Ventral Meatotomy Research Articles

The association of meatal stenosis and infant circumcision.

The association of meatal stenosis with age at circumcision is controversial. We noticed a high rate of meatal stenosis in a region where early circumcision is traditional. The aim of this study is to compare the age at circumcision between boys with or without meatal stenosis. After ethical approval, families of children with meatal stenosis were questioned about age at circumcision and reason for circumcision. Control group consisted of patients with diagnoses other than penile abnormalities, a normal urethral meatus, and having no symptoms about urination. Patients with a history of therapeutic circumcision were excluded from the study. Between November 2016 and November 2020, 115 patients with meatal stenosis were admitted. All were corrected with ventral meatotomy under general anesthesia. Median age at circumcision was 3 (min:0-max:111) monthsand age at admission was 74 (min:22-max:194) months. Control group consisted of 205 boys. Median age at circumcision was 5 (min:0-max:122) months and age at admission was 96 (13-202) months. There was a statistically significant difference between groups in terms of age at circumcision (p=0.024) but none for age at admission (p=0.356). There was a twofold increase in the meatal stenosis rate (39% vs. 23%) if circumcision was performed before age one (p=0.018). There was no difference between the patients circumcised in the newborn period and later (38% vs 36%, p=0.778). Our study supports the previous reports suggesting a relation of risk for meatal stenosis and age at circumcision and presents data that age one might be a cutoff for this risk.

Ventral meatotomy as management of female urethral stricture: a case report

Introduction: Female urethral stricture is considered a rare condition. This condition may lead to recurrent lower urinary tract symptoms and urinary retention. Several techniques have been reported to overcome this disease with some advantages and disadvantages. This case report shows the author's experience in treating female urethral stricture using the ventral meatotomy technique.Case description. A 63-year-old female suffered from poor urinary flow, recurrent urinary tract infection and lower urinary tract symptoms. Physical examination and urethrocystoscopy showed narrow urethral opening and severe trabeculation, respectively, which indicated bladder outlet obstruction due to urethral stricture. A ventral meatotomy was performed, followed by an indwelling catheter for a week. The patient showed improvement of the symptoms postoperatively.Conclusion. Urethral reconstruction in female urethral stricture should be decided as definitive therapy, and an individualized approach must be applied based on patient factors and surgeon experience.

Novel measurement tool and model for aberrant urinary stream in 3D printed urethras derived from human tissue.

An estimated 10% of male adults have split or dribbled stream leading to poor hygiene, embarrassment, and inconvenience. There is no current metric that measures male stream deviation. To develop a novel method to measure spray in normal and abnormal anatomical conformations. We developed a novel platform to reliably describe spray. We used cadaveric tissues and 3D Printed models to study the impact of meatal shape on the urinary stream. Cadaveric penile tissue and 3D printed models were affixed to a fluid pump and used to simulate micturition. Dye captured on fabric allowed for spray detection. Spray pattern area, deviation from normal location, and flowrates were recorded. Computational fluid dynamic models were created to study fluid vorticity. Obstructions at the penile tip worsened spray dynamics and reduced flow. Ventral meatotomy improved flowrate (p<0.05) and reduced spray (p<0.05) compared to tips obstructed ventrally, dorsally or in the fossa navicularis. 3D models do not fully reproduce parameters of their parent cadaver material. The average flowrate from 3D model was 10ml/sec less than that of the penis from which it was derived (p = 0.03). Nonetheless, as in cadavers, increasing obstruction in 3D models leads to the same pattern of reduced flowrate and worse spray. Dynamic modeling revealed increasing distal obstruction was correlated to higher relative vorticity observed at the urethral tip. We developed a robust method to measure urine spray in a research setting. Dynamic 3D printed models hold promise as a methodology to study common pathologies in the urethra and corrective surgeries on the urine stream that would not be feasible in patients. These novel methods require further validation, but offer promise as a research and clinical tool.

