The distal urethra is commonly involved in pediatric urologic surgical interventions. The most frequent indications for distal urethral reconstruction are meatal stenosis and distal hypospadias. Less common indications, such as penile repair after circumcision injury, are beyond the scope of this chapter and are not covered.
Meatotomy
Preoperative Preparation and Planning
Meatal stenosis can be either congenital or acquired. Acquired stenosis typically results after surgery such as circumcision or hypospadias repair. Congenital stenosis may be seen with a flap of glanular tissue on the ventral edge of the meatus, and this obstructing tissue presents with marked upward deflection of the urinary stream. Acquired stenosis can result in a pinpoint meatus that can lead to symptoms of a narrowed, deflected stream or obstructive voiding symptoms.
Of note: Irritative voiding symptoms are rarely caused by meatal stenosis, although the two can coexist. Do not expect a meatotomy to correct a child’s voiding dysfunction.
Application of lidocaine 2.5%/prilocaine 2.5% cream (EMLA) to the glans with a bio-occlusive dressing for 60 minutes allows most meatotomies to be conducted in the office without sedation in cooperative boys.
Patient Positioning and Surgical Incision
For office meatotomy, the child should be positioned supine on the examination table. A large book or tablet on the lap can be used to distract the child’s attention from the procedure.
For repairs under general anesthesia, the child should also be supine. Depending on the anesthesia team, a book or tablet may also be useful for them.
Operative Technique
For office meatotomy, the glans is grasped between two fingers to stabilize the meatus. A straight hemostat or needle rider is used to crush the midline tissue ventral to the meatus ( Fig. 129.1 ). This allows subsequent cutting of the meatus with minimal bleeding. Crush approximately double the desired final size of the meatus because there will inevitably be some degree of healing of the wound edges. The crushed tissue is then cut with fine sharp straight scissors ( Fig. 129.2 ). This is mentioned below.
In refractory cases or when the family wishes to avoid an awake office procedure, a formal meatoplasty in the operating room may be necessary. Although use of the terms “meatotomy” and “meatoplasty” are often somewhat arbitrary, we use the latter to imply a more involved repair under sedation or general anesthesia. After the initial crush and cut, the resulting lateral “dog ears” are then recrushed and trimmed to create a slightly wider, V-shaped ventral defect ( Fig. 129.3 ). Three sutures of 7-0 synthetic monofilament absorbable sutures are then placed in the glans at the 4, 6, and 8 o’clock positions, creating eversion of the mucosa to fix the meatus open and to reduce the odds of restenosis.
Postoperative Care and Complications
The most common complication of meatotomy is restenosis. Immediately after the procedure, the newly enlarged meatus is spread and shown to the parents so that they can perform this maneuver at home to prevent recurrent stenosis. We prefer to use ophthalmic antibiotic ointment for this purpose, inserting the tip of the tube to gently dilate the meatus. The family is taught to gently perform this twice daily for 4 weeks. Alternatively, steroid ointment (betamethasone valerate 0.1%) can be applied.
Bleeding after meatotomy is uncommon and typically results from inadequate crushing or overzealous cutting beyond the crushed margin. Manual pressure is usually sufficient.
Distal Hypospadias Repair
Preoperative Preparation and Planning
The importance of preoperative assessment and planning cannot be overstressed for distal hypospadias repairs. Attention should be drawn to key physical examination findings: the exact location and size of the meatus, the degree of penile curvature, the width of the glans, the width and character of the urethral plate, the presence and character of the foreskin, the thickness of the ventral penile skin, the appearance of the scrotum, and the presence of any other concurrent abnormalities (e.g., if both testes are not in the scrotum, further workup to rule out a disorder of sex development should be undertaken). It is not uncommon for a “distal” hypospadias repair to become a challenging proximal reconstruction in the setting of significant chordee or exceptionally thin ventral skin; adequate preparation (planning instead of preparation) is key.
Hypospadias repair is generally performed between 6 and 12 months of age. An uncomplicated hypospadias repair is an outpatient procedure. Prophylactic antibiotics (e.g., cefazolin) are administered preoperatively; the use of postoperative antibiotics is debatable.
Surgical magnification is crucial. At a minimum, 2.5× surgical loupes (we use 3.5×) are necessary. The use of an operative microscope has been recommended by many pediatric urologists, with reportedly good results.
The success of hypospadias repair is directly related to the skill, experience, and training of the urologist. Experience in mobilizing and rotating tissue flaps is mandatory, and the tissues must be handled with exceptional care. Working knowledge of multiple repair techniques is crucial so that unexpected findings can be dealt with appropriately. No two boys with hypospadias are exactly the same, and the urologist must have a full toolbox to provide each patient the best chance of a successful outcome.
Patient Positioning and Surgical Incision
Positioning
The patient is typically placed in the supine position.
Selection of the Operative Technique
Several procedures are available for the repair of hypospadias; the initial incision will depend heavily on the chosen repair technique. Currently, the most common technique is the tubularized incised plate (TIP) urethroplasty. As noted earlier, however, there are several procedures available for the repair of hypospadias depending on penile anatomy and surgeon experience. The most common of these is the TIP, but we routinely use other procedures as indicated by variations in penile anatomy; these include but are not limited to the Thiersch-Duplay (without urethral plate incision), Meatal Advancement Glansplasty Incorporated (MAGPI), Glans Approximation (GAP), and Mathieu (flip-flap) repairs. Inlay, onlay, or two-stage repairs are rarely needed for distal hypospadias repairs. If the family or patient desires, the foreskin can also be preserved if sufficient tissue is present. For the purposes of this chapter, we will primarily focus on the standard TIP and Thiersch-Duplay repairs.
Preoperative Analgesia
To reduce the amount of general anesthesia, a local or regional block should be used. Preoperative caudal nerve block is the standard for local anesthesia at most centers. However, recent reports suggest that there may be an association between caudal block and urethrocutaneous fistula after hypospadias surgery. At the beginning of the surgery, we therefore use a 22-gauge needle to place a penile nerve block with 3 to 4 mL of 0.2% ropivacaine in the midline just deep to the notch of the symphysis. Draw back the syringe before injection to ensure that the local anesthetic is not injected intravascularly.
Operative Technique
Distal Tubularized Incised Plate Repair ( Fig. 129.4 )
A holding suture of a 4-0 monofilament suture is placed through the glans to provide retraction during the case. An 8-Fr sound is then gently placed within the urethra to help gauge the thickness and quality of the ventral urethra and skin. The initial incisions are then marked out based on these findings.
