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

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

Methods: Multi-institutional analysis was performed at 9 centers on males 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: 231 patients were included with a median stricture length of 5 cm and median follow-up of 53 months among those without stricture recurrence. 1, 5 and 10 year stricture-free estimates were 90%, 80% and 75% respectively. 55% (127/231) underwent SSU with OMG, 19% (44) staged urethroplasty and 26% (60) underwent PU. On log-rank, there was no identifiable difference in stricture recurrence between techniques (p=0.6) with 5-year stricture-free estimates of 82%, 76%, and 75% respectively. On Chi-square, there was no significant difference in 90-day complications (7.1% vs. 16% vs. 8.3%;p=0.2), erectile dysfunction (7.1% vs. 4.5% vs. 3.3%; p=0.6), chordee (5.5%vs. 6.8% vs.1.7%; p=0.4) or urethrocutaneous fistula (2.4% vs. 6.8% vs. 0%; p=0.09). On Cox regression, only obesity (BMI≥35) was associated with stricture recurrence (Hazard Ratio 2.31, 95%CI 1.28-4.17; p=0.006).

Conclusion: Favorable comparative outcomes confirm single-stage urethroplasty as a highly feasible treatment for LS induced PUS in properly selected patients, especially when considering the decreased number of surgeries required and preservation of an orthotopic meatus.