Meatal Dilatation Research Articles

V2-03 THE MALONE MEATOPLASTY: A DORSAL APPROACH TO MEATAL STENOSIS IN PATIENTS WITH LICHEN SCLEROSUS

INTRODUCTION AND OBJECTIVES: The treatment of meatal stenosis associated with lichen sclerosus is traditionally treated either by meatal dilatation or ventral meatotomy. These operations have high recurrence rates or create a hypospadiac meatus. We present an established technique in the use of a dorsal approach. METHODS: Initially a small ventral meatotomy is performed. The epithelium of the urethra and glans is opposed with 3, 6-zero polyglactin (PG) sutures. This acts to widen the meatus slightly without making it hypospadiac but more importantly it allows the insertion of forceps to assess and ensure that the stricture does not extend significantly into the navicular fossa. Next a deeper dorsal meatotomy is performed. Again the epithelium of the urethra/glans are opposed. The combination of small ventral and deeper dorsal meatotomies should completely open the stenosed meatus but the cosmetic appearance at this stage is poor since the sutures of the dorsal meatotomy pucker the glans due to the thickness of the corpus spongiosum. This is overcome by an inverted V-shaped relieving incision with the apex of the V close to the proximal limit of the dorsal meatotomy. The edges of the relieving incision are freed by sharp dissection. The opposing left and right inner edges are closed with continuous PG to form the roof of the distal neourethra. The outer glans layer is opposed with interrupted PG. RESULTS: The final result is a slit-like but good calibre meatus at the tip of the glans. CONCLUSIONS: During a follow-up of 4.2 years there were recurrences in 6/116 patients, 5 of whom required re-operation (4.3%). 93% patients were either happy or very happy with the cosmetic result. Conclusion: This technique can achieve excellent aesthetic results, with low incidence of a spraying stream.

MP13-01 THE MALONE MEATOPLASTY FOR PURE MEATAL STENOSIS ASSOCIATED WITH LICHEN SCLEROSUS: RESULTS OF AN INTERNATIONAL, MULTICENTRIC STUDY

INTRODUCTION AND OBJECTIVES: The treatment of pure meatal stenosis associated with lichen sclerosus (LS) is traditionally treated either by meatal dilatation or ventral meatotomy. These operations have a high recurrence rate and/or create a hypospadiac meatus. We present a well established operation in the use of a dorsal approach first described by the senior author in 2004. METHODS: 116 consecutive patients with stenosis of the external urinary meatus underwent a Malone meatoplasty in between 1989-2011. Mean age was 40.5 years (range 4-87 years). Range of follow up was between 6 weeks and 21 years (mean 4.2 years). Patients were followed up by questionnaire. The questionnaire ascertained if the patients were happy with the post-operative cosmetic appearance, if he sprayed when he passed urine and if so to what extent. RESULTS: 90 (78%) patients responded to a questionnaire. There were recurrences in 6 patients, 5 of whom required re-operation (4.3%). 93% patients were either happy or very happy with the cosmetic result. 87% patients never sprayed or sprayed only occasionally. Of those who sprayed only 2 patients described it as severe, one of whom had declined circumcision and had progressive LS of his foreskin. CONCLUSIONS: These results confirm that the Malone meatoplasty reliably relieves pure meatal stenosis in the long term. It is reproducible and can be performed under local anaesthetia. It can achieve excellent aesthetic results, with a low incidence of a spraying stream. Given these findings, it is not justified to perform more complex urethroplasties for strictures that do not involve the navicular fossa. Equally it seems better to perform this meatoplasty as the primary procedure rather than as salvage after failed meatal dilatation or ventral meatoplasty.

