Zoran I Radojicic, Paediatric Urology, University Children's Hospital, Belgrade, Serbia, Yugoslavia. e-mail: email@example.com
To assess the early disclosure and treatment of meatal stenosis after hypospadias repair, using calibration of the neourethral meatus at regular intervals to detect stenosis, and to assess the curative effects of dilatation with topical corticosteroids.
PATIENTS AND METHODS
Between 2001 and 2003, 83 boys (median age 19 months, range 12–28) had a proximal hypospadias repair using a tubularized skin island-flap urethroplasty. The neourethra was calibrated every 7–15 days with newly designed small and fine metal sounds (5–12 F) for 3 months starting 7–10 days after surgery. The patients with meatal stenosis were treated by dilatation using topical 0.05% betamethasone cream daily (twice per day) for 3 months.
The mean (range) follow-up was 29 (12–37) months; 19 patients who developed early stenosis were treated by dilatation with topical steroids. After treatment, 14 neourethras were passable with a minimum sound of 10 F at regular 6–12 months assessments. Stenosis persisted in five patients who did not respond to the treatment; of these, a diverticulum developed in one and a fistula in two. All patients with permanent complications were re-operated. There were no adverse effects in any of the patients treated with topical 0.05% betamethasone cream.
Early calibration and dilatation of the neourethra after hypospadias repair is a useful method for the early disclosure and treatment of meatal stenosis. The newly designed sounds made calibration/dilatation less unpleasant and more acceptable for the patient. Topical corticosteroids improved scar elasticity, which facilitated dilatation and prevented the formation of meatal stenosis.
Complications after urethroplasty in hypospadias repair are well known and fairly common even with the best surgeons. The rate depends on the severity of hypospadias, the choice of the type of operation, and the experience and skill of the surgeon. The most frequent complications are stenosis, fistulae and diverticula. Dilatation is one of the preventive or curative methods of meatal stenosis soon after repair, but the topic remains controversial. Some authors recommend regular calibration/dilatation as an integral part of the technique , while others regard calibration/dilatation as useless or unacceptable [2,3]. Corticosteroids have been used to increase both scar elasticity and retractability of the foreskin in phimosis [4–8], so we hypothesized that it might have positive effects on meatal stenosis after forming a neourethra from preputial skin. Thus we calibrated the neourethral meatus at regular intervals after repair; if there was stenosis we treated it by gradual dilatation with topical corticosteroids, the aim being the early disclosure and treatment of meatal stenosis, and to assess the curative effects of such treatment.
PATIENTS AND METHODS
Between 2000 and 2003, 83 boys had their proximal hypospadias repaired using a tubularized skin preputial island-flap urethroplasty and the ‘glans wings’ technique of glanuloplasty  performed by the same surgeon or under his supervision (S.V.P). The median (range) age of the patients was 19 (12–28) months.
Calibration was started after removing the stent from the neourethra, usually at 7–10 days after surgery, first weekly and later every 15 days, using the smallest sounds (5 F) and later larger sounds from the set were gradually introduced to a maximum of 12 F. The newly designed fine metallic sounds comprised two parts (Fig. 1.), i.e. a narrow working part and a wide handling part. The size and the shape of sounds allowed the easy and atraumatic placement into the child's neourethra. The wide part prevented the sound from sliding too deeply into the bulbar part of the native urethra.
Patients who developed early meatal stenosis were treated by dilatation with topical 0.05% betamethasone cream daily (twice per day) for 3 months. The first dilatation was in the outpatient department but parents were then educated in the further use of the sounds at home. The results were assessed by a medical history and calibration at follow-up visits every 3 months.
The mean (range) follow-up was 29 (12–37); by 15–30 days after surgery 19 patients had developed meatal stenosis and were treated by dilatation with topical steroids. After treatment 14 of the neourethras were passable with a minimum sound of 10 F on regular assessments 6 and 12 months after surgery. Five patients developed late and recalcitrant meatal stenosis, of whom one developed a diverticulum and two a fistula. All patients with such persisting complications were re-operated.
The children were usually afraid of calibration/dilatation, so it was done as gently as possible. With time, both the patients and parents accepted it, and thus some older children used dilatation with the sound by themselves, as confirmed on periodic assessments. There were no adverse systemic or local effects in any of the patients treated with topical corticosteroid cream.
