Two-stage urethroplasty using buccal mucosa graft in patient with penile stricture and Lichen sclerosus
Lichen sclerosus (LS) is a disease of unknown etiology that affects the penile organ.
It is more common in young adults, but can affect any age.
It is characterized by atrophy of the epidermis.
LS affects especially the genital mucosa.
The disease can give: itching of the glans and penis, trauma during intercourse, difficulty in preputial mobility, erectile dysfunction, phimosis and paraphimosis and furthermore can lead to urethral stricture .
Materials and Methods
From January 2015 to February 2016 10 patients (pts) with LS and urethral stricture were enrolled for this study. Patient mean was age 45 years.
All of the patients underwent physical examination, uroflowmetry, retrograde and voiding urethrography in order to evaluate the stricture. The mean Qmax was 7 ml/sec. Mean stricture length was 3.7 cm.
All pts underwent two-stage urethroplasty with buccal/labial mucosa graft.
When the stricture affected the navicular urethra it was used a labial graft for its minor thickness.
A midline longitudinal incision was made along the penile skin ventrally. The penile urethra was exposed with minimal dissection. The urethra was opened along its ventral surface under the guidance of the guide wire, previously inserted. The urethra is spatulated up to 3 cm into normal caliber and pink urethral mucosa. The entire urethral plate affected by the LS was removed. Then the buccal mucosa graft was suteured on the urethral plate with two lateral running sutures and many single stiches on the whole graft in 5.0 Vicryl suture.
Second-stage procedure was carried out at 6 months from the first procedures in order to have a soft urethra and relaxed scar tissues. The neo-urethra is incised laterally and tubularized with 5.0 Vicryl suture.
The glans was reconstruct on the tubularized urethra. Dartos fascia and skin were closed. A sovrapubic catheter and a 10 Fr urethral stent were inserted and left for two weeks post-operatively.
Pts were discharged from the clinic 2 days after surgery. Pts were suggested to use anti-scar and moisturizing creams 3 times/day until the second-stage surgery.
At 3 months follow-up after the second stage all pts underwent uroflowmetry in order to assess the voiding.
Two pts needed calibration with Nelaton catheter 16 Fr. One patient underwent surgery with buccal mucosa graft.
Mean Qmax was 21 ml/sec. All Pts were satisfied with the result of the surgery.
In pts with penile strictures caused by LS, the penis is fully involved in the disease : glans, meatus, skin, fibrotic dartos. For these pts one-stage repair would be risky, having a poor chance of success. For this reason it is recommended the two-stage repair . At moment buccal mucosa graft is the best tissue to replace the urethra
Penile urethroplasty is a complex procedure with high risk of insuccess so it should be perfomed only by surgeon specialized in genital reconstructive surgery. This procedure is the only technique that can treat LS and penile strictures.
1) Kulkarni S, Kulkarni J, Surana S, Joshi PM. Management of Panurethral Stricture. Urol Clin North Am. 2017 Feb;44(1):67-75
2) Angulo JC, Arance I, Esquinas C, Nikolavsky D, Martins N, Martins F. Treatment of long anterior urethral stricture associated to lichen sclerosus. Actas Urol Esp. 2016 Nov 2. pii: S0210-4806(16)30131-0.Argomenti: andrologia, chirurgia ricostruttiva