Reply to: ‘Does routine histology alter management post-circumcision?’

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. Reply to: 'Does routine histology alter management post-circumcision? '