Heroic measures may not always be justified in extensive urethral stricture due to lichen sclerosus (balanitis xerotica obliterans)

Urology 2004; 64: 565-568.

Objectives: Strictures due to lichen sclerosus (LS) may affect the urethra as far proximally as the mid-bulb. For such strictures, a staged full-length repair is required and should use a nonpenile graft source such as buccal mucosa. Many cases occur in a population already accustomed to seated voiding, leading us to re-evaluate this approach and, in some circumstances, recommend definitive perineal urethrostomy alone.

Methods: We reviewed the medical records and retrograde urethrograms of all patients undergoing surgery for LS at our facilities between January 1991 and June 2002.

Results: A total of 63 patients, with an average age of 54.2 years, underwent surgery for LS stricture with an average follow-up of 38.5 months (range 4 to 117). Of the 63 patients, 19 underwent grafting in preparation for future reconstruction. Of these, 11 completed the second-stage repair, and 8 patients elected not to undergo the second stage of the repair, leaving a functional perineal urethrostomy. This led us to look more critically at definitive perineal urethrostomy alone for some patients. Parallel with the staged repairs, and subsequent to them, 44 patients underwent perineal urethrostomy alone.

Conclusions: The often extensive nature of LS, the prevailing philosophy that urethroplasty must use nonpenile skin, the limited availability of such sources, and the acceptance of many patients for seated voiding makes definitive perineal urethrostomy alone a viable treatment option. In all our cases, this satisfied patients’ quality of life concerns, leaving the anterior urethra dry and amenable to future repair. Younger men desirous of penile voiding should still be considered for staged repair using current techniques.