Dorsal midline incision: A versatile technique for correction of meatal stenosis during hypospadias repair

Objectives: To our knowledge, the incidence of congenital meatal abnormalities associated with hypospadias varies from 9.6% to 31%, of which meatal stenosis is the most common, affecting 9.1–16.7% of patients. Traditionally, meatal stenosis has been dealt with by meatal dilatation, although ventral meatotomy until the normal urethra is encountered has also been used. Here, we report the outcome of a technique where, during hypospadias repair, a dorsal midline incision was performed instead of a ventral urethral incision, starting at the narrow meatus and subsequently extending proximally to treat the meatal stenosis. Methods: Patients having distal hypospadias with meatal stenosis were included in this study. In this technique, a dorsal midline incision was extended until normal calibre urethra was encountered. Patients with chordee &gt;15°, proximal hypospadias, redo cases, glans width &lt;14 mm, where separation of the skin from the underlying urethra was not possible and with a follow-up of less than three months were excluded from the study. A total of 73 patients were operated on using this technique. Results were assessed with regards to urethrocutaneous fistula (UCF) and stricture formation. Results: Five (6.85%) patients developed UCF: one (5%) in the subcoronal group, two (8.0%) in the distal penile group and two (14.3%) in the mid-penile hypospadias group. Postoperatively, only one patient had meatal stenosis. Conclusion: We think hypospadiac meatal stenosis is best treated by a dorsal midline incision, as it does not lead to a proximal shift of the meatus, and this defect heals by re-epithelisation without significant scarring, which in turn decreases the possibility of UCF. That is why the fistula rate in our study was 6.85%, which is lower than in various published series.

MP60-04 PILOT EXPERIMENTAL ANALYSIS OF MEATUS CONFORMATION AND DEVELOPMENT OF NOVEL MEASUREMENTS FOR ABERRANT URINARY STREAM IN 3D PRINTED URETHRAS DERIVED FROM CADAVERIC MODEL

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II (MP60)1 Apr 2020MP60-04 PILOT EXPERIMENTAL ANALYSIS OF MEATUS CONFORMATION AND DEVELOPMENT OF NOVEL MEASUREMENTS FOR ABERRANT URINARY STREAM IN 3D PRINTED URETHRAS DERIVED FROM CADAVERIC MODEL Andrew Cohen*, German Patino, Seyed Mirramezani, Sudarshan Srirangapatanam, Anas Tresh, Bhagat Cheema, Jenny Tai, Dylan Romero, Anthony Enriquez, Shawn Shadden, and Benjamin Breyer Andrew Cohen*Andrew Cohen* More articles by this author , German PatinoGerman Patino More articles by this author , Seyed MirramezaniSeyed Mirramezani More articles by this author , Sudarshan SrirangapatanamSudarshan Srirangapatanam More articles by this author , Anas TreshAnas Tresh More articles by this author , Bhagat CheemaBhagat Cheema More articles by this author , Jenny TaiJenny Tai More articles by this author , Dylan RomeroDylan Romero More articles by this author , Anthony EnriquezAnthony Enriquez More articles by this author , Shawn ShaddenShawn Shadden More articles by this author , and Benjamin BreyerBenjamin Breyer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000929.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: An estimated 10% of male adults have split or dribbled stream which can lead to poor hygiene, embarrassment, inconvenience and social distress. There is no metric that measures the degree of stream deviation from normal, nor is there a definition of normal in this context. Our objective is to develop an innovative method to measure spray. We also evaluate the effect of common pathologies in the distal urethra and corrective surgeries on the urine stream. METHODS: We use cadaveric tissues and 3D Printed models to define distal meatus conformations and their impacts on stream characteristics (Figure). We developed a novel platform to reliably measure spray of urinary flow. Silicone was used to cast the lumen of cadaveric urethra, this was subsequently converted to 3D printable model. Cadaveric penile tissue and 3D printed models were affixed to fluid pump and used to simulate micturition events. Dyed fluid captured on fabric allowed for spray detection. Spray pattern area, deviation from normal location, and flowrates were recorded as obstructions were surgically created in cadaveric tissue or modelled using 3D printing. RESULTS: Characteristic voiding scenarios were validated with high precision. Spray patterns of each void were recorded (Figure d). Obstructions at the penile tip worsen spray dynamics and reduce urinary flow. Ventral meatotomy improves flow rate and reduces spray compared to tips obstructed ventrally, dorsally or in the fossa naviculars. 3D printed models to do not fully reproduce parameters of their parent cadaver material. All other variables constant, the flow rate from 3D model is 3 ml/sec less than that of the penis from which it was derived (p=0.03). Nonetheless, increasing obstruction in 3D models leads to the same pattern of reduced flow rate and worse spray. Via dynamic modelling, distal obstruction was experimentally shown to worsen fluid vorticity. CONCLUSIONS: We developed a robust method to measure urine spray in a research setting. Dynamic 3D printed models hold promise as a methodology to study common pathologies in the distal urethra and corrective surgeries on the urine stream. We recapitulate clinical observations that increased meatal obstruction worsen flow and spray whereas meatotomy leads to improvements. These novel methods require further validation, but offer promise as a powerful research and clinical tool. Source of Funding: Alafi Fund © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e890-e890 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Cohen* More articles by this author German Patino More articles by this author Seyed Mirramezani More articles by this author Sudarshan Srirangapatanam More articles by this author Anas Tresh More articles by this author Bhagat Cheema More articles by this author Jenny Tai More articles by this author Dylan Romero More articles by this author Anthony Enriquez More articles by this author Shawn Shadden More articles by this author Benjamin Breyer More articles by this author Expand All Advertisement PDF downloadLoading ...

