Affirming Long-Term Outcomes After Contemporary Urethroplasty: The Adverse Impact of Increasing Stricture Length, Lichen Sclerosus, Radiation, and Infectious Strictures.

PURPOSE: There is a paucity of reported long-term outcomes after contemporary urethroplasty. Our objective is to determine the long-term success of modern urethroplasty and identify factors associated with stricture recurrence in this context. MATERIALS AND METHODS: Patients undergoing urethroplasty from July 2003 to May 2013 with at least 100 months of follow-up were identified. Long-term outcomes including stricture recurrence and patient satisfaction were evaluated by review of regional/provincial electronic records and telephone interview. Urethroplasty failure was defined as a recurrent stricture (<16F) confirmed on cystoscopy. Cox regression was used to evaluate variables associated with long-term stricture recurrence. RESULTS: A total of 733 patients were identified with ≥ 100 months follow-up. Median patient age was 45 years, stricture length was 4.7 cm, and 85.8% failed prior endoscopic treatment. At a median follow-up of 12.3 years, 89 recurrences were observed. Cumulative incidence of stricture recurrence was 6%, 10%, and 12% after 1, 5, and 10 years, respectively. From a patient-reported perspective, 89% of patients reported being satisfied with the outcome of surgery. On multivariable analyses, increasing stricture length (HR 1.1, 95% CI 1.05-1.15; P < .001) and stricture etiology (P < .001), in particular lichen sclerosus (HR 4.46, 95% CI 2.25-9.53), radiation (HR 4.25, 95% CI 1.65-10.9), and infectious strictures (HR 5.27, 95% CI 2.03-13.7), were independently associated with stricture recurrence. CONCLUSIONS: This study affirms the widely held belief that modern urethroplasty provides high long-term patency and patient-reported satisfaction. Patients with longer strictures as well as those with lichen sclerosus, radiation, and infectious etiologies have a higher hazard of stricture recurrence in the long term.

What is the role of single-stage oral mucosa graft urethroplasty in the surgical management of lichen sclerosus-related stricture disease in men? A systematic review.

PURPOSE: The benefits and harms of the available types of surgical management for lichen sclerosus-related (LS) strictures remain unclear and, thus, clear and robust clinical practice recommendations cannot be given. MATERIALS AND METHODS: To assess the role of single-stage OMGU in the management of LS strictures and explore how its benefits and harms compare with the alternative management options. Medline, Embase and Cochrane controlled trial databases (CENTRAL, CDSR) were systematically searched. Randomized (RCTs) and nonrandomized studies (NRCSs) comparing single-stage OMGU with other surgical management options for LS strictures and single-arm studies on single-stage OMGU were included. Risk of bias (RoB) was assessed. RESULTS: Of the 1912 abstracts identified, 15 studies (1 NRCS and 14 single-arm studies) were included, recruiting in total 649 patients. All studies were at high RoB. In the only NRCS available, stricture-free rate (SFR) for single-stage and staged OMGU was 88% vs 60%, respectively (p = 0.05), at a mean follow-up of 66.5 months. SFR range for single-stage OMGU in single-arm studies was 65-100% (mean/median follow-up, 12-59 months). Single-stage OMGU had low complication rates and beneficial impact on LUTS and QoL. CONCLUSIONS: The present SR highlights the methodological limitations of the available literature. In the absence of adverse local tissue conditions, and taking into consideration benefit-harm balance and surgeon's skills and expertise, single-stage OMGU can be justified in patients with LS strictures.

The evidence behind the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus: A state-of-the-art review.

