What is the surgical approach for a wide external urethral meatus?

Surgical Management of Wide External Urethral Meatus

For wide external urethral meatus, surgical repair using a V-shaped flap technique is the recommended approach, which involves mobilizing dorsal glanular tissue to reconstruct the meatus with proper caliber and positioning at the glans tip.

Evaluation Before Surgery

Before proceeding with surgical correction, the following assessments are essential:

• Determine the etiology of the wide meatus (congenital, post-hypospadias repair, traumatic, or iatrogenic)
• Assess for associated symptoms (urinary spraying, cosmetic concerns, psychological distress)
• Evaluate for concurrent urethral strictures using retrograde urethrography or cystoscopy
• Rule out other urethral pathologies that may affect surgical planning

Surgical Techniques

Primary Approach: V-Shaped Flap Technique

The V-shaped flap technique is the preferred surgical approach for wide external urethral meatus 1:

1. Create a V-shaped flap on the dorsal side of the glans
2. Mobilize bilateral glanular flaps to the ventral side
3. Turn over the flap at the ventral side of the urethral meatus
4. Reposition the urethral meatus to the tip of the glans
5. Cover ventral defects with the dorsal flaps
6. Reconstruct the conical appearance of the glans

This technique has demonstrated excellent outcomes with marked improvement in glans appearance and correction of meatal issues without stenosis 1.

Alternative Techniques

For cases where the V-shaped flap is not appropriate:

• Meatoplasty: For less severe cases, a simple meatoplasty may be performed to narrow the meatus
• Substitution urethroplasty: In complex cases, oral mucosal grafts may be used 2
  • Buccal or lingual mucosal grafts are equivalent alternatives
  • Lingual mucosa may be advantageous for distal urethral and meatal reconstruction due to its thinner nature

Postoperative Care

• Urinary drainage via urethral catheter for 7-10 days
• Regular follow-up with urethrography or cystoscopy to assess healing
• Monitor for complications such as meatal stenosis, which may require subsequent intervention

Potential Complications and Management

1. Meatal stenosis: May require dilation or meatotomy if it occurs 2
2. Urethral fistula: May require secondary repair after adequate healing
3. Cosmetic concerns: May require revision surgery

Special Considerations

• In patients with a history of hypospadias repair, the risk of meatal stenosis is higher, requiring careful planning and potentially staged procedures 3
• Longitudinal neourethral incision may result in functional meatal stenosis with formation of a wide neourethra due to disproportional low resistance of the urethral wall compared to the external meatus 3
• For complex cases or recurrent issues, referral to a urologist with expertise in urethral reconstruction is recommended 2

Follow-up Protocol

• Initial follow-up at 2-4 weeks post-surgery
• Urethrography should be performed every two weeks until complete healing 2
• Long-term follow-up to monitor for late complications such as stricture or recurrence of wide meatus

The surgical approach to wide external urethral meatus should focus on both functional and cosmetic outcomes, with the V-shaped flap technique offering excellent results in most cases. Proper patient selection and meticulous surgical technique are essential for optimal outcomes.