JCU - January 2022 - 19

982755
URO
Journal of Clinical UrologyBunker et al.
Letter
Reply to: 'Does routine histology
alter management post-circumcision?'
CB Bunker1, G Kravvas1 , R Watchorn2, A Spencer2,
E Ong1 , A Haider3, A Freeman3, NA Francis4,
H Alnajjar5, A Muneer5 and M Dinneen6
We write to express our reservations about the article
'Does routine histology alter management post-circumcision?'
by Kerr et al.1, recently published in the Journal
of Clinical Urology. The stated aims were 'to confirm
that routine histology for circumcision is not required
and that clinical diagnosis is largely accurate. . . and
whether histological confirmation of [lichen sclerosus]
does alter patient management'. We contend that these
aims are not properly addressed by the study undertaken
and that the stated conclusions are of limited validity.
We also contest some other statements that are made in
the article.
Essentially, the authors have compared retrospective
data from two groups of adult male patients circumcised
for a variety of indications at their institution. The groups
are (a) so-called 'controls', i.e. patients under the care of
some clinicians (n unspecified) at their institution who 'did
not send samples for histology unless malignancy was suspected';
and (b) the 'study group' comprising all the
patients who had circumcisions i.e. both those under the
care of the former clinicians (inferentially) where malignancy
was suspected and those circumcised, for whatever
clinical reason, by another group of surgeons (n again
unstated). The absence of histological analysis in the purported
control group is problematic and the effective consequence
is a diagnostic vacuum. To compare outcomes,
the authors rely solely on follow-up. However, the information
provided on follow-up is limited, with only the
range (1-6 years) and mean (40 months) described and no
information on the distribution within this range, nor the
frequency. No information is provided to explain the clinical
necessity for such lengthy follow-up, and thus the
question of whether patients required it for ongoing symptomatology
in the area remains open. The authors do not
provide information on how they established that there is
no difference in the outcomes or re-referral rates of patients
between the two groups, or accounted for patients that may
have been referred to other centres, and they do not consider
confounding factors that could influence re-referral,
such as death or severe comorbidity.
Although we appreciate the efforts that our colleagues
have made to scrutinise the retrospective data available to
them, the imperfections in this approach are muddling
because the groups are different in several key regards.
Also, we are not told the descriptive statistics of the ages
of the groups; in fact no information is provided on whether
the study group and control group were matched. A better
way to test the hypothesis that histology is not necessary
is, arguably, to submit all specimens by all surgeons for
histology, compare the clinical diagnosis with the histology
and, having those surgeons who would not routinely
have requested histology flag those cases where that would
not have been their clinical decision outside the investigative
circumstances of such a study, and compare the outcomes.
That would be a prospective endeavour of course.
We recognise that the clinicians who did not routinely
send foreskins for histology did not miss any cancers (happily),
but we have other misgivings about this clinical attitude
and the potential consequent endorsement of it that
might ensue following a publication such as this.
1 Department of Dermatology, University College London Hospitals,
UK
2 Department of Dermatology, Imperial College Healthcare, UK
3 Department of Histopathology, University College London Hospitals,
UK
4 Department of Histopathology, Chelsea and Westminster Hospital,
UK
5Department of Urology, University College London Hospitals, UK
6Department of Urology, Chelsea and Westminster Hospital, UK
Corresponding author:
G Kravvas, Department of Dermatology, University College London
Hospitals, 235 Euston Rd, Bloomsbury, London, NW1 2BU, UK.
Email: georgios.kravvas@nhs.net
Journal of Clinical Urology
2022, Vol. 15(1) 19 -22
© British Association of
Urological Surgeons 2020
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DOI: 10.1177/2051415820982755
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JCU - January 2022

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