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British Journal of Plastic Surgery (1984) 37, 117-120

0 1984 The Trustees of British Association of Plastic Surgeons

Meatoplasty for gross urethral stenosis: a technique of


repair and a review of 32 cases
S. PARKASH and V. GAJENDRAN
Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry,

India

Summary-This
paper is a review of the treatment of 32 cases of meatal stenosis arising as a
complication of recurrent balanoposthitis (26 cases) or balanitis xerotica obliterans (six cases). There
was gross scarring of the glans and the terminal urethra resulting in a contracted glans and a pinhole
meatus. These deformities were treated successfully by segmental excision of all the scar on the glans
and resurfacing the raw area with a local preputial or penile skin flap. In two patients a ventral midline flap
was introduced as an island flap. In no case was a ventral slit made as the only definitive treatment of the
meatal stenosis. Two instruments were made specifically to facilitate this type of operation.

Meatal stenosis without any proximal stricture of


the urethra is not an uncommon condition in our
surgical experience and the most common causes
of this lesion are recurrent balanitis and, less often
balanitis xerotica obliterans.
A contributory
factor is poor personal hygiene of the external
genjtalia and perineum (Parkash et al., 1973).
These cases usually demonstrate gross scarring of
the glans with extension into the terminal urethra

resulting in a contracted glans, a pinhole meatus


and occasionally fistulae. The usual technique
recommended for the treatment of meatal stenosis
is to make a ventral slit in the terminal urethra and
follow this by urethral dilatation. Unfortunately
this often produces a splattering stream of urine,
almost certain recurrence of the .stenosis in
addition to an ugly distal hypospadias deformity.
To reduce the incidence of these complications a

Fig. 1
Figure l-Scarred
glans with a pinhole
stenosis with two fistulae.

Fig. 2
meatus.

This was a case of stenosis due to balanitis

117

xerotica

obliterans.

Figure 2-Meatal

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BRITISH JOURNAL OF PLASTIC SURGERY

ventral slit has been combined with a closure of the


resulting defect using a penile skin flap (Cohney,
1963; Blandy and Tressider, 1967; Brennen, 1976).
In our experience a better technique is to carry
out segmental excision of the scar to open out the

acquired openings in the vicinity of the meatus


(Fig. 2). They had a thin stream or an interrupted
thready stream of urine, occasionally ending with
prolonged dribbling in drops. The bladder was
distended in almost all the cases at the time of

Fig. 3

Fig. 4
usting the spring-loaded
. .
r..

contracted and scarred glans and to restore a near


normal shape and size of the meatus. The raw area
is then covered with a local flap of which there are
several options available. A deliberate ventral slit
of the urethra is unnecessary.
Materials and methods
Over a period of 8 years (1973 to 1981), 32 patients
with meatal stenosis were treated in one of the
Surgical Units. They all had a pin point urethral
meatus which was often difficult to identify (Fig.
1). Two of the patients demonstrated ectopic

screw. Figure 4-Combined

examination. The proximal urethra was grossly


dilated and the terminal urethra, including the
meatus, was narrowed and thickened. Of the
patients in this series, 20 had been circumcised and
14 had been treated by a ventral slit only, 4 of them
repeatedly, without relief of symptoms. Serious
damage to renal function in one patient had
necessitated temporary suprapubic diversion.
Histopathological examination of the scar tissue
excised at operation showed evidence of recurrent
balanoposthitis in 26 cases and features of balanitis
xerotica obliterans in 6 cases.

MEATOPLASTY

FOR GROSS

URETHRAL

119

STENOSIS

Technique of meatoplasty
A suitably sized Bowmans lacrimal probe is gently
negotiated through the narrow meatus. This
usually gives enough dilatation to insert a specially
designed combined retractor-and-spreader
(Figs. 3
and 4) though sometimes an initial nick with a
narrow No. 11 scalpel blade is necessary. The
retractor-and-spreader
is then opened out and a
third to one half of the circumference of the
scarred glans around the meatus ventrally and the
adjacent urethral floor is radically excised extending proximally as far as 1 cm. Local injection of
saline-adrenaline (1 : 200,000) into the scar before
excision reduces bleeding. The resulting raw area is
covered by a split-skin graft or by one of the local
flaps listed in the Table below. The flap is sutured
to the margins of the raw area. The ends of the
deep stitches are left long and tied over rubber
tubing. A catheter of a suitable size is now
introduced and fixed in place by the sutures that
were left deliberately long. Stitches are removed on
the tenth day.
Table
Results of the use of free split-skin
local flaps in a series of 32 patients treated
for meatal stenosis
Procedure
Free graft

Number of
patients

grafts and various


by meatoplasty

Success

Failure

(a) Preputial

(b) Lateral

17

17

32

30

Flaps:

(cl

Median

(d) Island
Total

Results

A good pliable meatus was obtained in all the cases


and the urinary stream returned to normal (Fig. 5).
The patients were followed up for varying
periods, 12 of them for 5 years and these all did
well. Two patients had a complete break down of
the flaps and were subsequently treated successfully with a median advancement flap.

Fig. 5
Figure 5-Result
of meatoplasty
3 months after operation:
good stream of urine with no spraying or splattering.

median tongue-shaped penile flap. Our technique


differs from the earlier techniques in that only the
scarred tissue is excised and no ventral slit is made.
The excision must extend into the urethra until the
meatus can be opened out adequately, since the
gross scarring .of the glans includes an extension
into the terminal urethra. Once the scar is excised,
the glans and meatus open out and slitting of the
glans is then unnecessary. The raw area is best
resurfaced with a local flap; free skin grafts are not
recommended. Recently in two of our patients, a
ventral medial island flap was slid into position.
This appeared to be technically more convenient
but our experience is so far limited to only two
cases.

Discussion

Cohney (1963) advocated a ventral slit and covering the area with a lateral penile skin transposition
flap. Blandy and Tressider (1967) later preferred a

Acknowledgement
We wish to thank the South India Surgical Company, Madras,
India, for making the instruments
described in this paper.

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BRITISH JOURNAL OF PLASTIC SURGERY

References
Blandy, J. P. and Tressider, G. C. (1967). Meatoplasty. British
Journal of Urology, 39,633.

Brennen, G. E. (1976). Meatal reconstruction.


Urology, 116, 319.

Journal

of

Cohney, B. C. (1963). A penile flap procedure for relief of


meatal stenosis. British Journal of Urology, 35, 182.
Parkash, S., Jayakumar, S., Subramaniam, K. and Chaudhuri,
S. (1973). Human sub-preputial collection: its nature and
formation. Journal of Urology, HO,21 1.

The Authors
Satya Parkash, FRCS(Eng), Professor of Surgery and Medical
Superintendent,
Jawaharlal
Institute of Postgraduate
Medical Education and Research, Pondicherry, India.
V. Gajendran, MS, Senior Resident, Department of Surgery,
Jawaharlal Institute of Postgraduate Medical Education and
Research, Pondicherry, India.

Requests for reprints to: Dr Satya Parkash, FRCS(Eng),


Professor of Surgery and Medical Superintendent, Jawaharlal
Institute of Postgraduate Medical Education and Research,
Pondicherry 605006, India.