Distal urethrectomy for localized penile squamous carcinoma in situ extending into the urethra: an updated series

The presence of squamous carcinoma in situ (CIS) of the distal penis extending into the urethral meatus is generally considered a contraindication for glans-sparing procedures. Distal urethrectomy with subsequent reconstruction can provide an alternative approach toward urethral resection while providing penile preservation in select cases. Unfortunately, long-term oncologic outcomes with this approach are ill-defined. Between 1988 and 2012, five patients at Indiana University Medical Center underwent distal urethrectomy with reconstruction for penile squamous CIS extending into the urethral meatus. This cohort was retrospectively reviewed to evaluate functional and oncological outcomes. Of the five patients, four presented with glanular lesions and were initially managed with Mohs procedure in three cases, and local excision in one. The final patient presented with extensive urethral disease and was managed with primary urethrectomy. Reconstruction was performed with penile skin pedicle grafts in four patients and perineal urethrostomy in one. Final pathologic stage was T1 in one patient and Tis in the remaining four. Follow-up ranged from 6 to 96 months. One local recurrence was verified; however, it occurred outside the urethral area. This was confirmed in the pathologic analysis after the patient underwent a partial penectomy. Meatal dilation was necessary in two patients 12 and 7 months after the procedure. Distal urethrectomy for penile squamous CIS extending into the urethral meatus is a valid alternative to achieve negative surgical margins while preserving a penile function. Oncologic outcomes appear acceptable but larger series are still warranted to confirm our findings.

The effect of urethral catheter size on meatal stenosis formation in children undergoing tubularized incised plate urethroplasty.

Meatal stenosis is still a common problem in tubularized incised plate urethroplasty. In this study, we aimed to seek for a relationship between the size of urethral catheter and meatal stenosis formation in children undergoing tubularized incised plate urethroplasty. We retrospectively reviewed 83 children who underwent tubularized incised plate urethroplasty for hypospadias. The whole group was classified into the groups A and B based on the catheter size. One group (group A) consisted of 44 patients (mean age, 4.82 ± 3.83 years) with tubularized neourethra over a 6 Fr catheter, while the other group (group B) included 39 patients (mean age, 5.19 ± 3.83 years) with tubularized neourethra over a 8 Fr catheter. There were no significant differences between the groups according to their age, location of urethral meatus, dehiscence and urethrocutaneous fistula formation. Meatal stenosis formation in group B was markedly higher than that in group A. Number of meatal dilatation was higher in group B compared to group A. We suggest that the tubularization of urethral plate over a small-sized (6 Fr) catheter, regardless of the age of the patients, prevents meatal stenosis by reducing foreign body reaction and pressure injury and by hindering secondary healing.

Hiperkalsiüri ve Hipospadiaslı Bir Olguda Mesane Taşı

The incidence of nephrolithiasis, especially bladder calculi, is lower in childhood compared with adults; but pediatric nephrolithiasis is an important cause of morbidity and has various etiology. A 21 month male infant was admitted to our hospital with atypical position during micturition because of pain. In his history, he was operated because of penoscrotal hypospadias and meatal dilatation was done for meatal stenosis in 12 months old. He did not have urinary tract infection before, but in the last 3 months he was treated for febrile urinary tract infections for three times. On physical examination he had failure to thrive and poor weight gain. He had difficulty and pain during voiding and he could urinate only in right and downword position. X-Ray and ultrasonography revealed bladder calculi and in laboratory he had hypercalciuria. The calculi was removed with surgery and analysis revealed calcium oxalate stone.

Complications of Circumcision

Objective: Circumcision is one of the most frequently performed elective procedures in male. In general, post circumcision complications are minor and treatable but complications requiring expert intervention are seen when the circumcision is perrformed by inexperienced/untrained person and in non-sterile setting and inadequate equipments. Materials and Methods: From March 2008 to May 2012, 59 patients with circumcision related complications were received at age range of 6 months to 5 years with a mean age of 2.4 years. The most common complication was urethra-cutaneous fistulae in 18 patients, followed by meatal stenosis in 9, bleeding in 6, incomplete circumcision in 6, buried penis in 5, glanular injury in 4, skin bridge in 4, complete amputation of phallus 3, hole in the prepuce in 3 patients and one patient with coronal constriction and fistula. Results: Urethral fistulae were closed in all 18 patients with recurrence in 16%. Two patients with extensive bleeding required blood transfusion and all 6 children required hematoma evacuation under general anesthesia in the operating room. The circumcision was revised in those with an incomplete procedure, a hole in prepuce, burried penis and residual skin bridge. Meatotomy was the procedure of choice in 6 of 9 patients with meatal stenosis, but in the remainder meatal dilatation was efffective. Glanular injuries were managed conservatively. A short residual after glanular injury needed grafting. Conclusion: Circumcision is considered a simple and minor surgical procedure, yet it needs to be performed competently by only medically qualified and trained personnel and with a great care.

