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

Surgical Treatment of Meatal Stenosis: Lessons Learned from the Pediatric Urology Practice

OBJECTIVE

To evaluate the indications for surgery and outcome of meatotomy and meatoplasty in a big cohort of children.

METHODS

We retrospectively evaluated 2211 children who underwent either meatotomy or meatoplasty between 2009 and 2020 utilizing the same operative setup. For continuous data, we performed t-test and Mann-Whitney U test. For categorical data, chi-squared test or Fisher's exact test was used. A binary logistic regression model was used to compare the indications for surgery between the groups.

RESULTS

Of 2211 children, 1906 underwent meatotomy and 305 meatoplasty. The mean age was 5 years (range: 1m-15y) and there was no age difference between the groups. There was no difference between duration of surgery, recovery time, or complication rates between the groups. Deviated stream was the most frequent indication for treatment 1477 (67%). On Univariate logistic regression children with the following indications: dysuria, meatitis, and urinary retention had increased odds toward meatoplasty, while the indication of deviated stream had increased odds toward meatotomy. On Multivariate Logistic regression only deviated stream (Odd-ratios 1.47, P: .005) and urinary retention (Odds-ratio 4.5, P: .027) remained significant for meatotomy and meatoplasty respectively. Eleven (0.58%) children who underwent meatotomy developed recurrent Urethral Meatal Stenosis and underwent another surgery. Sixty-nine children (3.6%) after meatotomy required manual opening of the meatus on the first post-operative visit. None of the children, who underwent meatoplasty needed reoperation.

CONCLUSION

Meatotomy had a higher reoperation rate and frequently required manual meatal spreading in early postoperative period. We believe meatoplasty is a preferable surgery for pediatric UMS.

Wedge urethral meatotomy in meatal stenosis secondary to web formation

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.

Is there a correlation between meatal stenosis severity, lower urinary tract symptoms and uroflowmetry?

INTRODUCTION

We have recently validated a meatal Stenosis (MS) severity grading system that is based on physical examination.

OBJECTIVES

The study objective was to examine the correlation between this grading system, patients' urinary symptoms, uroflowmetry and postvoid residual parameters.

STUDY DESIGN

Patients referred for our clinic for urinary and non-urinary complaints, were prospectively enrolled. Urinary symptoms questionnaire, uroflowmetry parameters and post-voiding residuals (PVR) were assessed, and photographs of the urethral meatus were taken for each patient. The photographs were graded blindly according to the previously validated grading system and correlated with urinary symptoms, uroflowmetry parameters and PVR.

RESULTS

Overall, 75 patients were assessed (20 grade 0, 23 grade 1 and 32 grade 2). When using grade 0 as a reference, the odds ratio (OR) for reporting narrow stream was 6.4 (95%CI 1.65-24.77) and 4 (95%CI 1.18-14.16) for grade 1 and 2 respectively. OR for prolonged urination was 6 (95% CI 1.47-24.89) for Grade 1 and 2; OR for upward stream deviation was10.08 (95%CI -2.43-41.82) for grade 1 and 15.12 (95%CI - 3.74-61.17) for grade 2. Uroflowmetry results showed lower Qmax from 16.8(SD ± 8.0) ml/sec in grade 0-9.6 ml/s on grade 1 and 2 (p < 0.001) (Figure 1). PVR was not statistically different in the three groups.

DISCUSSION

Our main findings were that meatal stenosis severity grade is associated with narrow stream as reported by parent, prolonged urination, and upward deviation of urinary stream, with increasing severity with worsening stenosis. MS grade was also associated with significant worsening of uroflow measures: a lower Qmax, Qmean and a longer time-to-Qmax. Post-void residual volume was not significantly different between the different severity grades. This study showed the clinical significance of the grading system. With subjective and objective measures. The implementation of this grading system in clinics, may aid in decision making regarding surgical intervention in the appropriate patients, and avoid unnecessary procedures.

CONCLUSION

The Severity of MS seen on physical examination correlates well with obstructive symptoms and decrease of urine stream seen on uroflowmetry. These findings confirm the importance of the grading system in the evaluation of patients with MS and may be additional measure that assist in consulting parents on the indications to meatotomy.

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.