How to do a circumcision, when the foreskin is welded to the glans. The ROLOCS (Restoration Of the Lost Obscured Coronal Sulcus) procedure
Skrodzka, M1; Ayers, J2; Rea, A2; Hadway, P1; Britnell, W2; Malone, P1; Muneer, A1
1: University College London Hospital, United Kingdom; 2: Royal Berkshire Hospital, Reading, UK
Introduction: In patients with penile lichen sclerosus (LS), adhesions between the glans and prepuce are common. In the majority, these adhesions are easily separated at the time of circumcision, but in a small population, with particularly severe LS, these adhesions are difficult or impossible to separate. Our novel ROLOCS procedure uses a antegrade approach to the preputial adhesions leaving a fine layer of dartos covering the glans rather than denuding it. Residual epithelial cells in this layer are left to recover the glans over the following weeks.
Aim: To describe the ROLOCS procedure: a novel technique for circumcision in severe penile lichen sclerosus that sufficiently treats the disease and yields good cosmetic results.
Method: Over a five year period, 22 patients with severe preputial adhesions underwent the ROLOCS procedure in two UK centres. These ranged from age 23 to 93; mean age was 60. We prospectively analysed results of the treatment and complications. 20 patients have been followed up postoperatively (two lost to follow up) for a minimum of 8 weeks.
Results: Three patients had pre or post-operatively diagnosed penile malignancy. The remaining 19 had only lichen sclerosus. In the post-operative period the glans becomes raw and sloughy for the first two weeks, but by six weeks has re-epithelialised and healed without the need skin grafting in any case. There have been no major postoperative complications. Only one patient of our cohort has required adjuvant clobetasol treatment so far, one diagnosed with CIS underwent subsequent glans resurfacing procedure: in the other 18 cases the lichen sclerosus appears to be in remission.
Conclusions: The ROLOCS procedure is an effective method of circumcision for LS with severe preputial adhesions. Patients may experience an uncomfortable raw and sloughy area on the glans for a few weeks after surgery, but in all patients so far this has re-epithelialized and healed well. Cosmetically, the final outcome is better than that seen with a traditional approach and subsequent grafting, or partial circumcision. Oncologically, ROLOCS is also superior to partial circumcision by providing both better treatment of the LS and an adequate histological specimen to identify underlying malignancy or CIS. As with all novel techniques, more studies are needed, but ROLOCS is currently being used in two centres with encouraging results in both.
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