EFFECT OF URETHRAL DILATION ON ANTERIOR URETHRAL STRICTURE RECURRENCE AFTER INTERNAL URETHROTOMY IN MALES

Objective: The aim is to evaluate the effect of urethral dilation on anterior urethral stricture recurrences after direct vision internal urethrotomy (DVIU). Material & Method: Patients were classified into 2 groups after internal urethrotomy for urethral dilation or observation. All strictures included were anterior, single, and causing partial obstruction. Urethral dilation was performed using a metal sound. This procedure was performed every 1 or 2 weeks in the first and second month after operation and then once a month for 1 year or in case of voiding complaints or low flow rate (< 10 mL/s). Follow up at least until 1 year after DVIU. Results: A total of 32 cases could be reviewed, of which are 21 had urethral dilation and 11 observation only. In the urethral dilation group, we found 4 recurrences (19%) with mean time to recurrence 10,52 months. In the observation group, we found 7 recurrent cases (63,63%) with a mean time to recurrence of 8,09 months. P value is 0,02 which means urethral dilation significantly decreased the chance of stricture recurrence. By Kaplan Meier survival analysis, urethral dilation had a better and longer time to recurrence. Conclusion: In this study, regular meatal dilation is proven to prolong the time to recurrence of an anterior urethral stricture after DVIU. Keywords: Urethral dilation, anterior urethral stricture, stricture recurrence.

Management of boys with abnormal appearance of meatus at circumcision for balanitis xerotica obliterans

The aim of this study was to develop a standardised management plan for boys with abnormal appearance of meatus at circumcision for balanitis xerotica obliterans (BXO). Between 1995 and 2008, 107 boys underwent circumcision for BXO (confirmed on histology). Of these, 23 had abnormal appearance of the meatus at operation; their case notes were reviewed for age, presenting symptoms, management, outcome and follow up. The age range at operation was 3-15 years (mean: 9 years). Patients commonly presented with phimosis and balanitis. Seven patients had an additional procedure at circumcision: six had meatotomy, one had meatal dilatation. Thirteen were treated with topical steroid cream post-operatively. Eight of these (62%) subsequently required meatotomy. Three patients were observed and did not require further intervention. Meatotomy was required in 9 patients, 6-29 months after circumcision (mean: 11 months). Two patients required dilatation, including one with a previous intraoperative meatotomy, who required multiple dilatations. We propose the following standardised management plan: 1. With clinical evidence of BXO at circumcision, prepuce should be sent for histology. 2. If BXO is confirmed but the meatus appears normal, patients should be seen once post-operatively to give information about meatal stenosis. 3. When the meatus appears scarred with a narrowed lumen at operation, a meatotomy should be performed, with follow up for at least two years. 4. If the lumen is scarred but adequate, patients should be followed up in clinic for the same period for possible development of stenosis. 5. Topical steroid cream can be considered for voiding discomfort without decreased urine stream.

Long-term results with a one-stage complex primary hypospadias repair strategy (the three-in-one technique)

Purpose Complex primary hypospadias repair that warrants urethral plate division is treated mostly in two steps, not necessarily in two surgeries. Our aim was to review long-term results with a one-stage strategy based on reconstruction of the urethral plate with buccal mucosa graft and onlay transverse preputial flap anastomosis protected by a tunica vaginalis flap (the three-in-one concept). Material and methods We were able to report on 35 patients operated for primary scrotal, penoscrotal and perineal hypospadias between March 2002 and June 2008. We reviewed all charts and had phone interviews with patients not seen for the last 24 months. We investigated parameters such as UTI occurrence, fistula, residual curvature, meatal stenosis, urethral diverticula, dehiscence, orchitis and parental perception. Results Surgical complications occurred in 13 patients (37%): 4 meatal stenosis, 4 diverticula, 5 fistulae and 2 residual penile curvatures (total 42%). Meatal dilatation was successful in 2 cases, reflected in fistula resolution. The reoperation rate was 31.5% consisting mostly of simple procedures like fistula closure, meatotomy and penile curvature release, and complex diverticula repair in 4 cases. Parental perception was excellent for 57% (20 patients) and good or acceptable for the remaining. Mean follow-up was 4.6 years. Conclusions The one-step strategy is associated with 68.5% success in a single operation, whereas 31.5% will need a second repair. We recognize that meatal problems are mostly associated with fistulae and diverticula; therefore, we recommend a final acceptable proximal glandar opening that will not compromise the neourethra.

