Malone Meatoplasty for Meatal Stenosis

GHWHUPLQDWLRQV ZKLFK ZHUH  “  FF EHIRUH WKH RSHUDWLRQ meatus, particularly if the stenosis was severe, or if the meatus
DQG“FFDIWHUWKHRSHUDWLRQ was already in a ventral position within the gland, this in itself
All the patients answered the satisfaction degree ques- associating with a high recurrence rate[13-16]. On the contrary,
tionnaire which included both functional and aesthetic results dorsal meatotomy provides an increased opening of the meatus
obtained with the procedure. Data are resumed in Table 1. than that performed ventrally, but due to the higher thickness of
They were followed during a mean time of 39.5 months the corpus spongiosum in the dorsal face of the gland, the suture
UDQJH :HQRWLFHGUHFXUUHQFHRIWKHVWHQRVLVLQSD- stitches necessary to oppose the borders give rise to a very an-
WLHQWV  ZKHUHRQHRIWKHPKDGVXUJHU\SHUIRUPHGRQKLP WLDHVWKHWLFDOPHDWXV+RZHYHUWKHUHOD[LQJLQFLVLRQ³LQLQYHUWHG
again and the other one developed a submeatal stenosis 5 years V” we describe allows the creation of a lineal and optimally cos-
DIWHUWKHVXUJHU\+HLVFXUUHQWO\ZDLWLQJIRUDGLVWDOXUHWKURSODV- metic meatus.
W\ZLWKDEXFFDOPXFRVDJUDIWSDWLHQWV  GLGQRWLQIRUP A classic variation of the meatoplasty, described and
RIDGLVSHUVHXULQDU\ÀRZDQGRQO\RIWKHPPDQLIHVWHGKDYLQJ made widely known by Blandy and Tresider[17], consists of a
a disturbance which had an impact on their lives. The other 23 YHQWUDOÀDSKRZHYHUZLWKWKHGLVDGYDQWDJHRIOHDGLQJWRDK\-
patients had a very small dispersion of their micturition and it pospadic meatus, and with this a high tendency of dispersing the
GLGQRWHQWUDLODQ\VLJQL¿FDQWWURXEOHIRUWKHSDWLHQW 7DEOH  ÀRZDOVRDVLWKDSSHQVZLWKDOOORFDOJHQLWDOPHDWRSODVWLHVWKH
ÀDSZLWKWLPHEHFRPHVVXUURXQGHGLQOLFKHQVFOHURVXVDQGLWLV
Discussion the norm for a recurrence to occur[18-20]7KHSRVWHULRUPRGL¿FD-
tion proposed by De Sy[21] can improve the aesthetics, but as the
Multiple techniques were described for urethral steno- approach is also ventral, it becomes a poorly adequate technique
sis treatment related to lichen sclerosus, particularly those using for a ventrally localised meatus.
extragenital skin or buccal mucosa that are thought to correct Another proposed therapeutical method was circum-
lesions extending to the navicular fossa[7] +RZHYHU YHU\ IHZ ferential fotovaporization of the meatus using carbon dioxide
studies referring to the treatment of pure meatus lesions have laser[22], but as all the other procedures above described, it does
been carried out, but even if they represent a less important pa- QRW IXO¿OO WKH ³LGHDO PHDWRSODVW\´ FULWHULD ZKLFK DSDUW IURP
thology because of their small extension, they are still much permanently solving the obstruction, must proportionate a lin-
more frequent. eal meatus in the end of the gland which does not disperse the
Although meatal stenosis related to lichen sclerosus is XULQH ÀRZ$OO RI WKHVH SUHPLVHV DUH DFKLHYHG XVLQJ WKH WHFK-
D OHVV VHYHUH FRQGLWLRQ WKDQ WKLV VDPH SDWKRORJ\ D൵HFWLQJ WKH nique hereby exposed. Actually, we have had a very low recur-
urethra, it does not mean it represents an inferiorly dangerous rence rate, being 96% of patients bereft of recurrence during the
entity, as it can give rise to serious complications such as urinary mean surveillance time of 3.3 years (ranging from 6 months to
infections or chronic urine retention rarely associated to renal \HDUV (TXDOO\DFFRUGLQJWRWKHDHVWKHWLFUHVXOWSUDFWLFDOO\