A rare cause of acute urinary retention: Anterior urethral stones

Anterior urethra stones are extremely rare causes of acute urinary retention. The data of 34 adult patients who presented with acute urinary retention between August 2011 and September 2017 and treated with anterior urethra were evaluated retrospectively. Their ages, sizes of stones, locations, etiological factors, physical examination findings, treatment modalities, operation period and complications were analyzed. All the patients were male and the mean age was 46.9 ± 17.88 years. All of the stones evaluated in the study were single and the mean stone size was 12.17 ± 3.23 (6-19) mm. Location of the urethral calculi was fossa navicularis in 12 (35.3%) patients, bulbar urethra in 7 (20.6%) patients and penile urethra in 15 (44.1%) patients. A total of 20 patients had urinary calculi located in the other parts of the urinary system at the time of presentation. Stone of the 7 patients with fossa navicularis localized had been treated by intraurethral instillation of 2% lidocaine gel, the other 5 patients had been treated with ventral meatotomy. Urethral stone of the 7 patients with penile and bulbar urethra located was taken by the help of direct forceps without requiring any fragmentation operation. Other stones were treated with endoscopic holmium laser lithotripsy. As a result of surgery operations, urinary tract infection in 3 patients, urethrorrhagia in 2 patients and hematuria in 5 patients were observed. We consider that it is very important to keep anterior urethral stones in mind among differential diagnosis especially in male patients admitted with acute urinary retention. acute urinary retention.

Urethral Mobilization as an Alternative Procedure for Distal Hypospadias Repair

To evaluate the urethral mobilization procedure as the main technique in management of glanular, coronal, subcoronal, and distal penile hypospadias. Sixty patients with distal hypospadias were included in this prospective study between January 2013 and January 2015. All of them had urethral mobilization. All patients were followed up at 2 weeks, and at 1, 3, 6, and 12 months postoperatively. Duration of the operation, hospital stay, position of meatus and its shape before and after the operation, and the postoperative complications were recorded. The force and direction of the postoperative voiding stream were observed and assessed subjectively. The mean operative time and hospital stay were 38 minutes and 2.2 days, respectively. Postoperatively, 2 patients developed wound infection, 1 of them developed glanular suture dehiscence managed by simple glanular suturing 3 months later. None of our patients developed urethrocutaneous fistula. Three months postoperatively, 2 patients developed meatal stenosis, 1 of them managed by meatal dilation whereas the other patient required ventral meatotomy. Hypospadias surgery aim to construct a functionally and cosmetically normal penis with minimal complications. Recently, urethral mobilization started to regain its position in distal hypospadias repair. Its results are comparable with other popular procedures or even better. Urethral mobilization is an easy and simple procedure and it has an excellent cosmetic and functional outcome with minimal complications.