840 SINGLE-STAGE DORSAL ONLAY BUCCAL MUCOSA GRAFT URETHROPLASTY FOR COMPLEX (PENDULOUS AND PAN-UREHTRAL) STRICTURES

You have accessJournal of UrologyPenis/Testis/Urethra: Benign & Malignant Disease1 Apr 2011840 SINGLE-STAGE DORSAL ONLAY BUCCAL MUCOSA GRAFT URETHROPLASTY FOR COMPLEX (PENDULOUS AND PAN-UREHTRAL) STRICTURES Anand Sehgal and Harpreet Jolly Anand SehgalAnand Sehgal Ludhiana, India More articles by this author and Harpreet JollyHarpreet Jolly Ludhiana, India More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.660AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Buccal mucosa graft (BMG) is considered the tissue of choice for single stage reconstruction of the bulbar urethral strictures but its use for pendulous and pan-anterior urethral strictures has not been reported widely. This study was done to assess the outcome of single-stage dorsal onlay BMG urethroplasty for pendulous and pan-urethral strictures in terms of voiding function, erectile function and morbidity of oral cavity. METHODS A total of 44 patients underwent dorsal onlay buccal mucosa graft urehtroplasty from October 2006 to March 2010 out of which 21 were complex strictures involving pendulous urethra only (6), segments of both pendulous and bulbar urethra (6) and pan-urethral strictures (9). Age of the patients ranged from 30 to 67 (mean=51.8) years. Mean graft length was 9.5 cm (range, 6-16 cm). Etiology of the stricture was instrumentation (9), balanitis xerotica obliterans (5) and idiopathic (7). Ten patients underwent OIU and 4 patients had got suprapubic cystostomy done prior to surgery. Buccal mucosa graft site was left unsutured in all cases after securing hemostasis. All procedures were done through perineal incision. Recurrence rates, need for further procedures, erectile dysfunction and complications were analysed retrospectively. RESULTS Eighteen (85.7%) patients were stricture free at a mean follow up of 33.4 (range, 8–48) months. All 3 (14.3) recurrences presented within first 7 months of the procedure, 2 were panurethral strictures out of which one required meatal dilatation and other required OIU. One pendulous urethral stricture also required OIU. Two patients (both panurethral) complained of significant chordee. No patient complained of deterioration of erectile function after the procedure however 1 noted improvement in sexual activity. Four (19%) patients continued to have graft site numbness even after 6 months. No patient complained of difficulty in mouth opening. CONCLUSIONS Pendulous and panurethral strictures can be reconstructed satisfactorily by single stage dorsal onlay buccal BMG urethroplasty with acceptable complication rates. Leaving graft site unsutured causes minimal post-operative morbidity. Possibility of chordee (in patients with pan-urethral strictures) and numbness of oral mucosa should be explained to the patients before the procedure. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e337-e338 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anand Sehgal Ludhiana, India More articles by this author Harpreet Jolly Ludhiana, India More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Re: O’Connor KM and Kiely EA: Lessons learned using Snodgrass hypospadias repair (Irish J Med Sci 175:37)