The complication rate of urethroplasty in hypospadias repair is now lower than previously but is still high enough to concern surgeons who operate on this anomaly. Early meatal stenosis is a common complication of hypospadias repair and can be often associated or provoke the formation of other complications, e.g. diverticulum and fistula. The causes of meatal urethral strictures after repair are undoubtedly multifactorial. If excluding versatile techniques (in the present study, one surgeon performed or supervised one technique), and if attention is paid to avoid technical errors (i.e. not putting an extra suture during urethroplasty into the glans, or salvage vascularization of the end of the island flap, etc.), stenosis could be caused or aggravated by individual characteristics of the patient. We presume that these patients can have less elastic scars than others, so that they are prone to develop stenosis after hypospadias repair.
Dilatation or calibration of the neourethral meatus after repair is a controversial topic for distal and proximal hypospadias. There are authors who recommend regular dilatation [1,10], while others consider that dilatation is useless or unacceptable . Arguments for and against dilatation of the neourethra after tubularized incised-plate (TIP) urethroplasty were reported. Lorenzo and Snodgrass  consider dilatation after TIP urethroplasty unnecessary; Elbakry  recommended regular dilatation as an integral part of the TIP technique. In the present study we used calibration and dilatation only for meatal stenosis after flap tubularized urethroplasty, although we use the same procedure after repair for the distal form of hypospadias (an ongoing study).
Calibration is a generally accepted method for assessing the dimensions of the neourethral meatus after repair, or to disclose subclinical forms (obscure obstructions), especially in children who are not toilet-trained. The size of sounds passing through the neourethra depends on the child's age; we used 8 F sounds in 1-year-old children and 10 F in those aged > 1 year.
In previous attempts to make dilatation easier and more effective, we tested different creams (neutral, anaesthetic or with other substances that affect scars) that were then discarded, as either we or others found them to be ineffective. We assumed that corticosteroids might have effects on meatal stenosis after forming the neourethra from the preputial skin, based on knowledge about the effect of corticosteroids on the skin and scars. Corticosteroid therapy is a generally accepted method of cutaneous degeneration and is used to improve skin elasticity and moisturising . The effect of topical corticosteroids on the increased retractability of the scarred ring between the inner and the outer layer of the prepuce in phimosis has been reported [4–8]. The mechanism of action of topical steroids remains largely unknown; the effect is probably due to the inhibition and down-regulation of collagen synthesis . Also, steroids increase the activity of collagenase enzyme, which breaks down collagen so that scars become less thick. The amelioration or cessation of early balanitis xerotica obliterans on the prepuce, and glans and meatal stenosis after steroid therapy, particularly in children, was also reported [13,14]. There are some histological animal studies on healing after urethral surgery and inflammatory reaction on the site of suture that might explain the development of some complications . Therefore, the steroid anti-inflammatory reaction could be useful.
Operative technical errors could be considered as a less likely cause of stenosis, if an adequately sized meatus shows narrowing at later assessments. Regular, gentle and gradual dilatation resolved the stenosis in 14 of 19 of the present patients (so that only five of 83 patients required a re-operation). There were fewer complications than in our previously published results ; thus, even 20% of the patients whose neourethra was not regularly calibrated/dilated developed complications, the most frequent complication being diverticulum due to early stenosis.
We consider that our success in treating neourethral stenosis was a result of the combination of dilatation and corticosteroid effect on scar rigidity. This combination of mechanical traction and steroids on the retraction of preputial scarring in phimosis has a curative effect . Separately, treating the effect of either dilatation or steroids is difficult to assess (in phimosis and in meatal stenosis), because both therapies are applied concurrently. With no prospective double-blind randomized study it is not possible to be certain of the level of success achieved by spontaneous improvement compared with any of the treatments applied separately or combined (steroids and traction/dilatation).
There were no adverse effects in any of the present patients treated with topical corticosteroid cream; as 0.05% betamethasone cream was applied to the meatus of the neourethra using the sound, < 0.1% of the total body area (less than in phimosis) was exposed and thus such effects were very unlikely.
Arguments against dilatation are the pain that the patient experiences and possible injury of the neourethra during dilatation. We are fully aware of the unpleasantness of the procedure of calibration/dilatation; the size and shape of the newly designed sounds minimizes the possibility of urethral injury during the procedure. Despite its unpleasantness, both the patients and their parents accepted the procedure very well. The advantage of early discovery and treatment of urethral stricture over the possible unpleasantness caused by calibration (or dilatation) are obvious.
In conclusion, the present results support the utility of early calibration/dilatation of the neourethra after hypospadias repair, enabling the early disclosure and treatment of meatal stenosis. The new sounds make calibration/dilatation less unpleasant and more acceptable for the patient. Topical corticosteroids improve meatal elasticity, which in turn facilitates calibration/dilatation, and prevents the formation of meatal stenosis.