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 JoVE Clinical and Translational Medicine

Surgical Management of Meatal Stenosis with Meatoplasty

1

1Department of Urology, Pediatric Urology, Johns Hopkins School of Medicine

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    Summary

    Meatoplasty, surgical management of meatal stenosis.

    Date Published: 11/30/2010, Issue 45; doi: 10.3791/2213

    Cite this Article

    Wang, M. Surgical Management of Meatal Stenosis with Meatoplasty. J. Vis. Exp. (45), e2213, doi:10.3791/2213 (2010).

    Abstract

    Meatal stenosis is a common urologic complication after circumcision. Children present to their primary care physicians with complaints of deviated urinary stream, difficult-to-aim, painful urination, and urinary frequency. Clinical exam reveals a pinpoint meatus and if the child is asked to urinate, he will usually have an upward, thin, occasionally forceful urinary stream with incomplete bladder emptying. The mainstay of management is meatoplasty (reconstruction of the distal urethra /meatus). This educational video will demonstrate how this is performed.

    Protocol

    Introduction:

    Genital disorders are commonly encountered in the offices of primary care physicians. Meatal stenosis, an abnormal narrowing of the urethral opening (meatus) is a common complication after circumcision occurring in 9%-10% of males. This disorder is characterized by an upward deflected, difficult-to-aim urinary stream, dysuria, urgency, frequent, and prolonged urination. If left untreated, this can lead to urinary tract infections and kidney problems. Surgical meatotomy/meatoplasty is curative.

    Treatment/Diagnostics Procedure:

    A routine urine analysis will rule out urinary tract infection or diabetes as potential causes of urinary frequency.

    Detailed history and physical exam, include observation of micturition, confirm the diagnosis.

    Outpatient surgery/meatoplasty is curative. The procedure is done under a 5-10 minute anesthetic.

    Intraoperative preparation includes surgical loupe magnification, mosquito hemostat, fine tipped plastic microsurgical scissors, Castroviejo needle holder, and 7-0 vicryl suture;

    1. Child is placed in supine position.
    2. Minimal skin prep and drape of the genitalia. No prophylactic antibiotics needed.
      • Betadine POVIDONE IODINE solution is used to scrub the genital region, and allowed to remain for approximately 3 minutes prior to initial incision.
      • The penis should be draped off with sterile towels.
    3. A right handed surgeon will stand to the left side of the patient and one jaw of a well-lubricated mosquito hemostat is then introduced into the tip/ventral aspect of the urethral meatus to a depth of approximately 2-3 mm. The ventral tissue is then crushed by closing the hemostat. Total clamp time will be 60 seconds.
    4. The crushed ventral tissue is incised sharply with microsurgical scissors (figure 1) and the inner urethral mucosa and glanular tissue are reapproximated using 7-0 vicryl sutures (Castroviejo needle holder figure 2) in an interrupted fashion.

    Recovery time is minimal, and a child is sent home with Tylenol as needed for discomfort. Vaseline is applied to the wound 3-4x/day.

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    Discussion

    Outcome:

    Symptomatic meatal stenosis is frustrating for the child and family. If left untreated, there is a potential for chronic incomplete bladder emptying, with occasional development of urinary tract infection and subsequent kidney damage.

    Reconstructive meatoplasty is curative, and can be done under a brief anesthetic.

    Conclusion:

    Meatal stenosis is a common complication of circumcision. A thorough history and physical will reveal the diagnosis of meatal stenosis. Surgical management is the curative therapy. A well performed meatoplasty can be done with minimal instrumentation.

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    Disclosures

    No conflicts of interest declared.

    Acknowledgements

    The author thanks the Johns Hopkins operating room staff, and Media Relations in the department of Pediatrics at Johns Hopkins Children's Hospital.

    Materials

    Name Company Catalog Number Comments
    Betadine
    Mosquito hemostat
    Microsurgical scissor
    Castroviejo needle driver
    7-0 vicryl suture Ethicon Inc.

    References

    1. Van Howe, R.S. Incidence of meatal stenosis following neonatal circumcision in a primary care setting. Clin Pediatr (Phila). 45 (1) : 49-54 (2006).
    2. Litvak, A.S., Morris, J.A., McRoberts, J.W. Normal size of the urethral meatus in boys. J Uro. 115 (6) : 736-7 (1976).
    3. Brown, M.R., Cartwright, P.C., Snow, B.W. Common office problems in pediatric urology and gynecology. Pediatr Clin North Am. 44 (5) : 1091-115 (1997).
    4. Smith, C., Smith, D.P. Office pediatric urologic procedures from a parental perspective. Urology. 55 (2) : 272-6 (2000).
    5. Frank, J.D., Pocock, R.D., Stower, M.J. Urethral strictures in childhood. Br J Urol. 62 (6) : 590-2 (1988).
    6. Persad, R., Sharma, S., McTavish, J., et al. Clinical presentation and pathophysiology of meatal stenosis following circumcision. Br J Urol. 75 (1) : 91-3 (1995).
    7. Stenram, A., Malmfors, G., Okmian, L. Circumcision for phimosis: a follow-up study. Scand J Urol Nephrol. 20 (2) : 89-92 (1986).
    8. Hinman, F., Baskin, L. Hinman s Atlas of Pediatric Urologic Surgery. 2nd ed. chapter 155 : 773-775 (2008).
    9. Belman, A.B., King, L.R., Kramer, S.A. Clinical Pediatric Urology. 4th ed. 214-215 (2002).
    10. Wein, A.J., Kavoussi, L.R., Novick, A.C., Partin, A.W., Peters, C.A., Campbell-Walsh Urology. 9th ed. 1044-1045 (2007).

    Comments

    2 Comments

    what is the incidence of glanular hypospadius post meatoplasty?
    Reply

    Posted by: Majed S.December 11, 2010, 2:44 PM

    This should not occur, if only the ventral scar tissue is excised.

    It is possible hypospadias was missed on initial diagnosis.
    Reply

    Posted by: AnonymousDecember 12, 2010, 9:45 PM

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