The authors reviewed experience with TIP repair for distal hypospadias, finding 21% developed meatal stenosis. Unfortunately, they did not describe their postoperative assessment and so the reasons the diagnosis was suspected, means it was established, and time following surgery it occurred are not reported. As the authors note, meatal stenosis is a well-known complication from hypospadias urethroplasty. However, review of published series on TIP repair indicates this complication occurred in only 1.5% of patients [1], and in my own experience has been found in less than 1%. I perform a single calibration of the neomeatus 6 months postoperatively to confirm a size [ 8Fr in young boys. This low incidence of meatal stenosis in contrast to that reported by the authors most likely indicates technical error. The fact stenosis occurred in their first 2, but not the last 2, years performing TIP further reinforces this impression. Furthermore, the authors themselves state technical modifications improved their results. It is worth emphasizing deep incision of the urethral plate and care to avoid tubularizing the neourethra too far distally both decrease likelihood for stenosis. I tubularize the neourethra to approximately 3 mm from the tip of the glans, and then independently perform glansplasty without securing the neomeatus to the glans wings. In the Introduction, the authors state urethral plate incision should not extend beyond the midglans, but failure to carry the incision further distally to near the end of the plate could contribute to subsequent stenosis. I have never performed postoperative meatal dilation. The fact less than 5% of patients are at risk for meatal stenosis calls to question the authors’ recommendation for routine dilation for all boys the first months after surgery. While it may be ‘‘relatively painless’’, it is certainly not completely painless and may cause unnecessary anxiety for both the child and his mother.

A tie‐over dressing for graft application in distal penectomy and glans resurfacing: the TODGA technique

• To describe a novel method of split-skin graft (SSG) fixation for neo-glans formation after distal penectomy for penile cancer and glans resurfacing for carcinoma in situ or lichen sclerosus (LS); the TODGA technique. • Rather than 'quilting' the graft onto the neo-glans, which requires up to 5 days bed rest, the tie-over method fixes the graft adequately enough to allow immediate patient mobilization. • In all, 41 consecutive operations, with a follow-up of ≥ 12 months, were performed on 40 patients (mean age 62 years, range 32-83) from December 2000 to October 2008, where a SSG was applied to the raw glans or penile stump. • The protocol varied for the first 12 operations on 11 patients. The tie-over dressing was left in place for 6 (one patient) or 7 days (11) and various materials were used; paraffin gauze (one), expanded foam (five) and proflavine-soaked gauze (six). The first two patients had their dressing removed under general anaesthetic but all subsequent patients had their dressing removed on the ward. • The subsequent 29 operations used the same protocol where a proflavine-soaked gauze dressing was left undisturbed for 10 days. • In the original 11 patients, two required re-grafting. After this initial development period, we amended the technique to use stronger sutures and left the dressing undisturbed for 10 days. • In addition, we standardized the use of proflavin-soaked gauze, as we found it easy to apply and remove. Since we adopted this protocol, we have performed 29 operations over a 3-year period. • The cosmetic results were excellent with only one patient requiring re-grafting. The mean and median postoperative length of stay was 2 days. • One patient with a urethral squamous cell carcinoma associated with urethral and glans LS required a urethral dilatation to allow a check cystoscopy, and a further asymptomatic patient had a meatal dilatation in the clinic but meatal stenosis was otherwise not seen, with no patients requiring regular meatal dilatation. • The TODGA technique of SSG application and fixation allows immediate mobilization and reduces hospital stay whilst providing excellent cosmetic results with a high percentage of graft uptake.

Long-Term Results with A One-Stage Complex Primary Hypospadias Repair Strategy (The Three-in-One Technique)

