Strictures of the penile urethra caused by lichen sclerosus (LS) are a challenging clinical entity. These strictures typically involve the urethral meatus and insidiously progress over time proximally through the fossa navicularis into the penile urethra (see Figure).¹ Endoscopic treatments such as dilation or urethrotomy with or without intermittent self-catheterization offer only temporary relief, require lifelong instrumentation, and may ultimately increase stricture complexity.² Urethroplasty requires establishment of a functional and unobstructed urethra while creating a slit-like meatus, preserving sexual function, and retaining a cosmetically appealing glans.³ Additionally, LS is independently associated with stricture recurrence after urethroplasty.⁴ The ideal technique has not yet been elucidated, and various reconstructive techniques exist including both single-stage and multi-staged approaches with buccal mucosa. Traditionally, 2-stage or multi-staged buccal mucosal graft (BMG) repairs have been utilized. Recently, there has been an expansion of indications for single-stage repairs for complex strictures aimed at minimizing the inherent risks associated with a second procedure.⁵ From a patient perspective, single-stage urethroplasty is often preferred in order to reduce the total number of surgeries while avoiding temporary disfigurement of the penis.⁶ Lastly, depending on patient preference, a perineal urethrostomy is a viable option, albeit one that requires seated voiding. It is generally thought that a perineal urethrostomy offers improved stricture-free rates compared to reconstruction in properly selected individuals.⁷ A paucity of data exist directly comparing surgical options for these patients.

Our treatment approach to penile urethral strictures caused by LS has evolved over time, allowing an opportunity to assess the impact of these paradigm shifts on outcomes. We comparatively examined outcomes of single-stage BMG urethroplasty, staged urethroplasty, and perineal urethrostomy for the treatment of LS-associated isolated penile urethral strictures from August 2003 to May 2021. The primary outcome measure was urethral patency based on followup cystoscopy, while secondary outcomes included 90-day complications, sexual dysfunction, chordee, and urethrocutaneous fistula.

Overall, 132 patients were evaluated with a mean stricture length of 5.6 cm and a mean of 3 prior endoscopic treatment attempts. A total of 78 patients (59.1%) were managed with single-stage urethroplasty, 28 (21.2%) with staged BMG, and 26 (19.7%) with perineal urethrostomy. At a median followup of 74 months, overall stricture-free rate was 82.6%, and on Mantel-Cox testing there was no difference in stricture recurrence between techniques (11.5% vs 25.0% vs 26.9%; p=0.39). Additionally, there was no difference in 90-day complications (6.4% vs 14.3% vs 7.7%; p=0.043), erectile dysfunction (5.1% vs 3.6% vs 3.8%; p=0.093), chordee (6.4% vs 0.0% vs 3.8%; p=0.037), or urethrocutaneous fistula (1.3% vs 7.2% vs 0.0%; p=0.13).

Figure. Retrograde urethrogram demonstrating a penile urethral stricture caused by LS. These strictures typically and insidiously progress from a meatal origin, then extend proximally through the fossa navicularis into the penile urethra over time.

Reconstruction of penile urethral strictures related to LS yields satisfactory outcomes with no identified difference between techniques. Single-stage urethroplasty has similar outcomes compared to staged urethroplasty and thus has the potential to decrease the number of surgeries the patient is exposed to. With no noted difference between urethroplasty and perineal urethrostomy, it seems prudent to counsel undecided patients that urethroplasty is likely the best first choice, with perineal urethrostomy reserved for surgical failures should the need arise.