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Complex strictures - Lichen Sclerosus (BXO)

Balanitis Xerotica Obliterans (BXO) is a skin disease of the genitalia. Dr. Stuhner described BXO in 1928. Lichen Sclerosus (LS) is a chronic inflammatory skin disease of unknown origin and its pathogenesis has not yet been completely characterized. In 1995, the American Academy of Dermatologists recommended that the term LS should be used in future reports to define the true incidents and malignant potential of LS. LS in a male genitile area may cause destructive scaring that can lead to devastating urinary and sexual problems and a dramatic reduction in quality of life. Involvement of foreskin and the external urinary meatus is frequently reported in boys and adults. The difficult circumcision one encounters is usually due to LS. It is reported that with patients of failed Hypospadias repair show a high incidence of LS. LS may present at an early stage where the disease is limited to foreskin and circumcision is a treatment of choice. At a later stage, the patient may present with meatal stenosis and the treatment is meatotomy and meatoplasty. Ventral meatotomy are meatoplasty may give temporary relief. As we are using genital skin simple meatotomy and meatoplasty may lead to recurrence. We advise dorsal meatotomy and a buccal mucosa graft placed dorsally and our long term results are more than satisfactory. LS may present with penile urethral stricture. Various options are described in the literature. Use of genital skin a s an Orandi flap is not advocated as a recurrence rate is high. Some advocate excision of the scarred penile urethra followed by buccal mucosa graft in the first stage. In the second stage the buccal mucosa is turned into a tube. This two stage reconstruction of the penile urethra is preferred by many reconstructive urologists. Our experience of two stage buccal mucosa graft urethroplasty is not good. In India, the buccal mucosa graft shrinks and leaves a scarred buccal mucosa plate and the second stage reconstruction of the tube is difficult. Our method of choice for the treatment of penile urethral strictures due to LS is the Kulkarni Technique. The late presentation of LS is in the form of full length strictures of the penile and bulbar urethra. These patients may have undergone multiple failed urethroplasties, multiple DVIUs, multiple dilations. Circumferential fecio-cutaneous flaps of the prepuce and the penile skin have been used as ventral or dorsal augmentation urethroplasty but the recurrence rate is high. Two stage Johansson’s urethroplasty is used by some. In the first stage the urethra is opened ventrally and is the edge of the urethra is sutured to the skin edge on both sides. Three to six months later ‘U’ incision is made and new urethral tube is constructed. If the urethral plate was 10mm wide then 10mm skin on each side of the urethra is used to make a 30mm wide urethra forming 30 F urethral tube. This use of genital skin leads to high recurrence rate. We advocate the use of  ‘Kulkarni Technique’ for full length strictures of the urethra due to LS. The success rate of this urethroplasty is excellent in the long term.

Complex strictures - Urethral Cancer

Squamous cell carcinoma of the urethra is rare. I have seen only five patients of Squamous carcinoma in last twenty years of my practice and all patients had Lichen sclerosus as a precancerous disease. All patients presented with lump in the perineum. In two patients the lumps were incised thinking that they were periurethral abscesses. Two patients were referred after first stage of Johansson’s urethroplasty for non healing of the wound. One patient was diagnosed on endoscopy.

Traditional  treatment for penile urethral cancer will be decided by the local extent of the disease and may vary from wide local excision to partial or total amputation of the penis. For bulbar urethral cancer depending upon the local invasion wide local excision and or total amputation of penis may be required.  For large bulbar urethral cancers and posterior urethral cancers traditional treatment involves total amputation of penis with cystoprostato urethrectomy and lymph node dissection and the patient needs diversion may be ileal conduit. The local recurrence rate after such a major operation is very high, five year survival is less than 20% so 80% patients may die because of local recurrence and its problems. So in two patients, I have utilized a new technique of wide local excision followed by neo urethra formation with the dorsal penile skin. Under anesthesia a circumcision incision is made the dorsal penile skin far away from the side of the cancer is preserved with the its fascia. Total amputation of the penis with bilateral orchidectomy is performed in the traditional way.  As the patient may have a perineal incision for urethroplasty or biopsy or drainage in (thinking it is a periurethral abscess) perineal skin use may not be possible.  In one patient the prostate also was removed. Biopsies from the bladder neck were normal. For prostate removal inferior pubectomy was useful to control the dorsal vein complex. The bladder neck was preserved and was competed. If I introduced a forceps inside the bladder neck urine flowed out freely but as soon as I removed the forceps urine leak stopped immediately. Now the dorsal penile skin was turned into a tube with skin as its lining and was anastomozed to the bladder neck. The patient voided well and was cotenant. In second patient, we had taken biopsies from the prostatic urethra and they were normal so we could preserve the prostate and anastomose the new urethra to the apex of the prostatic urethra. One patient died within six months due to local recurrence but one patient has survived for more than a year and is still free from recurrence. This new technique of wide local excision and neo urethra allows the patient to void perineally and is continent it also prevents supra major surgery with ileal conduit as described above.

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