Purpose Complex primary Hypospadias repair that deserve urethral plate division is treated mostly in two steps, but not necessarily in two surgeries. Our aim in this review was to recheck our long-term results with a one-stage strategy we published in the past based on simultaneous reconstruction of the urethral plate with dorsal buccal mucosa graft and onlay transverse preputial flap anastomosis protected in the end by a tunica vaginalis flap (the three-in-one concept). Material and Methods We found 35 patients operated with primary scrotal, penoscrotal and perineal Hypospadias between March 2002 and June 2008. We reviewed all charts active in follow-up and made phone interviews for those not seen for the last 24 months. We investigated parameters such as UTI occurrence, fistula, residual curvature, meatal stenosis, urethral diverticula, urethral dehiscence, orchitis and parental perception. Results Surgical complications occurred in 11 patients (31%) and are listed: 4 meatal stenosis, 4 diverticula, 5 fistulas and 2 residual penile curvatures (total 42%). Meatal dilatation was successful in 2 cases that reflected in 2 fistula resolution. The reoperation rate was 25.7% and consisted mostly of simple procedures like fistula closure, meatotomy and complex diverticula repair in 3 cases. Two patients presented recurrent orchitis and UTI but were associated with infrequent voiding characteristics. End parental perception after treatment was excellent for 57% (20 patients) and good or acceptable for the rest. Conclusions We concluded that one-step strategy as here described is associated with 69% chance of one single operation without any complication to treat complex Hypospadias forms, whereas 25.7% will need a second repair. We recognize that meatal problems are mostly associated with fistula and diverticula and therefore we recommend a final acceptable proximal glandar opening that may not compromise the neourethra. Complex primary Hypospadias repair that deserve urethral plate division is treated mostly in two steps, but not necessarily in two surgeries. Our aim in this review was to recheck our long-term results with a one-stage strategy we published in the past based on simultaneous reconstruction of the urethral plate with dorsal buccal mucosa graft and onlay transverse preputial flap anastomosis protected in the end by a tunica vaginalis flap (the three-in-one concept). We found 35 patients operated with primary scrotal, penoscrotal and perineal Hypospadias between March 2002 and June 2008. We reviewed all charts active in follow-up and made phone interviews for those not seen for the last 24 months. We investigated parameters such as UTI occurrence, fistula, residual curvature, meatal stenosis, urethral diverticula, urethral dehiscence, orchitis and parental perception. Surgical complications occurred in 11 patients (31%) and are listed: 4 meatal stenosis, 4 diverticula, 5 fistulas and 2 residual penile curvatures (total 42%). Meatal dilatation was successful in 2 cases that reflected in 2 fistula resolution. The reoperation rate was 25.7% and consisted mostly of simple procedures like fistula closure, meatotomy and complex diverticula repair in 3 cases. Two patients presented recurrent orchitis and UTI but were associated with infrequent voiding characteristics. End parental perception after treatment was excellent for 57% (20 patients) and good or acceptable for the rest. We concluded that one-step strategy as here described is associated with 69% chance of one single operation without any complication to treat complex Hypospadias forms, whereas 25.7% will need a second repair. We recognize that meatal problems are mostly associated with fistula and diverticula and therefore we recommend a final acceptable proximal glandar opening that may not compromise the neourethra.

Ureteroscopia diagnóstica y terapéutica: ¿es necesaria siempre la dilatación del meato ureteral?

Objective To assess the feasibility and safety of diagnostic or therapeutic semirigid ureteroscopy without ureteral meatus dilatation. Materials and methods A comparative, retrospective study was conducted of patients undergoing ureteroscopy from January 2000 to May 2008. For data analysis purposes, the population was divided into two groups based on whether ureteroscopy had been performed with (Group 1) or without (Group 2) ureteral meatus dilatation. Variables recorded included age, sex, type of procedure, surgical diagnosis, passive or active dilatation, number of stones, stone location, stone diameter, peroperative and postoperative complications, internal urinary diversion after the procedure, therapeutic success rate, operating time, and hospital stay duration. A 8-9.8 Fr Wolf semirigid ureteroscope was used. Descriptive statistics of the population and cohorts were performed, providing medians, quartiles, and limit values for non-normally distributed interval variables, and absolute and relative frequencies for categorical variables. Shapiro-Wilk's, Mann-Whitney's U, Chi-square, and Fisher's exact tests were used for statistical analysis. A value of p 2 ⊠ ≤ 0.005 was considered statistically significant. Arcus Quickstat Biomedical 1.0 software was used. Results Among the 306 ureteroscopies studied, 286 performed in 256 patients were analyzed. Median age was 50 years (16-83), 59% of patients were male, and elective ureteroscopy was performed in 183 patients (64%). Group 1: 191 ureteroscopies, Group 2: 95 ureteroscopies. Stone location: 149 in distal ureter, 60 in middle ureter, and 35 in proximal ureter. Sixty-nine percent of stones had sizes ranging from 5 and 10 mm. The overall success rate was 86.5%. There were 5 peroperative and 22 postoperative complications, with no statistically significant differences between the groups. Conclusions In selected cases, ureteroscopy may be performed without ureteral meatus dilatation with success and morbidity rates similar to when the procedure is performed with meatal dilatation.