LQVX൶FHQF\ZKLFKLVZK\PHDWDOVWHQRVLVVKRXOGQRWEHFRQVLG- DOORIRXUSDWLHQWV  ZHUHVDWLV¿HGRUYHU\VDWLV¿HGZLWKWKH
ered as a trivial pathology[8]. achieved cosmetic appearance, including the fact that the dorsal
A sub-meatal urethral stenosis with normal external scar was barely perceptible.
PHDWXV FDQ KDYH GL൵HUHQW DHWKLRORJLHV LQFOXGLQJ LQIHFWLRQ DQG The controversy raised in the literature in regards to
urological instrumentation, especially after a prostate transure- the convenience of performing a postectomy in the case that
thral resection[9]+RZHYHUSXUHPHDWDOVWHQRVLV HYHQZKHQWKH it had not been done previously. Depasquale and cols[12] have
VWHQRVLVLVZLGHHQRXJKWRLQFOXGHWKHQDYLFXODUIRVVD LVPRUH demonstrated that circumcision alone is capable of halting the
frequently observed associated to lichen sclerosus even if it has lichen sclerosus’ progression in 92% of patients. Therefore, even
also been found in circumcised patients because of a previous though we do not consider it compulsory, even in those cases
phimosis no matter if the surgery was performed for religious, where lichen sclerosus is but perimeatal with no clinical signs of
cultural or hygienic reasons[10]. SUHSXFHD൵HFWLRQZHGRDGYLVHLWEHGRQHGXHWRLWVVWDELOL]LQJ
Moreover, the existing literature on the subject pro- H൵HFW RQ OLFKHQ VFOHURVXV WKXV GLPLQLVKLQJ WKH SUREDELOLW\ RI
vides the doctor trying to treat this pathology with a confusing ODWHUD൵HFWLRQRIWKHSUHSXFHGXHWRWKHGLVHDVH[23,24].
selection of therapeutic options because such publications in- On the other hand, it is known that alteration in the mor-
clude patients with pure meatal stenosis, meatal stenosis which phology of the meatus or the navicular fossa is usually translated
extends to the distal urethra, sub-meatal stenosis with a normal LQWRDQHVWDEOLVKPHQWRIXULQDU\ÀRZGLVSHUVLRQVJLYLQJULVHWR
meatus and any type of narrowness whichever may be the aethi- ³VSUD\PLFWXULWLRQ´DVWKHH[LVWHQWHRIDXQLIRUPXULQDU\ÀRZ
ology[11]7KLVLVZK\LQSDWLHQWVVX൵HULQJIURPOLFKHQVFOHURVXV bereft of turbulences, depends on the urethra’s and the meatus’
and presenting a distal urethral stenosis that involves the meatus VKDSH7KHUHE\LWKDVEHHQFRQ¿UPHGLQÀRZG\QDPLFVVWXGLHV
and the navicular fossa, it has been proven that urethroplasty ZKRVH VFLHQWL¿F IXQGDPHQWV ZHUH ¿UVWO\ UHSRUWHG E\ *HR൵UH\
ZLWKEXFFDOPXFRVDJUDIWR൵HUVEHWWHUUHVXOWVWKDQWKHORFDOVNLQ Taylor in the Royal Society in 1960[25], where the change from a
graft technique (a higher recurrence rate has been noticed when F\OLQGULFDOWXEHWRDOLQHDOH[LWVHHPVWREHFUXFLDOIRUWKHÀXLG¶V
XVLQJJHQLWDOVNLQ [12]1HYHUWKHOHVVZKHQVWHQRVLVLVFRQ¿QHGWR FXUUHQW WR EH IUHH IURP WXUEXOHQFHV )LJXUH   &RQVHTXHQWO\
WKHPHDWXVXUHWKURSODVW\LVXVXDOO\QRWMXVWL¿HGLQIDFWPRVWRI it seems to be that all meatoplasty technique which expects to
the time we use less complex techniques even if the results ob- DWWDLQDXQLIRUPXULQDU\ÀRZPXVWDWWHPSWWRFUHDWHDOLQHDOPH-
tained are not as satisfactory as expected. Meatal dilation is then, atus structure. In this way, the majority of our pations present-
related to a high recurrence rate which frequently requires con- HGDGLVSHUVLRQIUHHÀRZDQGZKHQWKHUHZDVÀRZXVXDOO\WKLV
tinuous auto-dilatation to maintain the meatu´s caliber. Equal- was a scarce quantity which minimally disturbed the patient, as
ly so, the ventral meatotomy usually gives rise to a hypospadic shown in Table 1.

