UROLOGICAL SURVEY   ( Download pdf )

 

RECONSTRUCTIVE UROLOGY

Lichen sclerosus of the male genitalia and urethra: surgical options and results in a multicenter international experience with 215 patients
Kulkarni S, Barbagli G, Kirpekar D, Mirri F, Lazzeri M
Center for Reconstructive Urethral Surgery, Arezzo, Italy and Seth Ramdas Shah Memorial Hospital, Pune, India
Eur Urol. 2008 Jul 30. [Epub ahead of print]

  • Background: Surgical options in male patients with genital lichen sclerosus (LS) involving the anterior urethra still represent a challenging issue.
  • Objective: To review the outcome of surgical treatment in patients with genital and urethral LS.
  • Design, Setting, and Participants: Multicenter, international, retrospective, observational descriptive study performed in two specialized centers. Two hundred fifteen male patients underwent surgery for histologically proven genital LS involving the foreskin and/or the anterior urethra.
  • Intervention: Circumcision (34 cases), meatotomy (15 cases), circumcision and meatotomy (8 cases), one-stage penile oral mucosal graft urethroplasty (8 cases), two-stage penile oral mucosal graft urethroplasty (15 cases), one-stage bulbar oral mucosal graft urethroplasty (88 cases), and definitive perineal urethrostomy (47 cases). Measurements: Primary outcome was considered a failure when any postoperative instrumentation was needed, including dilation, or when recurrence was diagnosed. Results and Limitations: The average follow-up was 56 mo (range: 12-170 mo). Circumcision showed 100% success rate with no recurrence of the disease; meatotomy, 80% success rate; circumcision and meatotomy, 100% success rate; one-stage penile oral mucosal graft urethroplasty, 100% success rate; two-stage penile oral mucosal graft urethroplasty, 73% success rate; one-stage bulbar oral mucosal graft urethroplasty, 91% success rate; and definitive perineal urethrostomy, 72% success rate. Limitations include short follow-up for recording neoplastic degeneration and no instrument to investigate quality of life.
  • Conclusions: Patients with LS disease restricted to the foreskin and/or external urinary meatus showed a high surgery success rate. In patients with penile urethral strictures or panurethral strictures, the use of one-stage oral graft urethroplasty showed greater success than the staged procedures.

  • Editorial Comment
    Although the cause of lichen sclerosus (LS) is still unknown, its clinical course has been well described in recent years, and in particular, in a current review of Kulkarni et al. (1). It is still astonishing that histological evaluation is not or incorrectly performed, according to the data by Jasaitiene et al. Thorough histological evaluation revealed that LS occurs almost equal in boy and men (2).
    With the systematic retrospective work-up of Kulkarni et al., it became obvious that early diagnosis and correct treatment leads to a long-term satisfying outcome (3). Therefore, it should be requested that any resected tissue of the foreskin, glans or urethra has to be examined by a pathologist with the exclusion of LS.
    Even for the most extensive reconstruction, the authors suggest the use of buccal mucosa in a one-stage urethroplasty, which is opposite to Patterson and Chapple who suggest the two stage approach, to have a higher success rate (4). This contribution makes it once again obvious how important it might be to exclude LS both for the course of the disease as well as the result of a possible reconstructive surgery.

References
1. Pugliese JM, Morey AF, Peterson AC: Lichen sclerosus: review of the literature and current recommendations for management. J Urol. 2007; 178: 2268-76.
2. Jasaitiene D, Valiukeviciene S, Vaitkiene D, Jievaltas M, Barauskas V, Gudinaviciene I, et al.: Lichen sclerosus et atrophicus in pediatric and adult male patients with congenital and acquired phimosis. Medicina (Kaunas). 2008; 44: 460-6.
3. Kulkarni S, Barbagli G, Kirpekar D, Mirri F, Lazzeri M: Lichen sclerosus of the male genitalia and urethra: surgical options and results in a multicenter international experience with 215 patients. Eur Urol. 2008; Jul 30. [Epub ahead of print]
4. Patterson JM, Chapple CR. Surgical techniques in substitution urethroplasty using buccal mucosa for the treatment of anterior urethral strictures. Eur Urol. 2008; 53: 1162-71.

Dr. Karl-Dietrich Sievert &
Dr. Arnulf Stenzl
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany
E-mail: arnulf.stenzl@med.uni-tuebingen.de