Management of urethral strictures in lichen sclerosus / balanitis xerotica obliterans: a systematic review and metaanalysis

Introduction. Lichen sclerosus (LS), also known as balanitis xerotica obliterans (BXO), is a chronic inflammatory dermatosis affecting the skin and mucous membranes, frequently with genital involvement. In men, LS induces sclerotic changes of the foreskin, glans penis, and urethral meatus. This can lead to phimosis and meatal stenosis, and in severe cases, to the development of urethral strictures.

Objective. To evaluate current treatment methods for BXO-associated urethral strictures and their outcomes.

Materials & Methods. A systematic literature review was conducted in accordance with the PRISMA protocol (PROSPERO CRD420251005196). The review included 18 studies that met the following eligibility criteria: male patients with urethral strictures secondary to histologically confirmed BXO, a minimum of 5 patients per study, and reported treatment outcomes. Reviews, case reports, and publications without differentiated BXO-specific data were excluded. A meta-analysis was performed to calculate the pooled efficacy of various treatment modalities (both conservative and surgical). Subgroup analyses were conducted (comparing, for instance, one-stage vs two-stage urethroplasty), with assessment of heterogeneity (using the I² statistic) and potential publication bias (utilising a funnel plot).

Results. The pooled data from the 18 studies, encompassing over 600 patients, were analysed. Conservative management, such as urethral dilatation and intracavitary steroids, provided temporary symptomatic relief in a significant proportion of patients, with a reported success rate of 80–90% at 2–3 years. However, disease progression requiring reconstructive surgery was observed in 10–20% of cases. One-stage urethroplasty with buccal mucosal graft demonstrated high efficacy, with a pooled success rate of 85% (95% CI 80–90%) over a mean follow-up of 3 – 5 years. Twostage urethroplasty was reserved for cases with extensive stricture disease; its outcomes were comparable (75 – 85% success), although some case series reported a risk of stricture recurrence between stages. As a palliative measure, perineal urethrostomy achieved a durable restoration of voiding, with a long-term success rate exceeding 90%. The principal complications included stricture recurrence (up to 15 – 20% at 5 years) and isolated cases of fistula formation and neomeatal stenosis; severe complications were uncommon. The meta-analysis found no statistically significant difference in outcomes between single-stage vs two-stage reconstructions (relative risk of recurrence 0.95; p > 0.05). The use of adjunctive postoperative topical steroid therapy was associated with a reduced incidence of recurrence.

Conclusion. BXO-associated urethral strictures are characterised by higher recurrence rates compared to strictures of other aetiologies, necessitating a distinct management approach. Conservative management may be suitable for a select group of patients, particularly those with contraindications to surgery or awaiting reconstruction; however, definitive cure is only achieved through surgery. Single-stage urethroplasty with buccal mucosa graft transplantation is the treatment of choice for BXO-associated strictures and provides optimal functional and cosmetic outcomes. In cases of extensive stricture disease, a staged reconstructive strategy or urethrostomy should be considered. A multidisciplinary approach involving dermatologists is essential for the postoperative control of underlying BXO disease activity. Further research, including RCTs, is required to optimise medical therapy for BXO and to improve the long-term success of reconstructive surgery.

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