Multi-Institutional Analysis of Surgery for Lichen Sclerosus-Induced Penile Urethral Stricture: Establishing Single-Stage Urethroplasty as a Primary Treatment Option

Abstract

Purpose: Ideal treatment of lichen sclerosus (LS)-induced penile urethral strictures (PUS) remains elusive. The objective of this study was to compare multi-institutional outcomes of single-stage urethroplasty (SSU) with oral mucosal graft, staged urethroplasty, and perineal urethrostomy (PU) for treatment of LS-induced PUS.

Materials and methods: Multi-institutional analysis was performed at 9 centers on men undergoing SSU, staged urethroplasty, or PU for LS-induced PUS. Meatal strictures (<2 cm), bulbar urethral involvement, and panurethral strictures (>10 cm) were excluded. The primary outcome was recurrence-free status on follow-up assessment. Secondary outcomes included 90-day complications (Clavien ≥2), erectile dysfunction, chordee, and urethrocutaneous fistula.

Results: Two hundred thirty-one patients were included with a median stricture length of 5 cm and median follow-up of 53 months among those without stricture recurrence. One-, 5-, and 10-year stricture-free estimates were 90%, 80%, and 75%, respectively. Fifty-five percent (127/231) underwent SSU with oral mucosal graft, 19% (44) staged urethroplasty, and 26% (60) PU. On log-rank, there was no identifiable difference in stricture recurrence between techniques (P = .6) with 5-year stricture-free estimates of 82%, 76%, and 75%, respectively. On χ², there was no significant difference in 90-day complications (7.1% vs 16% vs 8.3%; P = .2), erectile dysfunction (7.1% vs 4.5% vs 3.3%; P = .6), chordee (5.5% vs 6.8% vs 1.7%; P = .4), or urethrocutaneous fistula (2.4% vs 6.8% vs 0%; P = .09). On Cox regression, only obesity (BMI ≥35) was associated with stricture recurrence (HR, 2.31, 95% CI, 1.28-4.17; P = .006).

Conclusions: Favorable comparative outcomes confirm SSU as a highly feasible treatment for LS-induced PUS in properly selected patients, especially when considering fewer surgeries required and preservation of an orthotopic meatus.

Keywords: lichen sclerosus; multistage; penile; stricture; urethra; urethroplasty.