcome bias, there were no significant differences in baseline characteristics between the two groups, which helps to mitigate the potential bias introduced by patient self-selection.

The study’s primary outcome was comparing postoperative complication rates between two surgical methods. Notably, the modified DGS group exhibited a significantly lower overall complication rate than the dorsal slit group. Further analysis revealed no statistically significant differences in the rates of various types of complications between the two groups, except for excess skin removal. Excessive foreskin loss can induce erectile pain, significantly affecting patients’ sexual lives [18, 19]. The lower incidence of excessive foreskin loss in the modified DGS group may be attributed to the accurate marking of the prepuce for removal. To evaluate the amount of skin removed, we used a stretched measurement method. Wessells et al. found no significant difference between stretched and erect measurements [20]. Accordingly, we evaluated penile length by measuring it in the stretched state. Subsequently, the length of the penis shaft was determined as the residual skin length after circumcision.

Additionally, despite similar complication rates between the two groups, neither hematoma nor delayed wound healing was observed in the modified DGS group. A prospective study of adult men undergoing circumcision found hematoma as the most common complication [21], contrasting our findings in the modified DGS group. In the modified DGS technique, the marking line on the outer plate was usually distal to the corona, resulting in less removal of the outer plate than with the dorsal slit procedure. This reduction in tissue removal decreased damage to the superficial dorsal vein and lowered the risk of hematoma. The absence of delayed wound healing in the modified DGS group is mainly attributed to the precise evaluation of the residual skin, which is crucial for reducing wound tension. Furthermore, preserving a longer ventral foreskin and sparing the frenulum in the modified DGS technique reduced wound tension. Finally, restoring the continuity of the dartos fascia further decreased wound tension.

For surgical duration, the modified DGS technique provided comparable outcomes to the dorsal slit technique, a result not previously reported with the traditional sleeve technique [22]. Drawing from the guillotine technique, the one-cut procedure in the modified DGS technique helps reduce the surgical duration. The conventional sleeve technique typically involves delicate anatomical operations to separate the circular skin flap from the dartos fascia below, which can be challenging and time-consuming for junior urologists. In the modified DGS technique, the separation direction between the skin and the dartos fascia is opposite to that of the traditional sleeve technique, with the dartos fascia lifted from the skin. This modification simplifies the procedure. Additionally, sparing the frenulum in the modified DGS technique eliminates the need for intricate frenulum-related operations. Overall, these three technological modifications have contributed to shorter surgical durations.

Male genital self-image may influence levels of depression, anxiety, and sexual performance [23]. Studies indicate that while safety concerns are paramount before circumcision, concerns about the postsurgical appearance grow afterward [24]. Our results demonstrated that the modified DGS technique significantly enhanced patient satisfaction with the overall appearance of the penis and reduced common complaints (skin color mismatch, hypertrophic scarring, and edema). Several factors may explain these findings. First, the healed wound is adjacent to the coronal sulcus, making the healing scar less noticeable and reducing the risk of skin color mismatch at the incision site. Second, the sleeve technique in the modified DGS group may reduce wound scar formation. A previous study linked severe scar wrinkling appearance after circumcision to the dorsal slit technique [25]. In traditional dorsal slit surgery, full-layer and tense sutures are often employed to control subcutaneous bleeding. However, the modified DGS technique separates the dartos fascia before trimming the inner plate, significantly reducing bleeding risk. This approach, along with restoring dartos fascia continuity, reduced the need for sutures. Third, compared to the dorsal slit, the modified DGS technique reduced the foreskin edema rate. Penile lymphatic vessels beneath the penile skin are crucial in tissue fluid reflux and maintaining penile function. Disorders in penile lymphatic reflux can cause penile foreskin edema, affecting morphology and function [26]. The modified DGS technique, like the sleeve technique, preserved most lymph vessels and connective tissue of the dartos fascia, reducing injury and refractory intractable lymphedema. Moreover, trimming the inner plate further reduces edema. Finally, using the guillotine technique in the modified DGS group produced a neat cutting edge of the outer plate, while the marking line ensured a clean cutting edge of the inner plate. This neat cut significantly enhances patient satisfaction with penile appearance.

The novel circumcision method leverages the advantages of sleeve and guillotine techniques while addressing their limitations. For instance, the sleeve technique cannot be performed for patients with a fibrotic preputial ring, where the prepuce cannot be retracted easily. However, the modified DGS technique, which uses a dorsal slit to expose the glans, works well in such cases. Compared to the guillotine technique, the modified DGS technique may offer greater safety. Although the guillotine technique is simple and fast, it involves cutting the prepuce without visibility of the glans and frenulum, which may lead to potential penile injuries [27, 28]. Technical modifications were made to the DGS method to address concerns about the guillotine technique. First, the cutting line was located on the upper panel of the sponge clamp, reducing the risk of glans damage. Moreover, we recommended using Allis forceps to fix the frenulum, thereby avoiding urethra injury. Severe complications, such as glans amputation, corpus cavernosum injury, or urinary fistula, were not observed in our study, confirming the safety of the novel circumcision technique.

This study had several limitations. First, due to the retrospective study design and incomplete medical records, we were unable to compare detailed indicators between the two surgical methods, such as intraoperative blood loss, pain score, and wound healing times between the two surgical methods However, the baseline data were largely consistent, and the results are clinically meaningful, which may partially mitigate this issue. Second, as mentioned earlier, non-random patient allocation may introduce potential bias. Third, we did not evaluate the satisfaction of participants’ partners. Considering a partner’s perspective on circumcision might be important in the patient’s decision-making process [29]. Finally, we did not evaluate whether the modified DGS technique is suitable for cases with phimosis associated with severe lichen sclerosis. In such cases, where the plane between the glans and foreskin is completely lost, the modified DGS technique may be unsuitable.

Conclusion

The modified DGS technique is a novel circumcision method for adult phimosis. It is applicable to cases of phimosis with preputial scarring, demonstrating a surgical duration comparable to the dorsal slit technique. By combining the benefits of sleeve and guillotine techniques and refining technical details, the modified DGS technique exhibits fewer complications and better cosmetic outcomes. However, the study’s retrospective design may have influenced the results, necessitating validation through multicenter, randomized, prospective studies.

Data sharing statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.