Accepted Manuscript Title: Outcomes for Management of Lichen Sclerosus Urethral Strictures by 3 Different Techniques Author: Chintan K. Patel, Jill C. Buckley, Leonard N. Zinman, Alex J. Vanni PII: DOI: Reference:
S0090-4295(16)00134-5 http://dx.doi.org/doi: 10.1016/j.urology.2015.11.057 URL 19619
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Please cite this article as: Chintan K. Patel, Jill C. Buckley, Leonard N. Zinman, Alex J. Vanni, Outcomes for Management of Lichen Sclerosus Urethral Strictures by 3 Different Techniques, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2015.11.057. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Outcomes for Management of Lichen Sclerosus Urethral Strictures by 3 Different Techniques Chintan K. Patel1, Jill C. Buckley2, Leonard N. Zinman1, Alex J. Vanni1 1
Lahey Hospital and Medical Center 2University of California San Diego
Conflict of Interest: none Financial Disclosures: none
Corresponding Author: Alex J. Vanni Department of Urology Lahey Hospital and Medical Center 41 Mall Rd. Burlington, MA 01805 Phone: 781-744-2508 Fax: 781-744-5429 Email: [email protected]
Abstract Word Count: 238 Manuscript Word Count: 2994 Keywords: lichen sclerosus, urethral stricture, buccal urethroplasty, perineal urethrostomy Abstract Objective: To evaluate the intermediate-term outcomes from a large, single institution series of patients with lichen sclerosus (LS) who underwent surgical management of their urethral strictures. Methods: 1 Page 1 of 22
We retrospectively reviewed 79 patients who underwent surgical management of their LS urethral strictures from 2003-2014, comparing outcomes of patients undergoing a single-stage buccal mucosa graft (BMG) urethroplasty, 2-stage BMG urethroplasty, or perineal urethrostomy (PU). Demographic and surgical outcomes data were collected for all patients. Results: Of the 79 patients, the mean follow-up was 32.4 months, mean age 50.1 years, and the mean BMI 35.7 with morbid obesity (BMI>35) in 48% of the cohort. The mean stricture length was 9.6 cm (1.5-21 cm), with 62% of patients having a bulbopendulous stricture. Of the 37 patients who were planned for a 2stage BMG urethroplasty, 9 (24%) patients had stricture recurrence or recurrent LS in the 1st stage BMG. Single-stage BMG urethroplasty was performed in 20 patients with a mean stricture length of 9.47 cm (4-21 cm) and a success rate of 75%. 14 patients from the cohort received a PU as the primary treatment with a success rate of 93%. Conclusion: Management of LS strictures continues to pose challenges to the reconstructive surgeon due to the high rate of stricture recurrence and often progression. Patients undergoing single-stage or 2-stage reconstruction often require revision and must be carefully observed for recurrent urethral stricture. PU offers the highest degree of success and should be considered for all patients.
Introduction: Lichen sclerosus (LS) is a chronic, inflammatory skin disease which occurs in the male genital area and can cause destructive scarring of the urethra1,2,3. In male patients with urethral stricture disease, LS is presumed to be the etiology in 14-29% of cases4,5. While some men have 2 Page 2 of 22
disease limited to the meatus, many present with long segment penile or bulbopendulous strictures not amenable to conservative therapy5,6,7,8,9. LS urethral strictures are heterogeneous in their length, location, age of onset and virulence. Surgical options for long-segment urethral strictures secondary to LS represent a challenging issue, due to recurrence rates ranging from 12-71% 5,6,8,9,10,11. These factors can make the optimal surgical management challenging. Additionally, there may be regional variation in outcomes as patients treated by the same surgeon in different climates have demonstrated significantly varied outcomes12. Despite the substantial morbidity caused by LS strictures, few papers in the urological literature report on the long-term surgical outcomes of this complicated disease comparing the different surgical options commonly employed. There is no universally agreed upon reconstructive strategy for these difficult strictures, with some advocating a single-stage buccal mucosa graft (BMG) repair, while others prefer a 2-stage BMG reconstruction or perineal urethrostomy (PU)8,9,10, 13. We report a large, single institution series of patients with LS who underwent surgery for their urethral strictures with the aim of evaluating the surgical outcomes of single-stage and 2-stage BMG urethroplasty as well as PU. Materials and Methods: After institutional review board approval, we retrospectively reviewed 1039 patients who underwent urethroplasty from 2003 to 2014. Inclusion criteria were patients with pathologically confirmed or clinical findings consistent with LS – whitish skin, tissue fusion, scarring, chronic irritation -who underwent urethral reconstruction. All surgeries were performed by one of three reconstructive urologists at our institution. We excluded all patients 3 Page 3 of 22
with a history of hypospadias, and surgically corrected hypospadias, as well as patients only requiring meatotomy. Preoperative evaluation included clinical exam, uroflowmetry, post void residual and retrograde urethrogram. Patient demographics and reconstructive techniques were assessed (2-stage BMG urethroplasty, single-stage BMG urethroplasty, or PU). Patients who had not yet undergone second stage reconstruction were assessed only for their first stage outcomes. Prior to either a single-stage or 2-stage reconstruction, patients who were performing clean intermittent catheterization (CIC), were given a period of urethral rest for at least 4 weeks and a SPT placed if necessary. Surgical Technique: 2-stage BMG urethroplasty: A 2-stage repair was performed in cases of an obliterated urethral plate (