Summary
Introduction
Meatal stenosis is a common acquired urological problem facing pediatric surgeons
and urologists. It can affect both the circumcised and non-circumcised boys with a
higher incidence in the non-circumcised boys because of the increased risk of penile
inflammatory conditions, most commonly lichen sclerosis and urinary tract infection,
and in the most recent meta-analysis study, the incidence of meatal stenosis following
circumcision is only 0.65%. Urethral meatal web is a common cause of meatal stenosis
after circumcision (Fig. 1). Symptoms of meatal stenosis are not evident in non-toilet
trained infants. However, in older boys, an abnormal upward direction of urine stream
while urinating with a long narrow stream, dysuria, burning at the meatus, blood spot
at the meatus, frequency, prolonged urination and recurrent urinary tract infection
are the common presenting symptoms. Surgical correction of meatal stenosis is done
by either meatotomy or meatoplasty.
Objective
We describe a novel modification in the classical urethral meatotomy technique, which
is wedge urethral meatotomy, and assess the outcome of this procedure in managing
meatal stenosis secondary to a meatal web.
Patients and method
A prospective study was conducted on 60 cases of symptomatic meatal stenosis due to
a thin ventral web treated in the pediatric surgical centre in Mosul city from October
2018 until April 2021.
Exclusion criteria
Patients with meatal stenosis not accompanied by web, patients with a thick ventral
web (requiring suturing technique), and those with hypospadias or other associated
urinary disorders (like VUR) were excluded from the study.
Surgical technique
In all cases, the procedure was performed under general anaesthesia and by a single
surgeon (the author). A wedge (V-shaped) 2–3 mm long excision of the thin ventral
meatal web made after applying a hemostat in three directions (ventral midline and
two lateral crushes) (Figs. 2 and 3). The procedure did not require suturing or Foley
catheterization. The operative time was ranged from 4 to 6 min (mean 5 min). Postoperatively,
The parents were instructed to separate both edges of the meatus three times daily
for ten days, together with applying Fucidin cream locally with oral cefixime and
paracetamol.
Results
The age of the 60 patients ranged between 6 months and 10 years old (median age 38
months) (Fig. 4). Two (3%) patients developed mild meatal stricture, which did not
require further intervention as their urine stream remained straight with accepted
calibre. The remaining 58 (97%) cases did well postoperatively apart from temporary
dysuria in 23 (38%) patients, evident in the first 2–3 days postoperatively. They
had a single straight urinary stream while urinating with a good calibre meatus (Figs.
2(D), 3(D) and 5), and during short term follow up, there is a substantial reduction
in the frequency of urinary tract infections.
Discussion
Although two (3%) cases developed mild postoperative meatal stricture, none of them
required redo surgery compared with a study done by Godley SP in 2015, which showed
a reoperation rate after formal meatotomy of 2%. Cartwright in 1996 had a 2% reoperation
rate after office meatotomy. Another study in 2018 also reported a reoperation rate
of 2.2%. The reason for restenosis that necessitates revision surgery in the above
studies may be refusion of the cut edge of the web after meatotomy, which was not
a concern in wedge urethral meatotomy in which the web excised and not incised. In
2017, Özen MA applied the same procedure on 13 boys complaining from meatal web after
circumcision. The technique involved excision of the web, and two stitches were inserted
at 5 and 7 o'clock using 7/0 Polydiaxonone suture with excellent final results. In
our study, suturing was not applied, so spraying or divided urinary stream (although
temporary) was not observed in the postoperative period as seen in meatoplasty or
in cases of meatotomy that require suturing technique. This point was satisfactory
for patients and parents.
Conclusion
Wedge urethral meatotomy represents a novel modification in the formal meatotomy technique,
which can be applied in meatal stenosis secondary to a thin ventral web with satisfactory
results, as reoperation after this procedure was not recorded.
Keywords
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Article info
Publication history
Published online: March 09, 2022
Accepted:
February 24,
2022
Received in revised form:
February 12,
2022
Received:
September 17,
2021
Identification
Copyright
© 2022 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
