Definition:
the meatoplasty is the surgery whose purpose is the reconstruction of the glandular urethra and the external urethral meatus.
Indications:
it is a procedure aimed at the final solution of a stenosis of the glandular urethra, rather than having to periodically dilate it.
Description of the technique:
the intervention can be carried out with different techniques, which basically group in “simple” and “complex”, consisting in single time or in two surgical times, with or without the use of grafts (skin or mucosa) or preputial flaps. In the latter case circumcision is often required.
Among the meatoplasty types with the use of flaps a further distinction should be made between a free-flap meatoplasty and a pedicled flap meatoplasty. The first provides, after the longitudinal incision of the ventral side of the glans, from the external urethral meatus to the balanic furrow, the use of a free skin flap, usually taken from the foreskin, which is prepared and perforated on the epidermis surface, then suturing the margins to those of the urethral mucosa exposed with the incision. The spongy tissue of the glans is eventually sutured above the flap, which will have the epidermal surface facing outward the urethral walls. This will have a tutor, represented by a 12 Ch fluted Foley catheter, which will be removed after 7 days.
Indications:
stenosis of a navicular urethra covered by the glans, whose spongy tissue then guarantees the nutritive support to the flap.
Instead, the pedicled flap meatoplasty consists, after the longitudinal incision of the ventral side of the glans, from the external urethral meatus to the balanic furrow and eventually beyond, of the use of a cutaneous flap (preputial or penile) with lateral vascular pedicle, which is completely mobilized and subsequently sutured at the mucous edges of the urethra, with the epidermal face facing outward the urethral walls. Great care must be taken in the preparation of the flap, to avoid possible edema and blood collection. Once the foreskin has been rebuilt and / or the margins of the penile skin are brought together, the spongy tissue of the glans is sutured above the transplanted skin flap; a fluted Foley catheter is left to stand for 7 days.
Indications: stenosis of the navicular urethra possibly extended also to the penile urethra, especially in cases in which it is essential to prevent urethral fistula of ischemic nature (see Balanitis Xerotica Obliterans).
Preparation for intervention:
antibiotic prophylaxis.
Duration of intervention:
from 30 to 60 minutes.
Type of anesthesia:
peripheral or, in special cases, also local by infiltration at the base of the penis.
Type and duration of hospitalization:
during the operation a bladder catheter is applied which will be removed after 1 or 15 days depending on the type of surgical technique used. Although it can also be proposed in Day-Surgery, the need to follow in the early days the “vitality” of the pedunculated limb can induce to hold the patient for two or three days.
Complications:
possible, after surgery, a rotation of the penis in a flaccid state towards the side from which the cutaneous flap was taken: it will improve with the resumption of sexual activity. Within a few days, the appearance of urethral-cutaneous fistulas or complete ischemia of the used flap may occur, with the result, if the suture of the spongy body of the glans also cedes, in a picture comparable to a balanic hypospadias.
Other possible complications:
- Hematoma and penile edema: resolves spontaneously over a few days.
- Dehiscence of the wound: it heals by second intention.
- Penile scar: correction plastic may be needed.
- Stenosis of the urethral neomeate: surgical repair is used.
Attention at discharge:
guarantee the patency of the catheter for 7-8 days that the same remains in place; remove the urethral secretions that accumulate on the urethral new meatus; avoid the decubitus of the catheter on the ventral suture line, keeping the penis lying on the hypogastric region and the catheter fixed to it with a plaster. Avoid sexual activity for about 30 days after surgery.
How to behave in case of complications arising after discharge:
contact the urologist for any eventuality.
Results:
it is an intervention with a high percentage of success, where it is possible to adequately prepare a well-vascularized flap. In case of flap the vascular support offered by the spongy tissue of the glans becomes fundamental.
Advantages:
unlike meatotomy alone, it is possible to guarantee a better aesthetic and functional result.
Disadvantages:
no one compared to the alternative of meatotomy alone.
Checks:
outpatient evaluation at 7 and 15 days from the intervention; subsequent periodic re-evaluations to verify the patency of the urethral lumen and the absence of urethrocutaneous fistulas.