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Background: Surgical options for urethral strictures secondary to lichen sclerosis (LS) represent a challenging issue, due to a high recurrence rate as compared to most urethral strictures. The incidence of LS has increased in the last decade with no universally accepted management strategy. We report a large single institution series of patients with LS who underwent surgical management of their urethral strictures.
Methods: We retrospectively reviewed 77 patients who were referred to our institution for surgical management of their histologically proven LS urethral strictures from 2004-2014. Strictures were classified by location as fossa navicularis, penile urethra, or panurethral. Interventions consisted of 2 stage oral mucosal graft urethroplasty, one stage oral mucosal graft urethroplasty, perineal urethrostomy, combination 1 and 2 stage urethroplasty and creation of a proximal meatus. Patients were followed with a uroflow, PVR and cystoscopy at 3-12 months and yearly thereafter. Primary outcome was urethral stricture recurrence, defined as either the inability to pass a 16 Fr cystoscope, requiring an intervention (dilation or repeat reconstruction) or LS recurrence in the 1^st stage oral mucosa graft.
Results: 77 patients with a mean age of 50.2 years and BMI of 35.7 underwent urethral reconstruction with a mean follow-up of 33.2 months (1-116). The mean stricture length was 9.7 cm. 49 (63.6%) had panurethral strictures, 19 (24.6%) had pendulous urethral strictures and 9 (11.6%) had fossa navicularis strictures. 36 patients underwent a 2 stage oral mucosal graft urethroplasty. Of the 36 patients planned for a 2 stage repair, 16 patients (53.3%) underwent a second stage urethroplasty with a 68% success rate. Of the 20 remaining patients, 10 (27%) had recurrent LS in their graft and were not candidates for 2^nd stage repair, 6 were pending closure, and the remaining 4 had undergone first stage only with no plan for reconstruction; 19 patients underwent a 1 stage oral mucosal graft urethroplasty with a 74% success rate; and 14 patients underwent a perineal urethrostomy with a 93% success rate.
Conclusions: Management of lichen sclerosis strictures continue to pose challenges to the reconstructive surgeon due to the high rate of stricture recurrence and often progression. While 2 stage repairs are often necessary in cases with an obliterative urethral plate, a 1 stage repair appears to offer a higher rate of success. Perineal urethrostomy offers a high degree of success in cases of urethral salvage.