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Complex strictures - Lichen Sclerosus (BXO)

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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.

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