Long standing balanitis xerotica obliterans resulting in renal impairment in a child

Balanitis xerotica obliterans (BXO) is the most common cause of pathological phimosis in boys. Presented here is the case of a previously well 13-year-old boy who developed obstructive renal impairment (serum creatinine = 190 micromol/l) at least in part from phimosis due to BXO. A circumcision and, 2.5 months later, meatal dilatation were done. Nine months after his initial presentation, his serum creatinine returned to a permanently elevated nadir of 119 mumol/l. Presentation with the complications of phimosis can be delayed in teenage boys because they may feel embarrassed to come forward. Circumcision remains the definitive treatment of BXO induced phimosis though if the penile meatus is involved, more complex surgery is sometimes required. Topical steroids are useful for residual disease. Follow-up is very important due to the frequent involvement of the skin of the glans. In the very long term there is an increased chance of penile malignancy, which can occur even after circumcision.

Evaluation of the results of eccentric circummeatal-based flap with combined limited urethral mobilization technique for distal hypospadias repair

Objective To evaluate the outcome of patients with distal hypospadias who are operated using the eccentric circummeatal-based flap (ECBF) with combined limited urethral mobilization (LUM) technique. Patients and methods We retrospectively reviewed the medical records of all patients who underwent distal hypospadias repair at our institution between January 2000 and December 2005. Seventy-one patients with distal hypospadias were operated. Eighteen cases were operated with glanular approximation and 11 cases using the Snodgrass procedure. Forty-two cases of distal hypospadias without a thin distal urethra were operated using an eccentric circummeatal-based flap with combined limited urethral mobilization. We reviewed these 42 patients according to age at surgery, position of meatus, presence of ventral curvature or glanular tilt, previous operations, duration of catheterization and hospitalization, and early and late postoperative complications. Results The mean age at operation was 5.9 ± 3.1 years. The position of the meatus was coronal in 29 patients (69%), glanular in seven (16.7%) and subcoronal in six (14.3%). Two patients had ventral curvature. Five patients had undergone previous unsuccessful hypospadias repair and five had undergone circumcision. The average length of catheterization was 4.64 ± 1.07 days. All patients were discharged after stent removal. At follow up of 1–31 months (median 6 months, 22 patients over 6 months), three patients had a slightly glanular urethral meatus and six patients had a decrease in calibration during urination which responded to meatal dilatation. No fistula had occurred. All patients achieved a normally situated vertical slit-like glanular meatus. Conclusion This technique is simple with satisfying cosmetic results, and can also be applied to patients who have undergone previous failed operations. The absence of fistula formation and short duration of hospital stay are additional advantages.

Lessons learned using Snodgrass hypospadias repair

This is a review of our experience with the Snodgrass technique for distal hypospadias repair and we point to lessons learned in improving results. We reviewed all patients who underwent Snodgrass hypospadias repair for distal hypospadias over a four-year period by a single surgeon. Chart review followed by parental telephone interview was used to determine voiding function, cosmesis and complication rate. Thirty children and three adults were identified. Age at surgery ranged from seven months to 39 years. The urinary stream was straight in 94%, and 97% reported a good or satisfactory final cosmetic outcome. One patient (3.3%) developed a urethral fistula and 21% developed meatal stenosis which required general anaesthetic. The Snodgrass urethroplasty provides satisfactory cosmetic and functional results. High rates of meatal stenosis initially encountered have improved with modifications to technique which include modified meatoplasty and routine meatal dilatation by the parents.

Comprehensive analysis of tubularized incised‐plate urethroplasty in primary and re‐operative hypospadias