Acute Urinary Retention due to Impacted Urethral Meatal Stone - An Infrequent Entity in Children

Introduction Acute urinary retention in children is a relatively uncommon entity. There are various causes that leads to acute retention but are poorly defined in the literature [1,2]. Most common cause of acute retention of urine in children is lower urinary tract stone in one report [1] and neurological disease in another report [2]. Here we present a case of boy who presented with acute retention of urine due to impacted meatal stone. Case Presentation: An 8 year old boy came to emergency surgical unit with complain of sudden onset inability to pass urine and severe pain in lower abdomen since 12 hours, there was no history of trauma to abdomen and perineum, and haematuria. Clinical examination reveal palpable bladder and impacted urethral meatal stone (Figure 1), child was taken to emergency operation theatre and ventral meatotomy and extraction of stone was done, post operatively urinary catheter was kept for 24 hours. Stone analysis reveal presence of calcium and oxalate.This case highlight a seldomnly seen but still common mechanical cause of sudden onset urinary retention in boys, importance of thorough clinical examination of genitalia, planned surgical procedure to reduce the complication and stone analysis to know and treat any metabolic cause of it.

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.

Double Y glanuloplasty for glanular hypospadias

Purpose A double Y glanuloplasty technique is described for the repair of glanular hypospadias with mobile meatus. Materials Ninety-seven children with glanular hypospadias and mobile meatus were operated on using this technique in the period from January 2003 to January 2009. Mean age of patients was 12 (range, 4-60) months. Results Patients were discharged home within 3 days. The operation resulted in a slit-like meatus. Follow-up ranged from 8 months to 6 years (mean, 45 months). Good cosmetic and functional results were obtained in 94 patients. Complications occurred in 3 patients (3%). Two patients experienced meatal stenosis. This was corrected using ventral meatotomy. One patient suffered from dehiscence of the wound and retraction of the meatus. The meatal retraction was corrected using a modified inverted Y Mathieu technique. Conclusions The double Y glanuloplasty technique is suitable for appropriately selected patients with glanular hypospadias and mobile meatus. It provides a cosmetically natural vertical slit at the tip of the glans.

External urethral stenosis: a latent effect of sulfur mustard two decades post‐exposure

Sulfur mustard (SM), a chemical weapon used widely during World War I and against Iranians during the Iran-Iraq War of the 1980s, causes massive inflammatory tissue damage in the immediate post-exposure period, resulting in debilitating chronic disease in years to decades following contact with the agent. These syndromes most often are pathologies of the lungs, eyes, and skin, the primary target organs of SM. Typically, they are characterized by severe and increasingly painful inflammation, often accompanied by fibrosis and constriction of the anatomic channels needed for normal life, such as the small airways of the lungs and, in the present report, the urethra. The present case study is a 43-year-old man with a history of heavy SM exposure to the groin in 1984. Within 1 year after exposure, the patient was found to have developed meatal stricture, occlusion of the external urethral meatus, and difficulty in urination. Two years post-exposure, he underwent ventral meatotomy and meatoplasty. This case presents a unique example of the latent effects of SM exposure to the groin, and will be of value in the prevention of similar injury and complications to persons at risk of SM exposure in the future.

