Tailored sutureless meatoplasty: a new technique for correcting meatal stenosis

Meatal stenosis following three types of circumcision with frenular artery preservation (FAP), the Plastibell device (PD), and frenular artery ligation (FAL): a long-term follow-up

BACKGROUND

Despite the simplicity of male circumcision, complications occur frequently. Post-circumcision meatal stenosis is a concerning complication that might require several interventions.

AIM

This study aims to evaluate the incidence of meatal stenosis in long-term follow-up, following three common circumcision methods: frenular artery preservation, frenular ligation, and the Plastibell device.

METHODS

This study is the continuation of the previous randomized clinical trial, the preliminary abstract of which has been accepted in the annual meeting of the American Urological Association in 2011. However, in this paper, we only included the patients with results of long-term follow-up. Patients were followed for a median of 11 years (range, 7-17). Follow-ups were recorded by evaluation of meatus and signs and symptoms of meatal stenosis.

RESULTS

Two hundred six boys (80 neonates and 126 non-neonates) at the time of procedure were included in this study. The circumcision was conducted on 23.3% (48/206) of boys with the Plastibell device (PD) and 39.3% (81/206) of cases with frenular artery preservation (FAP) and 37.4% (77/206) of cases with frenular artery ligation (FAL). Meatal stenosis presented in 13 children during follow-up. Considering the three methods of circumcision, a significant difference in the incidence of meatal stenosis among the types of circumcisions was observed (6.3% in PD and 1.2% in FAP, 11.7% in FAL, P = 0.026).

CONCLUSION

The present study revealed that the technique preserving the frenular artery is associated with a significantly lower incidence of meatal stenosis. Hence, the FAP is the recommended technique for circumcision as compared to two other methods.

Optimal clamping time in meatotomy procedure for children with meatal stenosis: Experience with 120 cases

OBJECTIVE

During meatotomy procedure for children with meatal stenosis (MS), a straight clamp used as a hemostat on the ventrum of the meatus before incised with scissors for clamping and holding bleeding from the site of operation. The aim of this study was to evaluate the optimum clamping time for meatotomy in children with MS.

MATERIALS AND METHODS

All the patients with MS between 2014 to 2019 were enrolled in this retrospective study. Patients with uncircumcised penis, traumatic catheterization, any kind of penile abnormality such as hypospadias or penile curvature, and active urinary tract infection (UTI) were excluded. The indication of meatotomy was a pinpoint meatus that develops with dorsal or lateral deflection of the urinary stream and high-velocity urine flow. During meatotomy procedure, clamping time was examined in different groups such as 2, 3, and 4 minutes. The main symptoms of presentation and ultrasonography (US) findings were recorded and compared between groups. To assess the optimum time clamping, postoperative bleeding was noted carefully in all groups. The success rate was recorded at onemonth postoperative follow-up in the clinic.

RESULTS

Of the 120 patients with MS who underwent a meatotomy procedure, there were 40 (33.3%) participants in each group. The main symptoms were painful urination and urine stream deviation that represented in 54 (46%) patients. Bladder wall thickness was the main pre-operation finding in the US which was observed in 67 (55.8%) patients. In comparison between the groups related to clamping time, bleeding was observed and required suturing when clamping was applied for 2 minutes in 4 (3.3%) patients (p = 0.016). With a minimum follow-up of 12 months, no recurrent meatal stenosis was reported.

CONCLUSIONS

Clamping time for more than 2 minutes may prevent bleeding during and after meatotomy.

Increased risk of atopic diseases in boys with meatal stenosis: a possible pathophysiological relation

PURPOSE

To evaluate the role of atopy (i.e. atopic dermatitis, allergic rhinitis, asthma, and food allergies) and its consequences on developing meatal stenosis in boys.

METHODS

After obtaining ethics approval from institutional review board, a retrospective chart review was conducted to gather records of patients with meatal stenosis (Group A) presented to our pediatric urology center between August 2012 and May 2016. History of any allergic reactions including allergic rhinitis, asthma, skin, food and drug allergies was considered as positive history of atopy. A control group of children referring to our center due to other etiologies were considered as control group (Group B). Data were analyzed using student t-test and Chi-square test.

RESULTS

During the study period, a total of 206 boys (mean age 41.01 months) were assigned to group A and 221 (mean age 35.56 months) to group B. 126 (61.16%) boys had history of allergic reactions in group A compared to 29 (13.12%) in the control arm (group B). Patients with meatal stenosis have a significantly higher (P-value <0.001) likelihood of suffering from allergic reactions.

