Recurrence after management of meatal balanitis xerotica obliterans (BXO)

Summary Introduction We review outcomes after management of meatal balanitis xerotica obliterans (BXO). The primary outcome was recurrent meatal BXO. Methods A database comprising mostly hypospadias patients was queried for meatal BXO. The disease was confirmed histologically in all cases. Management included topical steroids and/or immunosuppressants, and/or surgical excision of BXO with two-stage oral mucosa graft circumferential replacement urethroplasty. Results A total of 12 patients had meatal BXO (8 boys and 4 adults). Of these, 10 had hypospadias, two presenting without prior surgery and eight returning 5–30 years after one or multiple ( n = 2) repairs. Another two boys did not have hypospadias: one developing BXO 10 years after newborn circumcision and the other having persistent meatal BXO following therapeutic circumcision. Topical and intraluminal steroids (1% betamethasone or clobetasol) and tacrolimus were used for ≥ 12 weeks each as primary therapy or for meatal recurrence in a total of six cases. Complete response with resolution of white discoloration and relief of stranguria only occurred in two of the three receiving clobetasol, with follow up ≤ 12 weeks. BXO excision and urethroplasty was done in 11 patients, 10 using oral mucosa grafts; one with a focal lesion and a negative frozen section had reoperative TIP. Of the 10 undergoing excision with two-stage replacement urethroplasty, six remain disease free at a mean follow-up of 23 months (8–48 months), and four had recurrent stranguria and visible meatal BXO at a median of 26 months (22–105 months). Three of the four with recurrences had additional treatment and one was lost to follow-up. All initially had topical steroids, and two also used tacrolimus, without clinical resolution. These three then underwent a second BXO excision and two-stage oral graft replacement urethroplasty. In two recurrences, BXO was found invading from the meatus proximally within oral mucosa ( figure ). Of these three with secondary urethroplasties, two are free of disease at 6 and 18 months, and the third had another meatal recurrence 6 months after the second stage. Discussion We found topical steroids and immunosuppressants to have limited efficacy, with two clinical complete responses achieved only with clobetasol in patients with short follow-up. Forty percent of patients recurred at 2–9 years after visually complete BXO excision and two-stage oral mucosa graft replacement urethroplasty, and in two cases