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Bunker et al.
21
diagnosis of male genital dermatoses can be a complicated
endeavour and that clinical impressions cannot be
relied upon.
This leads us next to comment on the extraordinary
statement made by the authors that 'there is ongoing debate
regarding whether penile [lichen sclerosus] is a premalignant
condition although current literature does not allow a
definitive conclusion' and '[lichen sclerosus] is not currently
considered a premalignant condition based on the
existing literature'; they cite an 18-year-old reference and
omit consideration of the overwhelming and consistent evidence
that has accrued in the interim. Publication of misleading
assertions based on outdated and discredited
literature cannot be allowed to pass unchallenged; they
have the potential to confuse healthcare professionals and
undermine efforts to develop preventative strategies against
penile cancer. It is unassailably and undeniably the case
that lichen sclerosus is a precursor of squamous carcinoma
of the penis; there is no ongoing debate. The evidence is
overwhelming.8 It is regrettable that this clear association is
not widely recognised; although it is acknowledged by the
British Association of Urological Surgeons (BAUS),9 it is
not acknowledged by Cancer Research UK10 or Orchid11. It
is also important to accept that although the risks of penis
cancer (and urethral disease) plummet after circumcision
for lichen sclerosus, they will not reach zero (although best
practice can mitigate these risks);5,6 the fact that a man has
had lichen sclerosus must be categorically ascertained if at
all possible (bearing in mind that foreskin histology is not
the gold standard); concomitant and perhaps persistent
residual PeIN has to be confirmed or excluded; and the
patient counselled and managed accordingly.
In summary, we protest that this article fails 'to confirm
that routine histology for circumcision is not required and
that clinical diagnosis is largely accurate' and that 'histological
confirmation does not alter patient management'.
Further, we assert that the authors' conclusions that 'there
is difference in the outcomes or re-referral rates of patients
who have routine histology requested following circumcision
compared with those who do not', that 'clinical diagnosis
is consistently accurate', that 'histological diagnosis
does not alter the management of patients with confirmed
[lichen sclerosus] compared with a clinical diagnosis', that
'it is very rare for patients to present with a [lichen sclerosus-related]
problem following circumcision' and that 'the
presence or absence of histology does not alter this', are
completely untenable.
Finally, we take issue with the specious point about cost.
In modern medicine and urology £40 is not excessive, even
at volume. Histology is an essential investigation in all of
medicine in addressing a differential diagnosis, making a
firm diagnosis, excluding confounding or compounding
factors, and formulating effective management and suitable
follow-up. Compare, if you will, the cost of the investigation
with the cost of failing to make the correct diagnosis.
It is a retrograde, arguably perilous, step to dispense
with histology under pretty well all circumstances but
especially following circumcision. It is an unhelpful exercise
to argue for its discontinuation based on contentious
data, flawed analyses and ill-conceived arguments.
Conflicting interests
The authors declare that there is no conflict of interest.
Funding
The authors received no financial support for the research,
authorship and/or publication of this article.
Ethical approval
Not applicable.
Informed consent
Not applicable.
Guarantor
Not applicable.
Contributorship
All listed authors have contributed to the writing and research
associated with this article.
Contributions
All authors contributed to the management, writing, and literature
review associated with this study
Acknowledgements
None.
ORCID iDs
G Kravvas
https://orcid.org/0000-0002-1924-0149
E Ong https://orcid.org/0000-0002-5457-462X
References
1. Kerr L, Hendry J, Crookshanks A, et al. Does routine histology
alter management post circumcision? J Clin Urol. 2020;
13, 279-282
2. Kravvas G, Ge L, Ng J, et al. The management of penile
intraepithelial neoplasia (PeIN): Clinical and histological
features and treatment. J Dermatolog Treat. Epub before print
6 August 2020. DOI: 10.1080/09546634.2020.1800574.
3. Bunker CB. Male genital skin disease. 2nd ed. London:
Bruce Shrink, 2019.
4. Bunker CB. Zoon balanitis - does it exist? J Eur Acad
Dermatol Venereol 2020; 34: e116-e117.
5. Kravvas G, Shim TN, Doiron PR, et al. The diagnosis and
management of male genital lichen sclerosus: A retrospective
review of 301 patients. J Eur Acad Dermatol Venereol
2018; 32: 91-95.
https://www.orcid.org/0000-0002-1924-0149 https://www.orcid.org/0000-0002-5457-462X

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