Navalón, P., et al. 123 J Anesth Surg | volume 4: issue 2

Malone Meatoplasty for Meatal Stenosis
9. Treiyer, A., Anheuser, P., Reisch, B., et al. Tratamiento de la estre-
chez del meato uretral por balanitis xerótica obliterante: resultados a
ODUJRSOD]RHPSOHDQGRPHDWRSODVWLDGH0DORQH  $FWDV8URO(VS
  
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35.
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W\IRULVRODWHGIRVVDQDYLFXODULVDQGPHDWDOVWULFWXUHV  %-8,QW
  
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URWLFDREOLWHUDQV  %-8,QW  
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H[LWGHVFULEHGE\*HR൵UH\7D\ORULQWKH5R\DO6RFLHW\   .XONDUQL6%DUEDJOL*.LUSHNDU'HWDO/LFKHQVFOHURVXVRI
the male genitalia and urethra: Surgical options and results in a multi-
We believe the procedure described in this article is FHQWHULQWHUQDWLRQDOH[SHULHQFHZLWKSDWLHQWV  (XU8URO
easily reproductible in any urology service, it does not require a 945-956.
complex infrastructure and it ostensibly improves the functional Pubmed | Crossref | Others
and aesthetic results of meatoplasties. )LVWDURO6.,WLQ3+'LDJQRVLVDQGWUHDWPHQWRIOLFKHQVFOHURVXV
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Conclusion 3RZHOO-5REVRQ$&UDQVWRQ'HWDO+LJKLQFLGHQFHRIOLFKHQ
VFOHURVXVLQSDWLHQWVZLWKVTXDPRXVFHOOFDUFLQRPDRIWKHSHQLV  
Dorsal “inverted V” meatoplasty is a technique easily %U-'HUPDWRO  
carried out which is possible to perform under local anaesthesia, Pubmed | Crossref | Others
prevents the appearance of postsurgical hypospadias delivers ex- *XWLpUUH]09LFHQWH)-/ySH]-//LFKHQVFOHURVXVDQGVTXD-
cellent functional and aesthetic results, and has a low recurrence PRXVFHOOFDUFLQRPD  $FWDV'HUPR6L¿OLRJU(QJO(G  
rate, therefore we consider that it must be included in urologists’ 28.
habitual repertoire. Pubmed | Crossref | Others
%ODQG\-37UHVLGGHU*&0HDWRSODVW\  %U-8URO  
633-635.
References Pubmed | Crossref | Others
18. Celis, S., Reed, F., Murphy, F., et al. Balanitis xerotica obliterans in
&DOOHMD(+HUQiQGH]$(0DUKXHQGD&%DODQLWLV[HUyWLFDRE- FKLOGUHQDQGDGROHVFHQWVDOLWHUDWXUHUHYLHZDQGFOLQLFDOVHULHV  
OLWHUDQWHSDWRORJtDLQIUDGLDJQRVWLFDGDGHUHOHYDQFLDFOtQLFD  &LU -3HGLDWU8URO  
Pediatr 28: 133- 136. Pubmed | Crossref | Others
Pubmed | Crossref | Others 1DML+-DZDG($KPHG+$HWDO+LVWRSDWKRORJLFDOH[DPLQD-
-RUGDQ*+0F&DPPRQ.$6XUJHU\RIWKH3HQLVDQG8UHWKUD WLRQRIWKHSUHSXFHDIWHUFLUFXPFLVLRQ,VLWDZDVWHRIUHVRXUFHV"  
 8QLWHG6WDWHVRI$PHULFD(OVHYLHU6DXQGHUV $IU-3DHGLDWU6XUJ  
Pubmed | Crossref | Others Pubmed | Crossref | Others
.|KQ)06FKXOWKHLVV'.UlPHU6FKXOWKHLVV.'HUPDWRORJLFDO 20. Lewis, F.M. Vulval disease from 1800s to the new millennium.
GLVHDVHVRIWKHH[WHUQDOPDOHJHQLWDOLD  8URORJH$    -&XWDQ0HG6XUJ  
842. Pubmed | Crossref | Others
Pubmed | Crossref | Others  'H 6\ :$ $HVWKHWLF UHSDLU RI PHDWDO VWULFWXUH   - 8URO
3XJOLHVH-00RUH\$)3HWHUVRQ$&/LFKHQVFOHURVXV5HYLHZ   
RIWKHOLWHUDWXUHDQGFXUUHQWUHFRPPHQGDWLRQVIRUPDQDJHPHQW   Pubmed | Crossref | Others
-8URO   22. Windahl, T. Is carbon dioxide laser treatment of lichen sclerosus
Pubmed | Crossref | Others H൵HFWLYHLQWKHORQJUXQ"  6FDQG-8URO1HSKURO  
1DYDOyQ33DOOiV<-XDQ-HWDO/DPHDWRSODVWLDGRUVDOSDUDHO Pubmed | Crossref | Others
tratamiento de la estenosis de meato en pacientes con balanitis xerótica )LDOD59UWDO5=HQLVHN-HWDO9HQWUDOSUHSXFLDOÀDSPHDWR-
REOLWHUDQWH  $UFK(VS8URO   SODVW\LQWKHWUHDWPHQWRIGLVWDOXUHWKUDOPDOHVWULFWXUHV  (XURSH-
Pubmed | Crossref | Others DQ8URORJ\  
6. Malone, P. “A new technique for meatal stenosis in patients with Pubmed | Crossref | Others
OLFKHQVFOHURVXV´  -8URO   24. Acimovic, M., Milojevic, B., Milosavljevic, M., et al. Primary dor-
Pubmed | Crossref | Others sal buccal mucosa graft urethroplasty for anterior urethral strictures in
7. Nikolavsky, D., Abouelleil, M., Daneshvar, M. Transurethral ventral SDWLHQWVZLWKOLFKHQVFOHURVXV  ,QW8URO1HSKURO  
buccal mucosa graft inlay urethroplasty for reconstruction of fossa na- Pubmed | Crossref | Others
vicularis and distal urethral strictures: surgical technique and prelimi- 7D\ORU*)RUPDWLRQRIWKLQÀDWVKHHWVRIZDWHU  3URF56RF
QDU\UHVXOWV  ,QW8URO1HSKURO   London 259: 1-17.
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www.ommegaonline.org 124 J Anesth Surg | volume 4 : issue 2