CONCLUSIONS

The pathophysiology of meatal stenosis remains not fully understood yet. This study reveals a significant relation between hypersensitivity reactions and meatal stenosis in boys. Persistent inflammation in meatal area could potentially lead to scarring and stenosis. However, more investigation is required to elucidate this pathophysiology.

TYPE OF STUDY

Case-control study.

LEVEL OF EVIDENCE

Level III.

Are mechanical and chemical trauma the reason of meatal stenosis after newborn circumcision?

Mechanical and chemical trauma are a widely accepted theories to explain the pathogenesis of meatalstenosis after newborn circumcision. The aim of the present study was to explore the theory that an exposed glans is prone to meatal stenosis. This was done by a novel investigation of boys who were born with "hooded prepuce", a condition in which the glans is completely exposed. Physical examination, lower urinary tract symptoms, urethral meatus configuration, and surgical procedures of 18 children admitted for routine circumcision, who had congenital hooded prepuce with normally located urethral meatus, were analyzed. The study period was 2013 and 2018. All the cases have been seen because of neonatal circumcision request, but was postponed due to hooded prepuce. The only presenting complaint in children was a cosmetically unattractive appearance. There were no symptoms associated with meatal stenosis, they circumcised in an average of 6 years and non of them required any additional procedure.Conclusion: Meatal stenosis did not occur in cases whose glans penis are naked with hooded prepuce. These findings do not support the default chemical and mechanical trauma theories. Hooded prepuce without any penile anomalies is only a cosmetically unattractive appearance and circumcision can correct this. What is known: • The common theory of meatal stenosis etiology is that the meatus undergoes irritation with chemical/mechanical trauma in the absence of a prepuce after newborn circumcision. • Circumcision is usually postponed in newborns with hooded prepuce. What is new: • We did not notice meatal stenosis in cases whose urethral meatus were not covered with a prepuce congenitally. Ammoniacal dermatitis or mechanical trauma theories may not explain the cause of meatal stenosis. • Hooded prepuce is not a handicap to newborn circumcision. It is just a cosmetic problem and circumcision can solve it.

Uroflowmetry Before and After Meatotomy in Boys with Symptomatic Meatal Stenosis Following Neonatal Circumcision - A Long-term Prospective Study

OBJECTIVE

To assess uroflowmetry in the long-term follow-up of symptomatic meatal stenosis patients prior to and following meatotomy. Severity of symptoms and treatment success has been defined by patient history, physical examination, and witnessed voiding. Uroflowmetry might add objective parameters for the assessment, however long-term data are lacking.

METHODS

A prospective study following 25 symptomatic toilet-trained boys before and after meatotomy was performed with short and long-term follow-up after surgery. Patient history, physical examination, and uroflowmetry variables were recorded.

RESULTS

Fifteen patients were fully evaluable. Mean age at operation was 6.4 years (2.5-10.5) with an average follow-up of 43 months. All patients were symptomatic before surgery; complete symptomatic resolution was achieved in all patients at short-term follow-up, and in 12 at long-term follow-up. A stenotic meatus was seen in all patients before surgery, at long-term follow-up 12 of 15 (80%) had an open appearing meatus (P = .0001). Abnormal uroflowmetry pattern was present in 8 of 15 (53%) prior to surgery and 2 of 15 (13%) at long-term follow-up (P = .02). Normal maximal flow rate as defined by ICCS were seen in 5, 11, and 12 patients before, 1 month after and at long-term follow-up (P = .06 and 0.02, respectively). PVR improved significantly at long-term follow-up (P = .0012).

CONCLUSION

Symptom evaluation and physical examination should be the hallmark assessing children with meatal stenosis. Clinical assessment one month after surgery suffices and long-term follow-up is unnecessary. Uroflowmetry provides objective assessment as well as surgical success; however, it is unnecessary since it does not change the management.

Minor procedure, major impact: Patient-reported outcomes following urethral meatotomy

INTRODUCTION

Urethral meatotomy as treatment for meatal stenosis is a common pediatric urology procedure; however, little is known about the patient experience following this procedure.

OBJECTIVE

We aim to evaluate clinical factors associated with patient-reported symptom improvement after urethral meatotomy.

