What surgical options are available for a child with a wide external urethral meatus?

Surgical Options for a Child with Wide External Urethral Meatus

For a child with a wide external urethral meatus, meatoplasty according to the Heineke-Mikulicz principle followed by a Thiersch-Duplay procedure (also known as the distal urethroplasty and glanuloplasty procedure or DUG) is the recommended surgical approach.

Assessment and Diagnosis

Before considering surgical intervention, proper evaluation is essential:

• Assess for associated symptoms such as:

  • Urinary stream abnormalities
  • Recurrent urinary tract infections
  • Voiding dysfunction
  • Incomplete bladder emptying

• Evaluate for potential underlying conditions:

  • Lichen sclerosus (LS)
  • Prior hypospadias repair complications
  • Congenital anomalies

Surgical Options

Primary Surgical Approaches

1. Distal Urethroplasty and Glanuloplasty (DUG) Procedure

   • Involves a vertical incision in the 12 o'clock direction with the margin of the external urethral meatus as the center
   • Followed by Thiersch-Duplay procedure to reconstruct the urethra
   • Highly effective for glanular/subcoronal hypospadias with wide meatus 1
   • Achieves slit-like shape of external urethral meatus in most cases

2. Meatoplasty

   • For isolated meatal issues
   • Can be performed as ventral meatotomy or dorsal V-meatoplasty
   • Particularly useful for meatal stenosis 2

3. Meatal Advancement

   • For glandular abnormalities requiring correction
   • Aims to position the meatus at the tip of the glans, which is the anatomically correct position 3

Special Considerations

• For children with lichen sclerosus (LS):

  • Medical management with topical treatments should be attempted first
  • Surgical treatment may be needed in cases of disease progression despite medical management 2
  • All tissue removed during procedures should be sent for pathological review to rule out LS

• For recurrent urinary tract infections:

  • External urethral meatus incision has shown effectiveness in reducing UTIs, especially febrile ones 4
  • Particularly beneficial in girls with anterior deflected urinary stream and detrusor overactivity

Postoperative Care

• Urinary drainage is essential after surgical repair:

  • In adults, urethral catheter without suprapubic catheter is recommended 2
  • For pediatric patients, suprapubic cystostomy may be preferred 2

• Follow-up should include:

  • Assessment of wound healing
  • Evaluation of urinary stream
  • Monitoring for complications such as meatal stenosis or regression

Potential Complications

• Meatal stenosis or regression
• Urethral stricture formation
• Saccular dilatation of the neourethra 5
• Altered urinary flow dynamics
• Recurrent infections

Pitfalls to Avoid

1. Overly aggressive surgical correction in cases with long hypoplastic urethra extending to the distal penile shaft 1

2. Inadequate follow-up - Regular assessment is needed to detect early complications

3. Failure to send tissue for pathological review - All tissue removed during procedures in children should be examined to rule out conditions like lichen sclerosus 2

4. Inappropriate patient selection - Not all meatal variations require surgical correction; type B meatal position (middle third of glans) may be acceptable without intervention 3

The normal anatomical location of the urethral meatus should be at the tip of the glans in males. Studies have shown that in 94% of boys, the meatus is located at the tip of the glans 3. Therefore, surgical correction should aim to achieve this anatomical position when intervention is warranted.