In recent years, LASER has been introduced as a minimally invasive treatment for a broad range of vaginal and vulvar symptoms and diseases. However, the efficacy and safety of vaginal and vulvar LASER has continuously been questioned. The aim of this study is to create an overview of the current literature and discuss the controversies within the use of LASER for genitourinary syndrome of menopause, vulvovaginal atrophy, urinary incontinence and lichen sclerosus. A search string was built in PubMed. The search was commenced on August 25, 2021 and closed on October 27, 2021. Two authors screened the studies in Covidence for inclusion according to the eligibility criteria in the protocol. The data were extracted from the studies and are reported in both text and tables. This review included 114 papers, of which 15 were randomized controlled trials (RCTs). The effect of LASER as a vaginal treatment was investigated for genitourinary syndrome of menopause in 36 studies (six RCTs), vulvovaginal atrophy in 34 studies (four RCTs) and urinary incontinence in 30 studies (two RCTs). Ten studies (three RCTs) investigated the effect of vulvar treatment for lichen sclerosus. Half of the included RCTs, irrespective of indication, did not find a significant difference in improvement in women treated with vaginal CO2 or Er:YAG LASER compared with their respective controls. However, most non-comparative studies reported significant improvement after exposure to vaginal or vulvar LASER across all indications. Included studies generally had a short follow-up period and only a single RCT followed their participants for more than 6 months post treatment. Adverse events were reported as mild and transient and 99 studies including 51 094 patients provided information of no serious adverse events. In conclusion, this review found that the effect of vaginal and vulvar LASER decreases with higher study quality where potential biases have been eliminated. We therefore stress that all patients who are treated with vaginal or vulvar LASER should be carefully monitored and that LASER for those indications as a treatment should be kept on a research level until further high-quality evidence is available.

One-Stage Buccal Mucosal Graft Urethroplasty for Lichen Sclerosus-Related Urethral Stricture Disease: A Systematic Review and Pooled Proportional Meta-Analysis.

PURPOSE: Performing 1-stage urethroplasty in patients with urethral strictures caused by lichen sclerosus (LS) is hotly debated among reconstructive urologists due to conflicting reports of success. Therefore, the objective of this study was to determine the pooled incidence of stricture recurrence following 1-stage buccal mucosal graft (BMG) urethroplasty in patients with LS, to determine the impact of surgical technique on recurrence and to compare recurrence risk between patients with and without LS after 1-stage repairs. MATERIALS AND METHODS: A systematic review was conducted in accordance with PRISMA criteria. The primary outcome was pooled incidence of recurrence, which was calculated using a Der-Simonian-Laird binary random effects model with a Freeman-Tukey arcsine transformation. A total of 21 studies were included, of which 15 provided data for comparative analyses. RESULTS: Pooled data from 625 LS patients revealed a stricture recurrence rate of 10% (95% CI 6-14). Among studies with longer followup (≥24 months), this increased to 18%. Among patients with penile urethral involvement, studies utilizing a penile skin incision had significantly higher pooled recurrence rates than those utilizing penile invagination (p=0.004). Across all studies, there was no evidence to suggest a difference in pooled recurrence rate between patients with and without LS (p=0.36). However, across only long-term studies, recurrence risk was significantly higher for patients with LS (OR 1.83, p=0.05). CONCLUSIONS: One-stage BMG urethroplasty is likely a viable surgical option for patients with LS-related strictures; however, high-quality data are limited. Future multi-institutional, long-term prospective studies are needed to assess durability of 1-stage repair.

Balanitis Xerotica Obliterans:an underestimated cause of secondary phimosis.

Balanitis Xerotica Obliterans is a chronic, progressive, sclerosing inflammation of unclear etiology. It involves the external genitalia of males and more specifically the prepuce and its frenulum, the glans, and the external urethral meatus while it may extend to the peripheral part of the urethra. Recent studies have noted an increasing incidence in the paediatric population. It is the most common cause of secondary (pathologic) phimosis. Even more, in boys with physiologic phimosis that does not respond to conservative treatment, Balanitis Xerotica Obliterans should be considered as the underlying condition. In this study, we present all the latest data and attempt to create a diagnostic and curative algorithm regarding this condition.

Protein Expression Profiles among Lichen Sclerosus Urethral Strictures-Can Urethroplasty Success be Predicted?

