Meatal stenosis: getting the diagnosis right

Factors Affecting Parental Satisfaction after Male Circumcision

Background

The safety of the male circumcision depends on many factors, including the surgeon, type of anesthesia, and associated complications. The scientific knowledge regarding safe MC is not so prevalent among masses.

Aims and Objectives

To study the level of awareness regarding circumcision amongst parents and highlight factors linked to parental satisfaction.

Materials and Methods

Information regarding various factors was gathered with the help of structured questionnaire-based evaluation of parental knowledge and experience. This was followed by clinical examination by a pediatric surgeon for assessment of cosmetic outcome, complications and need for additional surgical procedure.

Results

Most circumcisions were performed by non-surgeons beyond neonatal period. Majority of the procedures were done under local anesthesia and around 17% procedures were done by quacks without anesthesia. More than 20% parents were dissatisfied with the procedure. Around 80% parents considered perioperative period mildly to moderately stressful. The overall complication rates were higher than usual with need for surgical correction in more than 40% patients.

Conclusion

There is lack of awareness regarding safe MC practices in general public. MC by inexperienced people contributes to higher complication rates and need for redo, which in turn is related to parental dissatisfaction.

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.

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.

The Plate Objective Scoring Tool (POST): Further Reflections and Extended Applications

Hypospadias is a common birth defect of the male external genitalia. However, there are conflicting arguments about the optimal classification approach and ideal surgical technique. We have introduced the Plate Objective Scoring Tool (POST) to define critical glanular phenotypic landmarks of the urethral plate. We propose that POST can objectively, reproducibly, and accurately determine urethral plate quality, thus permitting robust comparison between the different surgical techniques commonly utilized in hypospadias repair. Furthermore, the POST scoring system represents a versatile tool that can objectively quantify key variables in hypospadiology that are currently not well defined. Further validation of POST should lead to better identification and management of postoperative complications.

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use:

https://youtu.be/yy_2-OaaCVw

Critical evaluation of arguments opposing male circumcision: A systematic review

OBJECTIVE

To systematically evaluate evidence against male circumcision (MC).

METHODS

We searched PubMed, Google Scholar, EMBASE and Cochrane databases.

RESULTS

Database searches retrieved 297 publications for inclusion. Bibliographies of these yielded 101 more. After evaluation we found: Claims that MC carries high risk were contradicted by low frequency of adverse events that were virtually all minor and easily treated with complete resolution. Claims that MC causes psychological harm were contradicted by studies finding no such harm. Claims that MC impairs sexual function and pleasure were contradicted by high-quality studies finding no adverse effect. Claims disputing the medical benefits of MC were contradicted by a large body of high-quality evidence indicating protection against a wide range of infections, dermatological conditions, and genital cancers in males and the female sexual partners of men. Risk-benefit analyses reported that benefits exceed risks by 100-200 to 1. To maximize benefits and minimize risks, the evidence supported early infant MC rather than arguments that the procedure should be delayed until males are old enough to decide for themselves. Claims that MC of minors is unethical were contradicted by balanced evaluations of ethical issues supporting the rights of children to be provided with low-risk, high-benefit interventions such as MC for better health. Expert evaluations of case-law supported the legality of MC of minors. Other data demonstrated that early infant MC is cost-saving to health systems.

CONCLUSIONS

Arguments opposing MC are supported mostly by low-quality evidence and opinion, and are contradicted by strong scientific evidence.