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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.

Context There is no clear evidence that determines which type of urethroplasty to perform under which particular circumstance. Objective To review the options for urethroplasty at different sites in the urethra and for different types of stricture indicating which procedure should be used in which circumstances according to the best available evidence. Evidence acquisition Recent publications have been reviewed and supplemented with the authors' personal experience. Evidence synthesis Currently, in the developed world, the most common types of stricture are relatively short and are situated in the bulbar urethra. There is good evidence that these are best treated by excision and end-to-end anastomosis if they are short enough or by patch urethroplasty using a buccal mucosal graft if they are longer. Distal penile urethral strictures are the next most common type of stricture, but the evidence base is weaker, although there is agreement that penile strictures due to lichen sclerosus often require a staged approach to reconstruction, again using buccal mucosal grafts. Urethroplasty for pelvic fracture urethral injury is an altogether different type of technique for an altogether different type of pathology. There is good evidence that this is best treated by bulbo-prostatic anastomotic urethroplasty. Other types of strictures and salvage surgery have no good evidence base and are specialised areas where experience and judgement are necessary. Conclusions The evidence base for urethral surgery has been developed for the more common types of urethral strictures in the last 20 yr, but it is still as much an art as it is a science.

Introduction Whilst buccal mucosa is the most versatile tissue for urethral replacement, the quest continues for an ideal tissue replacement for the urethra when substantial tissue transfer is needed. Previously we described the development of autologous tissue-engineered buccal mucosa (TEBM). Here we report clinical outcomes of the first human series of its use in substitution urethroplasty. Methodology Five patients with urethral stricture secondary to lichen sclerosus (LS) awaiting substantial substitution urethroplasty elected to undergo urethroplasty using TEBM, with full ethics committee support. Buccal mucosa biopsies (0.5cm) were obtained from each patient. Keratinocytes and fibroblasts were isolated and cultured, seeded onto sterilised donor de-epidermised dermis, and maintained at air–liquid interface for 7–10 d to obtain full-thickness grafts. These grafts were used for urethroplasty in a one-stage ( n =2) or a two-stage procedure ( n =3). Follow-up was performed at 2 and 6 wk, at 3, 6, 9, and 12 mo, and every 6 mo thereafter. Results Follow-up ranged from 32 to 37 mo (mean, 33.6). The initial graft take was 100%, as assessed by visual inspection. Subsequently, one patient had complete excision of the grafted urethra and one required partial graft excision, for fibrosis and hyperproliferation of tissue, respectively. Three patients have a patent urethra with the TEBM graft in situ, although all three required some form of instrumentation. Conclusions Whilst TEBM may in the future offer a clinically useful autologous urethral replacement tissue, in this group of patients with LS urethral strictures, it was not without complications, namely fibrosis and contraction in two of five patients.

Three cases of glans penis epidermoid carcinoma after lichen sclerosus et atrophicus (LSA) or balanitis xerotica obliterans are discussed. Relationships between both diseases are analyzed but remain unclear. Balanitis xerotica obliterans causes foreskin and urethral meatus stenosis that requires circumcision. Glans penis carcinoma can be observed many years later even after circumcision. The knowledge of LSA is important to do circumcision at the beginning of the disease with a long-term follow-up of these patients to realize a glans penis biopsy if necessary. Most cases of LSA are not recognized, and the frequency is higher than reported.

A clinical report of 5 cases of balanitis xerotica obliterans (BXO) with urethral involvement is presented. Involvement of the urethra in the BXO is emphasized and the fact that this process is often unnoticed, is stressed. The clinical and histological characteristics of this disease are described in its different localizations. Investigations are suggested to diagnose urethral involvement and the suitable therapy is outlined.

A case of BXO treated with complete surgical removal of the mucosal lesion and skin flap meatoplasty with excellent results 26th months later is reported.