PURPOSE: Urethroplasty of lichen sclerosus strictures has a significantly higher failure rate than strictures due to other causes. We sought to determine predictors of urethroplasty failure in men with lichen sclerosus urethral stricture disease by evaluating protein expression profiles. MATERIALS AND METHODS: Urethral tissue was excised from patients with lichen sclerosus who were undergoing urethroplasty of urethral stricture disease at a single institution. A tissue microarray was created with cores from each sample. Immunohistochemistry was performed to compare protein expression related to inflammation, cell cycle disruption, oxidative stress, hormone receptor status and infection. Stricture recurrence was defined by the need for a subsequent unanticipated procedure for urethral stricture disease. RESULTS: We evaluated 50 men with lichen sclerosus urethral stricture disease, including 31 with successful reconstruction and 19 with recurrent stricture. Recurrent strictures expressed lower levels of several inflammatory markers and had a lower Ki-67 mitotic index and significantly higher vascular endothelial growth factor levels than nonrecurrent strictures. CONCLUSIONS: To our knowledge this is the first study to use tissue protein expression to identify risk factors for urethroplasty failure among men with lichen sclerosus urethral stricture disease. Our findings suggest that recurrent lichen sclerosus strictures demonstrate a suppressed inflammatory response, a decreased cell turnover rate, and poor oxygenation and nutrient delivery. Prospective studies are needed to clarify the role of these pathways in the pathophysiology of lichen sclerosus urethral stricture disease, determine whether preoperative biopsy can predict urethroplasty success, help counsel patients and develop future treatments.

Current treatment of lichen sclerosus and stricture.

INTRODUCTION: Lichen sclerosus (LS) is a common cause of urethral stricture disease. The purpose of this article is to review the literature over the past 5 years, to describe current treatment of lichen sclerosus as it relates to urethral stricture in men. MATERIALS AND METHODS: Literature reviews were performed using PUBMED, with search terms "lichen scleros*" and "urethral stenosis", as well as "lichen scleros*" and "urethral stricture". Relevant articles published within the past 5 years were selected for review. A summary of current treatment of lichen sclerosus was prepared and synthesized. RESULTS: For LS affecting genital skin, topical steroids are a mainstay of therapy but in advanced cases, surgery may be required such as circumcision. When LS causes urethral stricture, urethral dilatation is unlikely to be successful long term, and surgery is often required, such as meatoplasty, single- or two-stage urethroplasty, or perineal urethrostomy. Oral mucosal grafting is the graft of choice, and usage of genital skin for flaps or grafts is best avoided due to predilection for recurrence. Biopsy and long-term surveillance of LS are recommended, due to its potential association with squamous cell carcinoma development. CONCLUSION: Although debate still exists regarding the pathogenesis of LS, it is agreed that LS can pose a treatment challenge to physicians and surgeons. Treatment options for LS range from pharmacological to surgical, depending on severity and location of disease, patient factors, and response of previous treatments.

Dorsal onlay urethroplasty using lingual mucosal grafts for lichen sclerosis anterior urethral strictures repair: Long-term outcomes.

OBJECTIVE: To evaluate the long-term outcomes of dorsal onlay urethroplasty using lingual mucosal graft for repairing urethral strictures associated with genital lichen sclerosis. METHODS: This study included 36 patients who had lichen sclerosis long anterior urethral strictures that were managed with dorsal onlay urethroplasty using lingual mucosal graft, and were followed up ≥5 years. Preoperatively, we measured the maximum urinary flow rate and the International Prostate Symptom Score, then every 3 months in the first year, and annually thereafter. During follow up, patients with obstructive symptoms were subjected to urethrography and/ or urethroscopy. A successful urethroplasty was defined as normal voiding and no need for further intervention. RESULTS: Of the 36 patients, two were lost during the follow up, thus 34 patients were involved in the assessment. After lingual mucosal graft urethroplasty, there were significant improvements in maximum urinary flow rate and International Prostate Symptom Score (P < 0.0001). This improvement was sustained during the 5-year follow-up period. The median follow-up period was 66.5 months (interquartile range 64-70 months). The overall success rate in this study was 88.2%. Postoperative complications that required intervention were reported within the first year in four (11.8%) patients. Oral site complications were mild in the early postoperative period with no long-term complications. CONCLUSIONS: Dorsal onlay urethroplasty using lingual mucosal graft is a reliable and durable procedure for repairing lichen sclerosis urethral stricture. It provides a long-term success rate with few failures occurring within the first year. Lingual mucosal graft harvesting is associated with minor, immediate oral complications, and no long-term morbidity.

Fractionated CO2 Laser as Therapy in Recalcitrant Lichen Sclerosus.

