What is the modern technique for adult male meatoplasty?

Modern Techniques for Adult Male Meatoplasty

The modern approach to adult male meatoplasty includes ventral meatotomy or dorsal V-meatoplasty, with interposition techniques recommended to prevent restenosis, particularly in cases of lichen sclerosus. 1

Indications for Meatoplasty

• Meatal stenosis in adult males
• Distal urethral stricture disease
• Lichen sclerosus (LS) affecting the meatus
• Failed previous endoscopic treatments

Surgical Techniques

1. Ventral Meatotomy vs. Dorsal V-Meatoplasty

For simple meatal stenosis, two primary approaches are used:

• Ventral Meatotomy: Simple incision of the ventral aspect of the meatus
• Dorsal V-Meatoplasty: More complex technique that avoids creating a hypospadiac meatus

The choice depends on the severity and etiology of the stenosis, with dorsal approaches preferred for lichen sclerosus to avoid recurrence 1, 2.

2. Malone Technique

This technique has shown excellent long-term results for treating meatal stenosis due to lichen sclerosus:

• Small ventral incision of the urethral meatus
• Extensive dorsal meatotomy
• Inverted V-shaped relieving incision to correct esthetic defect
• Avoids creating a hypospadiac meatus
• 85.7% patient satisfaction with functional results
• 83.3% satisfaction with cosmetic results
• No recurrences reported in follow-up 3

3. Preputial Island Flap Technique

For more complex cases requiring tissue transfer:

• Meatotomy is performed
• Preputial island flap raised on dorsal surface of penis
• Flap brought to ventral surface
• Anastomosed to opened fossa navicularis
• Excellent cosmetic results with preserved penile function 4

4. Jordan Flap Meatoplasty

Particularly useful for combined meatal and distal urethral strictures:

• Uses ventral prepucial flap
• High success rate with no recurrences in follow-up
• Excellent patient satisfaction with cosmetic results
• Consistent urinary flow without spray 5

5. Tailored Sutureless Meatoplasty

A newer technique that offers advantages:

• No sutures required to evert the mucosa
• Comparable efficacy to standard meatoplasty with mucosal advancement
• Significant improvement in maximum flow rate (Qmax)
• More efficient and cost-effective
• No reported complications or recurrences 6

Special Considerations for Lichen Sclerosus

For meatal stenosis due to lichen sclerosus:

• Extended meatoplasty (EM) with creation of a hypospadiac meatus may be necessary
• Success rate of 87% reported in complex or reoperative strictures 1
• Dorsal approaches preferred over ventral to reduce recurrence risk
• Avoid using genital skin for reconstruction due to high failure rates (90%)
• Consider non-genital skin or tissue grafts (buccal mucosa) for reconstruction 1

Postoperative Care

• Urethral catheter may be safely removed within 72 hours following the procedure 1
• Regular follow-up with uroflowmetry to assess for recurrence
• In cases of lichen sclerosus, continued topical steroid treatment may be necessary alongside surgical management 1

Pitfalls and Caveats

• Recurrence is common when residual moist skin folds are left, particularly in obese patients 1
• Genital skin should not be used for reconstruction in lichen sclerosus cases due to high failure rates 1
• Koebnerization (development of lesions at sites of trauma) may occur in the surgical site in patients with lichen sclerosus 1
• Repeated endoscopic treatments may cause longer strictures and increase complexity of subsequent urethroplasty 7

For cases requiring visual reference, the guideline by Morey et al. includes photographs of completed extended meatoplasty in patients with distal urethral lichen sclerosus stricture disease (Figure 9) 1.