Do men having routine circumcision need histological confirmation of the cause of their phimosis or postoperative follow-up?

Abstract

Objective: To assess the accuracy of pre-operative diagnosis of preputial pathology amongst urologists and general surgeons. Patients and Methods: Data were collected on 460 adult patients having had circumcision performed by either a general surgeon or a urologist over a 10-year period. Results: Pre-operative diagnosis was consistent with final histology in 83% of cases and further management was never altered by the histological result. Re-referral rates were 0% for general surgeons and 2.7% for urologists (P > 0.05) and there were no cases needing further surgical intervention. Conclusions: Routine submission of histological specimens for analysis and out-patient follow-up are not required following circumcision.Key words: Circumcision -Histology -Pathology - Follow-up Circumcision is one of the oldest and more frequently performed urological operations with over 35,000 being performed in England and Wales every year.' Several questions remain unanswered with regard to the management of this procedure: (i) what is the accuracy of pre-operative diagnosis compared with histological diagnosis; and (ii) does the histological diagnosis alter further management and do the patients require followup? Thus we retrospectively reviewed 460 consecutive patients who had a circumcision at our institution over a 10-year period.had circumcision performed at our institution for a variety of pathologies (Table 1). The clinical records were retrospectively analysed to determine the pre-operative diagnosis accuracy, frequency of histology requests and their effect on further management, and rates of follow-up. The incidence of re-referral and whether this led to surgical intervention were also assessed. For the purpose of analysis, a histological finding of non-specific inflammation or fibrosis was considered to be compatible with a preoperative diagnosis of phimosis. Results Patients and Methods

Does routine histology alter management post circumcision?

“…McSorley and Nigam (2011) 2 assessed 114 patients, 51 of whom were adults. Pearce and Payne (2002) 1 had a series of 460 patients, only 91 of whom had histological analysis of the prepuce. A total of 162 patients attended for follow-up in this series, with the majority discharged after review.…”

“…LS is not currently considered a premalignant condition based on the existing literature. 1 Previous studies have suggested histology should be requested if LS is suspected but this is not based on evidence. Although we had 201 histologically confirmed cases of LS, the re-referral rate for possible LS was only 1.6% after 6 years.…”

“…Many clinicians routinely send the excised prepuce for histological analysis, with concern over possible unexpected malignancy cited as a reason. Previous studies have shown that clinical diagnosis corresponds to histological diagnosis in over 80% of cases 1,2 and results rarely alter clinical management. Authors of these studies have suggested that histological analysis may only be appropriate in cases of suspected malignancy or lichen sclerosus (LS).…”

“…There is ongoing debate regarding whether penile LS is a premalignant condition although current literature does not allow a definitive conclusion. 1 As such, confirmation of diagnosis may be seen as reasonable. Progressive LS can potentially lead to meatal stenosis or significant urethral stricturing, which has been argued as a reason for histological confirmation at circumcision.…”

Pediatric Circumcision in the 21st Century National Health Service: A Snapshot of Practice in a United Kingdom Center

“…21 In a study of 460 patients by Pearce et al, none of the patients had their later management changed on the basis of original histology. 22 This study also a recorded cost of £34.33 for each specimen analyzed. In 15.7% (n ¼ 47) of the initial consultation letters, the surgeon had highlighted the strong wish raised by the family for the child to have partial or hemicircumcision only.…”