OBJECTIVES: The aim of this study was to evaluate the efficacy of the fractionated CO2 laser in treating recalcitrant lichen sclerosus (LS). MATERIALS AND METHODS: The study population was 40 women diagnosed with LS who were symptomatic despite medical treatment. Patients had at least 2 or more laser sessions with a 2-month follow-up visit at the Drexel Vaginitis Center. A fractionated CO2 laser was used on affected areas at mild or standard power settings. Analyses were performed of changes in symptom rating scales, verbal reports, and physical examination findings. RESULTS: In the LS cohort of 40 patients, 22 women (55%) experienced symptoms that had persisted longer than 5 years before treatment. After the appropriate laser sessions, 72.5% of women described their improvement as significant or more than 66% improvement. In addition, there was a statistically significant reduction in vaginal pain, itching, dyspareunia, and dysuria. The presence of white epithelium decreased 20% after treatment. Furthermore, the mean corticosteroid use declined from 4.28 times per week to 2.04 times per week, indicating a resolution of many symptoms. CONCLUSIONS: The fractionated CO2 laser may be a helpful approach for managing LS that is unresponsive to traditional treatment options.

Oral lichen sclerosus: a rare case and update.

Lichen sclerosus (LS) is a chronic inflammatory mucocutaneous disease that often affects the anogenital area; oral mucosal lesions are extremely rare. A 52-year-old woman presented for evaluation of an 8-year history of a persistent whitish plaque in the buccal mucosa. Intraoral examination revealed multiple elevated whitish plaques diffusely distributed in the buccal mucosa associated with an area of tissue atrophy. Although both leukoplakia and lichen planus were considered, incisional biopsy and later, full excision confirmed the histopathological diagnosis of oral LS. After 6 months of follow-up, there are no clinical signs of relapse. This case highlights the importance of clinical and histopathological findings for the correct diagnosis and treatment of oral LS.

Urethral lichen sclerosus under the microscope: a survey of academic pathologists.

INTRODUCTION: Given the poor understanding of the pathophysiology of genital lichen sclerosus (GLS) and a lack of accepted definitive diagnostic criteria, we proposed to survey pathologists regarding their understanding of GLS. We hypothesized that significant disagreement about GLS will exist. MATERIALS AND METHODS: All urologists participating in the Trauma and Urologic Reconstruction Network of Surgeons identified genitourinary (GUP) and dermatopathologists (DP) at their respective institutions who were then invited to participate in an online survey regarding their experience with diagnosing GLS, GLS pathophysiology and its relationship to urethral stricture disease. RESULTS: There were 23 (12 DP, 11 GUP) pathologists that completed the survey. The most agreed upon criteria for diagnosis were dermal collagen homogenization (85.7%), loss of the normal rete pattern (33.3%) and atrophic epidermis (28.5%). No pathologists believed GLS had an infectious etiology (19% maybe, 42% unknown) and 19% believed GLS to be an autoimmune disorder (42% maybe, 38% unknown); 19% believed LS to be premalignant, but 52% believed it was associated with cancer; 80% believed that LS could involve the urethra (DP (92%) versus GUP (67%); p = 0.272). Of those diagnosing urethral GLS, 80% of DUP believed that GLS must first involve the glans/prepuce before involving the urethra, while all GUP believed that urethral disease could exist in isolation (p = 0.007). CONCLUSIONS: There was significant disagreement in this specialized cohort of pathologists when diagnosing GLS. A logical first step appears to be improving agreement on how to best describe and classify the disease. This may lead to improve treatments.

Genital lichen sclerosus in childhood and adolescence-a retrospective case series of 15 patients: early diagnosis is crucial to avoid long-term sequelae.

Lichen sclerosus is a chronic skin disease, mainly localised at the introitus and perineum. When the condition remains untreated, gradual atrophy of skin structures leads to permanent scarring, making early diagnosis and treatment crucial. We reviewed all patients diagnosed with lichen sclerosus presenting to a tertiary referral centre for paediatric and adolescent gynaecology between January 2011 and December 2015 to assess disease presentation and response to treatment. We identified 15 cases, with a mean age at diagnosis of 8.8 years. Their main presenting symptoms were vulvar pruritus and vulvar soreness. Seven girls had already atrophic changes, and in four girls, this amounted to clitoral phimosis, labial resorption or labial adhesion formation. The median delay in diagnosis was 7 months. Thirteen patients received local treatment with potent corticosteroids, responding well to treatment. However, 4 girls relapsed within 2 to 36 months. Two adolescents required surgical treatment, one because of urinary retention and the second because of dyspareunia caused by clitoral entrapment. CONCLUSIONS: There was a delay in diagnosis in most patients and this resulted in irreversible genital skin changes, which would have been preventable, had treatment been instituted promptly. The response to treatment with local corticosteroids was usually effective, leading to both symptom alleviation and prevention of disease progression. Atrophic changes and skin complications however were not reversed. What is Known: • Lichen sclerosus affects women of all ages, including girls, particularly prior to adolescence. • Lichen sclerosus responds well to local corticosteroid treatment. What is New: • In the majority of patients with lichen sclerosus there was a long delay between onset of symptoms and diagnosis. • Nearly half of the children diagnosed with lichen sclerosus had irreversible atrophic genital skin changes at the time of first presentation. These changes may have been prevented by a timely diagnosis and intervention.