A Rare Case Of A Giant Urethral Calculus

Introduction: A urinary calculus in the urethra is rarely seen and usually encountered in men with urethral stricture or diverticulum. Herein, we are reporting a rare case of a giant calculus in the anterior urethra of a male patient. Case report: A 39-year-old male presented with acute retention of urine and a hard dull aching mass in the anterior perineum. On examination, a hard mass of 5x4x3cm was palpable in the perineum at the base of the scrotum. X-ray of the pelvis showed a stone in the anterior urethra. Urethrotomy with stone removal was done. The postoperative period was uneventful. Conclusion: A large primary urethral calculus is very rare and may form in the urethra when a urethral stricture or a diverticulum is present. INTRODUCTION Most of the urinary system stones are located in the upper urinary system. They are uncommon in the urethra (1,2,3), usually get formed proximally and get stuck in urethra or may rarely get formed primarily in urethra (2). Urethral calculi represent less than 1% of all urinary stone disease (3). Giant urethral calculi are even rarer. Most urethral calculi migrate from the urinary bladder. Urethral calculi may get formed primarily in the urethra proximal to a urethral stricture or in a diverticulum. The majority of urethral calculi occur in males (4) and urethral calculus is an extremely rare finding in females (1). We describe a case of a giant urethral stone, impacted in the urethra of a 39-year-old male. CASE REPORT A 39-year-old, otherwise healthy male patient presented to the surgical clinic with acute urinary retention. He had also been complaining of a hard mass in the anterior perineum for the past 8 years. The patient had been having onand-off history of burning micturition associated with fever for 6 years. Two episodes of hematurea were noted by the patient in the last 10 months. He was apparently alright 8 years back. There was no history of pelvic trauma in the past. On examination, the urinary bladder was distended up to the level of the umblicus. A hard mass of 5x4x3cm was palpable in the anterior perineal region at the base of the scrotum. It was painless, causing mild discomfort only. General physical examination did not reveal any abnormality. Routine metabolic work-up and the renal function tests were normal. Urine culture did not show any growth. Levels of serum parathyroid hormone and serum calcium were within normal range. Digital rectal examination did not detect any abnormality. Plain X-ray of the pelvis showed a large calculus in the anterior urethra. Plain X-ray and ultrasound scans of the kidney, ureter and bladder area were all normal. A Rare Case Of A Giant Urethral Calculus 2 of 4 Figure 1 Figure 1: Urethrotomy for removal of stone Figure 2 Figure 2: Foley's catheter being passed through the urethra Figure 3 Figure 3: Specimen of stone after removal Urgent surgical removal of the stone was planned because of its large size. Urethro-lithotomy was done. A stone weighing 75g was removed. Chemical analysis of the stone revealed the presence of triple phosphates. DISCUSSION Urethral stones are encountered infrequently in urological practice and the studies published in the literature consist of small series and several case reports. Most of the urinary stones are located in the upper urinary system and urethral calculi as such are uncommon (1%) (1,3). Depending upon their site of origin, urethral stones are classified as (a) primary or autochthonous and (b) secondary or migrating (5,6,7). Secondary stones are more common than primary stones and have migrated from higher up in the urinary tract (5,6,7,8). Urethral calculi are usually small (5,6). Giant urethral calculi are rare. The majority of urethral calculi occur in males (4). Urethral calculi may be completely asymptomatic or may be accompanied by one of the following symptoms: perineal or penile pain, frequency, urgency, diminished urinary stream, dribbling, hematuria or/and urethral discharge due to infection. The patient may present with acute retention of urine with insignificant past history. The diagnosis is based on clinical history and relevant investigations (5,6,7,8). Management of urethral calculi varies according to site and size and associated urethral disease. Retrograde manipulation into the urinary bladder followed by litholapaxy or lithotripsy is a suitable procedure for posterior urethral calculi. Anterior urethral calculi can be treated with instillation of 2% lidocaine jelly or ventral meatotomy according to their localization. Giant urethral calculi should be treated with open surgery. Besides, if the urethra has an associated stricture or has been damaged by prior attempts of extraction, stone removal and urethroplasty are preferable (3). CORRESPONDENCE TO DR. ONKAR SINGH RESIDENT SURGICAL OFFICER DEPARTMENT OF SURGERY M.G.M MEDICAL COLLEGE & M.Y.H GROUPS OF HOSPITALS INDORE, MADHYA PRADESH, INDIA-452001 (CONTACT NO. 91-98937-77321) (Email: dronkarsingh@gmail.com )