Treatment of balanitis xerotica obliterans with topical tacrolimus

[Contemporary management of urethral strictures in women]

Urethral strictures in women are rare and patients may present with varying symptoms. Hence, clinical guidelines regarding diagnostic algorithms and treatment approaches are scarce. Several small case series have presented results for several operative techniques, but patient cohorts are generally heterogeneous and relatively small, which hampers reliable comparability across institutions. The present narrative review aims to provide a contemporary overview of the literature regarding the clinical and therapeutical approach in women with urethral strictures.Iatrogenic reasons such as previous catheterization or genitourinary surgical interventions are the most common cause of female urethral strictures. In daily clinical routine, physical examination is the cornerstone for differential diagnosis and may aid in the decision to expand diagnostic workup by urethrocystoscopy, urethrography, or magnetic resonance imaging in case of suspected anatomic or morphologic cause of voiding disorder. Endoscopic approaches such as dilation or urethrotomy only provide short-term symptomatic relief and open urethroplasty is more commonly associated with durable long-term success. Regarding the surgical approach, there are comparable operative techniques at hand, using vaginal or labial flaps or oral mucosal grafts. Given the relative rarity of female urethral strictures with only small case series published, a statement regarding the superiority of one approach over the other is hardly possible. As for all rare disorders, multi-institutional, large patient series are needed to generate reliable evidence and to improve standards in the perioperative care of women with urethral strictures.

The contemporary management of urethral strictures in men resulting from lichen sclerosus

Lichen sclerosus (LS) is a chronic, inflammatory disease primarily involving the genital skin and urethra in males. Historically, the treatment of this common condition was a challenge due to its uncertain etiology, variable response to therapy, and predilection to recur. The etiology of LS is still debated and has been linked to autoimmune disease, infection, trauma, and genetics. Today, topical steroids are a mainstay of therapy for patients, even in the presence of advanced disease, and can induce regression of the disease. In advanced cases, surgery may be required and range from circumcision, meatoplasty, or, in the case of advanced stricture disease, urethroplasty or perineal urethrostomy. When urethroplasty is required, the use of genital skin as a graft or flap is to be avoided due to the predilection for recurrence. Surgical management should be approached only after failure of more conservative measures due to the high risk of recurrence of LS in the repaired site despite the use of buccal grafting. LS may be associated with the development of squamous cell carcinoma and for this reason, patients should undergo biopsy when LS is suspected and long-term surveillance is recommended.

Fossa navicularis reconstruction: impact of stricture length on outcomes and assessment of extended meatotomy (first stage Johanson) maneuver

PURPOSE

We evaluated the significance of stricture length and severity on the outcome of fossa navicularis reconstruction. We also determined the efficacy and usefulness of an extended meatotomy (first stage Johanson) salvage maneuver in refractory cases.

MATERIALS AND METHODS

Our 7-year experience with the surgical management of distal urethral strictures involving the fossa navicularis was reviewed. Stricture length, reconstructive method and outcomes were assessed in 40 consecutive cases performed at our institution from 1997 to 2003. Men undergoing flap or graft onlay reconstruction were divided into group 1-short, isolated fossa navicularis strictures (2.5 cm or less) and group 2-long pendulous urethral strictures (greater than 2.5 cm) extending into the fossa navicularis. Men treated with extended meatotomy for complex and/or reoperative distal strictures comprised group 3.

RESULTS

Average followup was 52 months (range 28 to 81). The majority of men with short isolated fossa navicularis strictures (group 1 average length 2.2 cm, range 1.5 to 2.5) had successful onlay reconstruction (10 of 11, 91%). Those with longer strictures (group 2 average length 7.4 cm, range 4 to 16) had significantly poorer outcomes with onlay reconstruction (7 of 13, 54%, p <0.05). Failures presented in a delayed manner with recurrent stenosis of the distal segment. Extended meatotomy (group 3) proved to be successful in 14 of 16 men (87%) with complex or reoperative strictures.

CONCLUSIONS

Stricture length influences the outcome of distal urethroplasty. Onlay repair via a penile fasciocutaneous flap technique is reliable for short perimeatal strictures, but is less well suited for longer distal strictures. Extended meatotomy appears to be a highly effective salvage maneuver for complicated strictures of the fossa navicularis.