Introduction: Treatment of penile urethral strictures (PUS) related to lichen sclerosus (LS) is a controversial topic. Traditionally, 2-stage buccal mucosal graft (BMG) repairs were utilized. Recently, there has been an expansion of indications for single stage urethroplasty (SSU) for complex strictures aimed to minimize the risks of a second procedure. Additionally, depending on patient preference, a perineal urethrostomy is a viable option. The objective of this study is to compare SSU, staged urethroplasty and perineal urethrostomy for the treatment of LS PUS.
Methods: A retrospective analysis was performed on patients undergoing urethroplasty for LS PUS at a single-centre from August 2003 - May 2021. Meatal strictures <2 cm and panurethral strictures (>10 cm) involving the bulbar urethra were excluded. Penile strictures were reconstructed with either SSU, a staged technique, or perineal urethrostomy. Primary outcome measure was urethral patency at follow-up cystoscopy. Secondary outcomes were 90-day complications, change in sexual dysfunction, chordee, or urethrocutaneous fistula. Outcomes were compared using Cox regression or Fisher’s Exact test where appropriate.
Results: Overall, 132 patients were included with a mean age of 51.3 years and mean stricture length of 5.6 cm. Prior endoscopic treatments were performed in 113 (85.6%) with a mean of 3 prior endoscopic treatment attempts (range 0-20). Overall, 78 (59.1%) were managed with SSU, 28 (21.2%) staged BMG, and 26 (19.7%) perineal urethrostomy. Median follow-up was 74 months (IQR 30-125). Overall stricture free rate was 82.6% (n=109). Clavien =2 90-day complications occurred in 11 patients (8.3%), de novo erectile dysfunction in 6 (4.5%), chordee in 6 (4.5%), and urethrocutaneous fistula in 3 (2.3%). There was no difference in stricture recurrence between techniques (11.5% vs. 25.0% vs. 26.9%; p=0.39), 90-day complications (6.4% vs. 14.3% vs. 7.7%; p=0.43), erectile dysfunction (5.1% vs. 3.6% vs. 3.8%; p=0.93), chordee (6.4% vs. 0.0% vs. 3.8%; p=0.37), and urethrocutaneous fistula (1.3% vs. 7.2% vs. 0.0%; p=0.13). There were no clinical factors associated with stricture recurrence.
Conclusions: Reconstruction of LS PUS yields satisfactory outcomes with no noted difference between techniques. SSU has similar outcomes compared to staged urethroplasty and has the potential of decreasing the number of surgeries the patient is exposed to.