Lichen sclerosus et atrophicus in a surgical scar treated with fractional laser.

Lichen sclerosus et atrophicus (LSA) is a chronic inflammatory disease of unknown cause that typically affects the genital area (1). It has been reported in post-traumatic areas as a result of Koebner phenomenon. LSA responds poorly to treatment making it a therapeutic challenge (2). Laser therapy has been described for LSA with variable results (3,4).

Complications after surgery for the relief of dyspareunia in women with lichen sclerosus: a case series.

INTRODUCTION: The objective of this study was to analyse complications after surgical intervention on the vulva, especially with grafting of the vaginal epithelium, for the relief of dyspareunia in women with lichen sclerosus. MATERIAL AND METHODS: A case series of 23 women with histologically confirmed lichen sclerosus who underwent vulvar surgery because of disabling sexual dysfunction. Surgical care was provided in a university hospital (tertiary referral center) between 2008 and 2012. The interventions were posterior vestibuloplasty (perineoplasty), dehooding of the glans clitoridis and anterior vestibuloplasty with grafts of vaginal epithelium. RESULTS: A posterior vestibuloplasty was performed in all 23 women. Short-term complications included postoperative infection with subtotal dehiscence of the advanced vaginal epithelium (n = 1), and reactivation of lichen sclerosus with the formation of bullae due to the postoperative discontinuation of dermatosteroid use (n = 1). The long-term complications included localized pain (n = 3); although the relation with the surgical intervention was unclear. Four women underwent dehooding of the glans clitoridis, all without complications. Anterior vestibuloplasty with a free full-thickness graft of vaginal mucosa was performed in five women. One woman underwent a second operation because of contraction and keratinization of the graft. The importance of estrogens for the condition of the graft was unclear. CONCLUSIONS: After reconstructive vulvar surgery in women with lichen sclerosus, issues such as infection, reactivation of the disease and pain require attention. The use of vaginal grafts in the repair of the anterior vestibule is a novel approach and deserves further exploration.

Evidence-based (S3) Guideline on (anogenital) Lichen sclerosus.

Lichen sclerosus (LS) is an inflammatory skin disease that usually involves the anogenital area. All patients with symptoms or signs suspicious of lichen sclerosus should be seen at least once initially by a physician with a special interest in the disease in order to avoid delay in diagnosis, as early treatment may cure the disease in some and reduce or prevent scarring. The diagnosis is made clinically in most cases. Biopsies should only be performed under certain circumstances. The gold standard for treatment remains potent to very potent topical steroids; however, mild and moderate disease in boys and men may be cured by circumcision. Certain triggers should be avoided. http://www.euroderm.org/images/stories/guidelines/2014/S3-Guideline-on-Lichen-sclerosus.pdf http://www.awmf.org/fachgesellschaften/mitgliedsgesellschaften/visitenkarte/fg/deutsche-gesellschaft-fuer-gynaekologie-und-geburtshilfe-dggg.html.

Meatal stenosis in boys following circumcision for lichen sclerosus (balanitis xerotica obliterans).