STUDY DESIGN

The families of boys undergoing urethral meatotomy between 2/2013 and 8/2016 received a survey by mail 6 weeks after surgery. Families were queried on changes in symptoms using a Likert-type scale (5 = much improved, 4 = somewhat improved, 3 = no change, 2 = somewhat worse, and 1 = much worse). Patient and procedure characteristics of the respondents were obtained via chart review. These included surgical indication(s) (abnormal stream, dysuria, or storage symptoms), postoperative complications, reoperation, and unplanned postoperative communications. Patients who had procedures other than simple urethral meatotomy were excluded. Descriptive statistics were compiled, and generalized estimating equations used to determine the associations of patient and procedure characteristics with symptom improvement.

RESULTS

We sent 629 surveys and received 194 responses (30.4%). Twelve respondents were excluded for complex procedures or miscoding. The majority of respondents were privately insured (74%) and were between 5 and 12 years old (45%) or 1 and 4 years old (42%). The most frequent surgical indication was abnormal stream (72%) followed by pain (21%) and storage symptoms (15.5%). Nine respondents had minor complications (4.9%). Four patients had restenosis requiring repeat urethral meatotomy. After surgery, a majority (79%) were "much improved," 16% were "somewhat improved," 3% had "no change," and 1% were "somewhat worse." No family reported "much worse." Those patients who had "abnormal stream" as a surgical indication were significantly more likely to report "much improved" (OR 1.83, p = 0.014) than those without. Patient-reported improvement was not associated with suture use, patient age, insurance, surgeon, or location of the procedure (Table).

DISCUSSION

Little has been written about patient-reported outcomes following urethral meatotomy. Our study affirms that the majority of boys improve following this procedure. However, improvement is significantly more likely if the child has a preoperative indication of an abnormal stream, such as deflection or spraying. Boys with symptoms of dysuria, frequency, or incontinence may be experiencing sequelae of meatal stenosis that simply take longer to improve. Alternatively, the meatal stenosis may be incidental to the primary symptoms.

CONCLUSIONS

A majority of families report substantial symptomatic improvement after urethral meatotomy. However, boys undergoing urethral meatotomy for reasons other than a urinary stream abnormality are less likely to experience improvement.

Complication of newborn circumcision: Meatal stenosis or meatal web?

INTRODUCTION

Meatal stenosis (MS) is a known complication of newborn circumcision. Symptoms are usually masked in young kids with a diaper. Deflation of urinary stream, dysuria, urinary frequency, and incontinence are the most common reported symptoms. Diagnosis of MS is still controversial. A narrow pinpoint urethral meatus is the current accepted diagnostic criteria.

OBJECTIVE

In our practice, we observed that our cases do not overlap to the classic definition and presentation of MS. In this study, we presented our cases and aimed to share our observations.

MATERIALS AND METHODS

Records of children who had meatoplasty between 2014 with 2016 were analyzed retrospectively. Only children with MS who had had newborn circumcision performed in our clinic were included in the study. Over 500 newborn circumcisions are performed per year in our clinic using the Gomco Clamp technique. Age at diagnosis, presenting complaints, penile anomalies including urethral meatus configuration, urinary symptoms, operation methods, and postoperative follow-up were gathered.

RESULTS

A total of 13 boys who were circumcised in the newborn period had undergone meatoplasty with the diagnosis of MS. The mean age at the time of meatoplasty was 52.5 ± 17.9 (range 37-93 months). All children were examined before and during the circumcision. There were no associated penile anomalies, including MS. The only presenting complaint was upward deflation of urinary stream instead of other lower urinary tract symptoms. Although the appearance of the meatus was pinpoint in all cases (Figure); it was easy to calibrate with an 8-10 Fr feeding tube. There was no stenosis, but a ventral web was detected. Meatoplasty with removal of this web was performed under general anesthesia. Two sutures were applied at 5 and 7 o'clock with 7/0 PDS. Mean postoperative follow-up time was 16.9 ± 7.5 months. Children were pleased with direction of urinary stream.

DISCUSSION

Both the diagnosis and morphological definition of MS have some controversies. To our knowledge, there is no similar reported study with pinpoint appearance and normal calibration of the meatus. There was no stenosis in any of them. Unlike classical MS presentations, upward deflation of urinary stream resulting from ventral web was a single presenting complaint.

CONCLUSIONS

Upward deflation of urinary stream can develop after neonatal circumcision because of a meatal web without stenosis, and can be cured easily with meatoplasty. Instead of 'meatal stenosis', 'meatal web' may be a more appropriate term to explain the pathology in these patients.