To retrospectively review our experience of the tubularized incised-plate (TIP) urethroplasty over the last 4 years. From 1998 to December 2001, 133 patients (mean age 7 years, sd 4, range 1-22), had a TIP urethroplasty by one surgeon for primary (103) and re-operative (30) hypospadias; the defects included 106 (79%) distal and mid-shaft, and 27 (21%) posterior shaft. The neourethra was covered by a subcutaneous flap in 66 (50%) patients or by corpus spongiosa (spongioplasty) in 31 (23%), with no cover in the remaining 36 (27%). In the last 20 patients (15%) a modified meatoplasty was used; the site and size of the new meatus was predetermined on the glans around a suitable catheter before any incision. Urethral stents were not used after repair in 39 (29%) patients, and regular meatal dilation was used only in patients with voiding difficulty and obvious tendency to stenosis. The presence of complications requiring re-operation and overall general appearance were recorded. The mean (sd) follow-up was 10 (5) months; there were 24 complications in 20 patients (15%), including a small fistula in 12 (9%), complete disruption of the repair in 4 (3%), meatal stenosis in seven (5%) and neourethral stricture in one (0.8%). Complications were not significantly different between primary and re-operative cases, and unaffected by the use of the stents. On univariate analysis complications were significantly higher with running than interrupted sutures, in repairs in the first 2 years of the study, in patients with posterior hypospadias, and in those with no neourethral coverage. However, the last two factors were the only significant independent risk factors in a multivariate analysis. Regular urethral dilatation was indicated in 43 patients (32%). Modified meatoplasty was associated with a significantly lower requirement for regular dilatation (P < 0.05) and no meatal stenosis. In the 113 complication-free patients the operation gave an excellent cosmetic appearance with a vertical slit meatus on the tip of conical glans in 110 (97%); there was slight meatal retraction in the remaining three patients. The TIP repair is a reliable method for treating both distal and proximal penile shaft hypospadias, is suitable for both primary and re-operative cases, and is more versatile than other repairs. Covering the neourethra with a flap or spongioplasty significantly improves the results. Regular urethral dilatation is required in a third of patients but modified meatoplasty obviates the need for regular dilatation and eliminates the risk of meatal stenosis.

Home-dilatation of the urethral meatus in boys.

To evaluate the efficacy of dilatation of the stenotic urethral meatus in boys at home. Eighteen boys aged 3-15 years, or their parents, were taught to dilate the urethral meatus at home. The cause of the stricture was balanitis xerotica obliterans (BXO) in five and consequent upon hypospadias surgery in 12, of whom two were complicated by BXO, and one after circumcision for cultural reasons. One boy was re-referred after an interval of 3 years because of apparent deterioration of the stream of urine. Meatal dilatation was taught in the home by one of the authors (J.M.S.). Nine patients were cured by the first course of dilatation, four relapsed early after initial success but responded to further treatment, and three proceeded to meatoplasty because they had no response. Two relapsed late and one responded to further dilatation but the other required surgery. Dilatation of the urethral meatus can be taught successfully to boys or their families at home, thus avoiding repeated hospital attendance and often general anaesthesia.

BUCCAL MUCOSAL GRAFTS: LESSONS LEARNED FROM AN 8-YEAR EXPERIENCE

We evaluated our 8-year experience with buccal mucosal grafts in complex hypospadias and epispadias repair. We reviewed the records of 29 patients in whom a total of 30 buccal mucosal grafts were placed as part of urethral reconstruction between 1991 and 1999. At surgery 16 tubes and 14 onlays were constructed and 24 of 30 repairs involved the meatus. All patients were followed at least 6 months postoperatively (median 5.3 years). Beginning in 1995 meatal design was enlarged to a racquet handle shape and patients were asked to perform meatal self-dilation for 6 months postoperatively. Complications developed in 17 of our 30 cases (57%) and reoperation was done in 10 (33%). All complications were evident by 11 months postoperatively except 1 that presented as recurrent stricture disease at 3 years. Complications developed in 5 and 12 of 15 patients who underwent surgery between 1995 and 1999, and before 1995, respectively (p = 0.027). No patient has had meatal stenosis since 1995. Complications included meatal stenosis in 5 cases, stricture in 7, glanuloplasty, meatal and complete graft breakdown in 1 each, and fistula in 2. Onlays were more likely to result in stricture than tube grafts (6 of 14 cases versus 1 of 16, p = 0.034). The complication and reoperation rates of buccal mucosal grafts are 57% and 33% at 5 years of followup. Changes in meatal design and temporary postoperative meatal dilation have improved the outcome in the last 5 years. Buccal mucosa remains a good choice in patients who require extragenital skin for urethral reconstruction.