ET AL.

STEFFENS ET AL.

Surgery Illustrated – Focus on Details

BJUI

Plastic meatotomy for pure meatal stenosis in patients with lichen sclerosus

BJU INTERNATIONAL

Joachim A. Steffens, Petra Anheuser, Adrian E. Treiyer, Britta Reisch and Peter R. Malone* Department of Urology and Paediatric Urology, St. Antonius-Hospital Eschweiler, Germany and *Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading, UK ILLUSTRATIONS by STEPHAN SPITZER, www.spitzer-illustration.com

INTRODUCTION Treatment of the urethral complications of lichen sclerosus is known to be problematic. Although buccal mucosa grafts or extragenital skin provide the best long-term results for pan-urethral or fossa navicularis strictures [1,2] the surgeon seeking to treat a patient with pure meatal stenosis finds little help from previous reports. The frequent pooling of results from meatal and submeatal strictures, and from children and adults, adds to the difficulty [3,4]. When planning surgery for meatal stenosis, the functional and cosmetic aspects should

568

be considered. An ideal operation should permanently relieve obstruction, while recreating a slit-like meatus at the tip of the glans penis that allows the patient to pass urine without spraying [5]. Several operations have been described, including meatal dilatation, simple ventral meatotomy and various types of distal urethroplasty. However, no procedure fulfils all of these criteria. When the stenosis is severe and particularly if the meatus is ventrally situated, adequate meatotomy creates a hypospadiac appearance of the glans penis, whereas buccal mucosa graft urethroplasty seems

unnecessarily complex for such a minor complaint. An alternative is the plastic meatotomy first described by Malone in 2004 [5], who reported excellent results with a mean followup of almost 4 years. Similar results have also been published by centres in Germany [6] and Spain [7]. This technique, which includes both ventral and dorsal meatotomies, allows a wide opening which is less likely to re-stenose whilst retaining the meatus at the tip of the penis.

© JOURNAL COMPILATION

©

2010 THE AUTHORS

2 0 1 0 B J U I N T E R N A T I O N A L | 1 0 5 , 5 6 8 – 5 7 2 | doi:10.1111/j.1464-410X.2009.09172.x

FOCUS ON DETAILS

Figure 1a A tourniquet is placed at the base of the penis to allow surgery with the clear vision that a bloodless field affords. Stay sutures are placed on either side of the narrowed meatus. Figure 1b,c A small ventral meatotomy allows passage of the forceps to ensure that fossa navicularis is not involved for more than a few millimetres If the navicular fossa is significantly involved by the stricture then consider a buccal mucosa graft urethroplasty.

a

12

b

3

9 6

c

©

2010 THE AUTHORS

JOURNAL COMPILATION

©

2010 BJU INTERNATIONAL

569

STEFFENS ET AL.

Figure 2a A deeper dorsal meatotomy is made to open the narrowed meatus. Figure 2b Epithelia of glans and urethra are again approximated with 6/0 or 7/0 polyglactin sutures. Although this widens the urethral meatus, the cosmetic appearance is poor at this stage due to puckering caused by thickness of glans spongiosus.

12

a 9

Figure 2c

3 6

The puckering is released by an inverted Vshaped relieving incision which is made with the apex of the V close to proximal limit of dorsal meatotomy. The edges are mobilized by sharp dissection, and opposing left and right inner edges are opposed with continuous 6/0 or 7/0 polyglactin.

b

c

570

© JOURNAL COMPILATION

©

2010 THE AUTHORS

2010 BJU INTERNATIONAL

FOCUS ON DETAILS

Figure 3a,b The outer layers of glans epithelium are opposed with interrupted 6/0 polyglactin sutures. Figure 3c The final result is a slit-like but good calibre meatus at the tip of the glans tip. No catheter is necessary.

a

b

c

©

2010 THE AUTHORS

JOURNAL COMPILATION

©

2010 BJU INTERNATIONAL

5 71

STEFFENS ET AL.

SUMMARY The results presented elsewhere show that the technique described is approaching the concept of an ideal operation [5–7]. It is certainly effective in the intermediate term, as there have been no recurrences. It produces a good cosmetic result, with nearly all of the patients pleased or very pleased with the results. Spraying is occasionally a problem after surgery, but is only rarely constant or severe. Attention to the shape of the navicular fossa with a slight narrowing at the tip to avoid a ‘blunderbuss’ urethra might reduce this possibility.

2

3

4 REFERENCES 1

Dubey D, Sehgal A, Srivastava A et al. A buccal mucosal urethroplasty for balanitis

572

xerotica obliterans related urethral strictures. the outcome of 1 and 2-stage techniques. J Urol 2005; 173: 463–6 Levine LA, Strom KH, Lux MM. Buccal mucosa graft urethroplasty for anterior urethral stricture repair. evaluation of the impact of stricture location and lichen sclerosus on surgical outcome. J Urol 2007; 178: 2011–5 Kulkarni S, Barbagli G, Kirpekar D et al. Lichen sclerosus of the male genitalia: surgical options and results in a multicenter international experience with 215 patients. Eur Urol 2009; 55: 945– 54 Pugliese JM, Morey AF, Peterson AC. Lichen sclerosus. review of the literature and current recommendations for management. J Urol 2007; 178: 2268– 76

5

6

7

Malone P. A new technique for meatal stenosis in patients with lichen sclerosus. J Urol 2004; 172: 949–52 Anheuser P, Treiyer AE, Steffens J. Die plastische Meatotomie nach Malone. Eine effiziente Technik zur Therapie der Meatusstenose bei Patienten mit Lichen sclerosus. Urology (Suppl ) 2009; 48: 90 Navalón P, Pallás Y, Juan J et al. La meatoplastia dorsal para el tratamiento de la estenosis de meato en pacientes con balanitis xerótica obliterante. Arch Esp Urol 2007; 60: 1156–60

Correspondence: Joachim A. Steffens, Chairman, Department of Urology and Paediatric Urology, St. Antonius-Hospital, Dechant-Deckers-Str. 8, 52249 Eschweiler, Germany. e-mail: [email protected]

© JOURNAL COMPILATION

©

2010 THE AUTHORS

2010 BJU INTERNATIONAL