PURPOSE: Of boys circumcised for penile lichen sclerosus, ie balanitis xerotica obliterans, 7% to 19% require late surgery for meatal stenosis. We review the management and outcomes of boys circumcised for lichen sclerosus. MATERIALS AND METHODS: Medical records of boys with clinical lichen sclerosus were reviewed for the period 2000 to 2010. Patients were excluded from the study if the foreskin was not submitted for histopathological analysis, circumcision was not performed at the center during the study period or medical records were unavailable. Data were compared by Fisher exact test and univariate analysis. RESULTS: Of 300 circumcised boys lichen sclerosus was confirmed in 250. A total of 50 patients had nonlichen sclerosus histology. Mean age was 9.0 years (range 4 to 16) in patients with lichen sclerosus and 8.3 years (2 to 15) in those with nonlichen sclerosus histology. Boys with lichen sclerosus were more likely to have the meatus described as abnormal (57 vs 4) and to have undergone a meatal procedure at circumcision (55 vs 2) or a meatal operation at a later date (49 vs 3, all p <0.05). Boys with lichen sclerosus requiring later meatal procedures (meatal dilation in 25, meatotomy in 24) rarely underwent a meatal procedure at circumcision (4 of 49) and were less likely to have received preoperative topical steroids than boys not needing a later meatal procedure (2 of 49 vs 49 of 151, p <0.05). CONCLUSIONS: After circumcision for lichen sclerosus up to 1 in 5 boys requires a subsequent operation for meatal pathology. Pre-circumcision topical steroids may help decrease the rate of later meatal pathology. Submission of the foreskin for histological analysis should always be considered, as prognosis differs for lichen sclerosus vs nonlichen sclerosus histology. We recommend a care pathway for boys with lichen sclerosus.

Buccal mucosal graft in reconstructive urology: uses beyond urethral stricture.

The use of buccal mucosal grafts for the reconstruction of urethral strictures is an established procedure. Because of its robustness, the buccal mucosal graft could also potentially provide an alternative for other indications in reconstructive urology. We report here six consecutive patients who received a buccal mucosal graft for ureteral strictures, glans reconstruction and stoma stenosis. The follow up for all patients ranged from 26 to 50 months. The buccal mucosal graft showed excellent functional results for the ureteral strictures and stenosis from ureterocutaneostomy. For glans reconstructions, the buccal mucosal grafts delivered excellent cosmetic and functional results without causing meatal stenosis. We conclude the buccal mucosal graft can be used in reconstructive surgery beyond the reconstruction of urethral strictures.

Meatal Surgery at the Time of Circumcision for Lichen Sclerosus (LS/BXO) Does Not Reduce the Need for Later Meatal Intervention: A Retrospective Cohort Study.

PURPOSE: We describe meatal outcomes for boys undergoing circumcision to treat Lichen Sclerosus (LS/BXO) with a focus on those who underwent meatotomy/meatoplasty at circumcision and factors associated with post-circumcision meatal intervention. METHODS: Retrospective review of patients undergoing circumcision for histologically confirmed LS between 2011 and 2020. Statistical testing was by Chi2 and multivariate analysis. RESULTS: 382 patients underwent circumcision at a mean of 9.1 years (SD 2.9). At circumcision, LS on the glans was documented in 213/365 (58%). Meatal involvement was documented in 74/382 (19%); 25/382 (6.5%) had a meatotomy, 94/382 (25%) had meatal calibration/dilatation and 234/367 (64%) were prescribed post-operative topical steroids. Patients with LS glans or meatal involvement were more likely to have a meatotomy (p = 0.0013) and to receive post-operative steroids (OR 5, p = 0.0001). Post circumcision, 40/382 (10%) required a median of 1 subsequent procedure (range 1-5), 10 (2.6%) underwent dilatation, 30 (7.4%) had a meatotomy. Patients undergoing meatotomy at circumcision had an odds ratio (OR) of 1.2 for subsequent meatotomy (p = 0.027). Analysis based on requirement for any subsequent procedure identified an OR of 3.1 for having had a meatotomy at circumcision (p = 0.022) and an OR of 6.0 of receiving post-operative steroids (p=<0.001). CONCLUSIONS: Meatal stenosis following circumcision for LS requiring meatal intervention affected 10% of boys. Meatotomy at circumcision increased the likelihood of subsequent meatal intervention and is therefore not recommended. LEVEL OF EVIDENCE: Level III.

Anterior obturator artery perforator (aOAP) flap: A last-resort treatment option for sexual dysfunction in lichen sclerosus et atrophicus.

