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.