Time to rethink routine histopathology after adult circumcision?: Long-term oncological outcomes from an 11-year cohort

Ghulam Nandwani; Mubeshar Hassan; Devanand Lohana; Prasad Bollina

doi:10.1007/s00345-026-06432-y

Time to rethink routine histopathology after adult circumcision? Long-term oncological outcomes from an 11-year cohort

Ghulam Nandwani (Lead / Corresponding author)
, Mubeshar Hassan
, Devanand Lohana
, Prasad Bollina

Undergraduate Medicine

Research output: Contribution to journal › Article › peer-review

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Abstract

Purpose: To evaluate whether routine histopathological examination of the prepuce following adult circumcision without clinical suspicion of malignancy influences patient management and healthcare resource utilisation, and to report circumcision frequency and long-term oncological outcomes. Methods: A retrospective cohort study was conducted of all adult circumcisions performed between January 2015 and December 2025. Patients aged ≥ 15 years undergoing circumcision for symptomatic phimosis, paraphimosis, or recurrent balanitis were included. Cases with suspected malignancy or known premalignant lesions were excluded. Demographic, operative, histopathological, and follow-up data were extracted from electronic records. Median follow-up was 85 months. Cost analysis was based on an estimated histopathology cost of £226 per specimen. Results: Of 1,648 listed patients, 1,523 met the inclusion criteria (median age 44 years). Phimosis was the primary indication (98.2%). Lichen sclerosus was identified in 62% of specimens, while incidental penile intraepithelial neoplasia (PeIN) was detected in 0.5%. No invasive carcinomas were identified. All PeIN cases were managed with circumcision alone, and no progression or additional intervention was required at a median follow-up of 81 months. Eliminating routine histopathology would have saved 304.6 consultant hours and £344,198 over 11 years (£31,291 annually). Conclusions: In the absence of clinical suspicion, routine histopathological examination of the prepuce rarely detects clinically significant malignancy or alters management. A selective, risk-adapted approach may optimise resource utilisation while maintaining oncological safety.

Original language	English
Article number	334
Journal	World Journal of Urology
Volume	44
Issue number	1
Early online date	30 Apr 2026
DOIs	https://doi.org/10.1007/s00345-026-06432-y
Publication status	Published - 30 Apr 2026

Keywords

Circumcision
Cost-benefit analysis
Foreskin
Penile intraepithelial neoplasia
Prepuce

ASJC Scopus subject areas

Urology

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10.1007/s00345-026-06432-yLicence: CC BY

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Cite this

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title = "Time to rethink routine histopathology after adult circumcision?: Long-term oncological outcomes from an 11-year cohort",

abstract = "Purpose: To evaluate whether routine histopathological examination of the prepuce following adult circumcision without clinical suspicion of malignancy influences patient management and healthcare resource utilisation, and to report circumcision frequency and long-term oncological outcomes. Methods: A retrospective cohort study was conducted of all adult circumcisions performed between January 2015 and December 2025. Patients aged ≥ 15 years undergoing circumcision for symptomatic phimosis, paraphimosis, or recurrent balanitis were included. Cases with suspected malignancy or known premalignant lesions were excluded. Demographic, operative, histopathological, and follow-up data were extracted from electronic records. Median follow-up was 85 months. Cost analysis was based on an estimated histopathology cost of £226 per specimen. Results: Of 1,648 listed patients, 1,523 met the inclusion criteria (median age 44 years). Phimosis was the primary indication (98.2\%). Lichen sclerosus was identified in 62\% of specimens, while incidental penile intraepithelial neoplasia (PeIN) was detected in 0.5\%. No invasive carcinomas were identified. All PeIN cases were managed with circumcision alone, and no progression or additional intervention was required at a median follow-up of 81 months. Eliminating routine histopathology would have saved 304.6 consultant hours and £344,198 over 11 years (£31,291 annually). Conclusions: In the absence of clinical suspicion, routine histopathological examination of the prepuce rarely detects clinically significant malignancy or alters management. A selective, risk-adapted approach may optimise resource utilisation while maintaining oncological safety.",

keywords = "Circumcision, Cost-benefit analysis, Foreskin, Penile intraepithelial neoplasia, Prepuce",

author = "Ghulam Nandwani and Mubeshar Hassan and Devanand Lohana and Prasad Bollina",

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AU - Hassan, Mubeshar

AU - Lohana, Devanand

AU - Bollina, Prasad

PY - 2026/4/30

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N2 - Purpose: To evaluate whether routine histopathological examination of the prepuce following adult circumcision without clinical suspicion of malignancy influences patient management and healthcare resource utilisation, and to report circumcision frequency and long-term oncological outcomes. Methods: A retrospective cohort study was conducted of all adult circumcisions performed between January 2015 and December 2025. Patients aged ≥ 15 years undergoing circumcision for symptomatic phimosis, paraphimosis, or recurrent balanitis were included. Cases with suspected malignancy or known premalignant lesions were excluded. Demographic, operative, histopathological, and follow-up data were extracted from electronic records. Median follow-up was 85 months. Cost analysis was based on an estimated histopathology cost of £226 per specimen. Results: Of 1,648 listed patients, 1,523 met the inclusion criteria (median age 44 years). Phimosis was the primary indication (98.2%). Lichen sclerosus was identified in 62% of specimens, while incidental penile intraepithelial neoplasia (PeIN) was detected in 0.5%. No invasive carcinomas were identified. All PeIN cases were managed with circumcision alone, and no progression or additional intervention was required at a median follow-up of 81 months. Eliminating routine histopathology would have saved 304.6 consultant hours and £344,198 over 11 years (£31,291 annually). Conclusions: In the absence of clinical suspicion, routine histopathological examination of the prepuce rarely detects clinically significant malignancy or alters management. A selective, risk-adapted approach may optimise resource utilisation while maintaining oncological safety.

AB - Purpose: To evaluate whether routine histopathological examination of the prepuce following adult circumcision without clinical suspicion of malignancy influences patient management and healthcare resource utilisation, and to report circumcision frequency and long-term oncological outcomes. Methods: A retrospective cohort study was conducted of all adult circumcisions performed between January 2015 and December 2025. Patients aged ≥ 15 years undergoing circumcision for symptomatic phimosis, paraphimosis, or recurrent balanitis were included. Cases with suspected malignancy or known premalignant lesions were excluded. Demographic, operative, histopathological, and follow-up data were extracted from electronic records. Median follow-up was 85 months. Cost analysis was based on an estimated histopathology cost of £226 per specimen. Results: Of 1,648 listed patients, 1,523 met the inclusion criteria (median age 44 years). Phimosis was the primary indication (98.2%). Lichen sclerosus was identified in 62% of specimens, while incidental penile intraepithelial neoplasia (PeIN) was detected in 0.5%. No invasive carcinomas were identified. All PeIN cases were managed with circumcision alone, and no progression or additional intervention was required at a median follow-up of 81 months. Eliminating routine histopathology would have saved 304.6 consultant hours and £344,198 over 11 years (£31,291 annually). Conclusions: In the absence of clinical suspicion, routine histopathological examination of the prepuce rarely detects clinically significant malignancy or alters management. A selective, risk-adapted approach may optimise resource utilisation while maintaining oncological safety.

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