INTRODUCTION: Lichen sclerosus et atrophicus is an inflammatory, scarring dermatosis of the female anogenital area and may lead to pain and sexual dysfunction. In select cases which are refractory to conservative therapy, surgery may provide significant symptom improvement. The objective of this study was to expand the range of surgical treatment options for these patients by presenting the operative outcomes of a specialised reconstructive method using the anterior obturator artery perforator (aOAP) flap. METHODS: A retrospective cohort study was conducted on sexual outcomes following the excision of affected vulvovestibular tissue by skinning vulvectomy and subsequent single-stage reconstruction using the aOAP flap. Additional procedures, such as the Omega-Domed (OD) flap, scar surgery and clitoral re-exposure, were performed when indicated. RESULTS: Between 2014 and 2022, a total of 61 patients were surgically treated and retrospectively included in this study. Vulvectomy and subsequent reconstruction with bilateral aOAP flaps were performed in 53 (87%) cases. There was a significant reduction in the prevalence of dyspareunia and inability to have sexual intercourse at the 1-year follow-up compared to baseline (p < 0.001). There were several minor, reversible complications that required secondary intervention. CONCLUSIONS: The outcomes of this study indicate a substantial improvement in sexual function, evidenced by a significant reduction in dyspareunia and an increased ability to engage in sexual intercourse. Altered tissue quality in patients with lichen sclerosus et atrophicus and long-term cortisone application may predispose this patient population to a higher risk of minor post-operative complications. CLINICAL TRIAL REGISTRATION NUMBER: DRKS00033261.

Genital lichen sclerosus/balanitis xerotica obliterans in men with penile carcinoma: a critical analysis.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The European Association of Urology guidelines identify lichen sclerosus (LS) as a strong risk factor for penile squamous cell carcinoma (pSCC). However, this statement is based on the findings of case-control studies (Level of Evidence 2a) and a direct causal relationship between LS/balanitis xerotica obliterans (BXO) and pSCC remains to be established. Firm guidelines with respect to the appropriate follow-up policy for LS/BXO are lacking, whereas the impact of synchronous LS/BXO on the prognosis of pSCC remains to be determined. The presence of histologically-confirmed synchronous LS/BXO in patients diagnosed with pSCC is relatively high, although it is not associated with an increased risk of adverse histopathological features. LS/BXO can develop in extragenital skin grafts used for reconstruction after organ-sparing surgery for pSCC. OBJECTIVES: To determine the rate of lichen sclerosus/balanitis xerotica obliterans (LS/BXO) in patients with penile squamous cell carcinoma (pSCC) and establish whether the presence of LS/BXO is associated with adverse histopathological features of pSCC. To report the phenomenon of LS involving non-genital skin grafts in patients who underwent organ-sparing surgery and split-skin graft (SSG) reconstruction PATIENTS AND METHODS: Between January 2002 and January 2010, 223 men underwent surgical treatment for pSCC. A group of 52 patients with histologically-confirmed synchronous LS was identified (group A; overall rate of LS/BXO = 23.3%) and compared with a group of patients without synchronous LS (group B; n = 171; 76.7%). A subgroup of patients who underwent surgical excision and SSG reconstruction was also identified The histology reports of graft biopsies obtained during follow-up were reviewed and the rate of LS involving the graft was also recorded. RESULTS: Mean (range) age at diagnosis was 60.9 (34-81) years and 60.7 (28-89) years for groups A and B, respectively (P = 0.958). The mean (range) duration of follow-up was 38.3 (4-92) months for group A and 45.5 (4-107) months for group B (P = 0.162) No statistically significant differences were noted between groups A and B in terms of tumour grade (P = 0.091), stage (P = 0.697), presence of lymphovascular invasion (P = 0.333), histological subtype (P = 0.107), associated carcinoma in situ (P = 0.246) or nodal status at initial diagnosis (P = 0.555). In the subgroup of 188 patients who underwent SSG reconstruction, 41 (21.8%) patients had histologically-confirmed synchronous LS; in this subgroup, 26 (13.8%) patients underwent graft biopsy during follow-up. Genital LS involving the graft was identified in seven specimens, although none of these seven cases had associated recurrent pSCC. CONCLUSIONS: The presence of histologically-confirmed synchronous LS in patients with pSCC is relatively high but is not associated with increased rates of adverse histopathological features, including carcinoma in situ. LS can develop in extragenital skin grafts, although its association with the long-term risk for recurrent pSCC is not apparent in the present study.