Distal urethroplasty for isolated fossa navicularis and meatal strictures

Authors


Joshua J. Meeks, Northwestern University, Feinberg School of Medicine, 675 North St Clair Street, Galter 20-150, Chicago, IL 60611, USA. e-mail: j-meeks@md.northwestern.edu

Abstract

Study Type – Therapy (case series)

Level of Evidence 4

What’s known on the subject? and What does the study add?

Strictures of the distal urethra/fossa navicularis are often difficult to manage and objective and patient reported outcomes have not been described.”

Meatotomy is highly successful in terms of both stricture recurrence and patient satisfaction. Meatoplasty, while often reserved for more complicated and long strictures, has a high rate of success. Men with lichen sclerosus have a higher rate of stricture recurrence with meatal repairs.

OBJECTIVE

• Urethral strictures located in the fossa navicularis are common and are often managed with meatotomy or meatoplasty.

• Few data have described the outcomes for men after urethroplasty or patient satisfaction following these procedures.

METHODS

• In all, 93 men at two different institutions underwent surgical repair of distal urethral stricture disease using meatotomy (73) or meatoplasty (20), with 13/20 (65%) of the latter group undergoing substitution urethroplasty.

• In patients with lichen sclerosus (LS), all involved tissue was excised prior to reconstruction.

• In a subset of men undergoing meatotomy, patient satisfaction was evaluated by questionnaire.

RESULTS

• Average clinical follow-up for men undergoing distal urethroplasty was 61 months.

• Successful reconstruction requiring no further intervention occurred in 84% of men overall. Subgroup analysis revealed success in 87% of men with meatotomy, 75% with meatoplasty and 66% with substitution urethroplasty.

• Men with LS had a significantly greater rate of stricture recurrence (20.5% vs 7.5%, P= 0.04).

• Of the subset of men who completed a patient-based questionnaire 84% reported they were either satisfied or very satisfied with the results of their meatotomy.

CONCLUSIONS

• We report the success of distal urethral stricture management.

• Meatal strictures may be approached successfully in a stepwise manner progressing from meatotomy to meatoplasty for longer recurrent strictures, with a high overall success rate for meatotomy.

• Although substitution grafts may be useful for men with longer distal strictures and those with LS, the risk of recurrence was significantly higher in this cohort.

Abbreviations
FN

fossa navicularis

LS

lichen sclerosus.

INTRODUCTION

Strictures of the fossa navicularis (FN) are common in adult men because of the susceptibility of the distal urethra to lichen sclerosus (LS), infection and instrumentation. In an evaluation of 175 men with urethral stricture disease, 18% were found to have strictures of the FN [1]. Although a relatively common occurrence, the management of distal urethral stricture disease remains unclear. Short (<2 cm) distal urethral strictures may respond initially to dilatation or incision with success rates between 68% and 77%[2]. However, the success rate of simple meatotomy in adult men is unknown and this procedure may be under-utilized.

In patients with recurrent, dense or long FN strictures, meatoplasty by tissue transfer or substitution grafts offers another option in the armamentarium of the reconstructive urologist. If urethroplasty is required, success with local penile skin flaps has been described [3]; however, genital skin flaps may be undesirable in cases of LS where penile skin is scarred and non-pliable. Distal urethroplasty may be beneficial for select patients who desire urethral reconstruction [4]; however, long-term outcomes following meatotomy or substitution meatoplasty with oral graft are lacking. We describe a large cohort of men from two separate institutions undergoing these procedures as well as the results of patient-based satisfaction and quality of life postoperative questionnaires in a subset of these men.

METHODS

In this institutional review board approved study, a total of 91 men underwent 93 procedures. Of these, 61 men underwent treatment in Arezzo, Italy, while 30 were treated in Chicago, IL, USA. Patients were evaluated preoperatively by history, physical examination, retrograde urethrogram and/or cystoscopy and data were recorded prospectively. Patients with a history of failed previous hypospadias repair were excluded. In all cases, the minimal procedure required to treat the diseased segment was performed. The decision to perform a meatotomy compared with meatoplasty was at the discretion of the surgeon and was usually based on the length of stricture and the degree of fibrosis involved. In general, meatotomy was used in patients with meatal or short distal FN strictures. Meatoplasty or substitution urethroplasty was used in men with more extensive, proximal FN stricture disease or previous meatotomy failure.

SURGICAL TECHNIQUE

Meatotomy

A meatotomy was performed when the meatus could not be calibrated to 16 F. The meatus was incised ventrally with excision of glans fibrosis. The mucosal edges of the urethra were then reapproximated to the glans skin with interrupted 4–0 polyglactin 910 sutures (Ethicon, Cincinnati, OH, USA) and calibrated to 24 F.

Meatoplasty

A meatoplasty was classified as a stricture requiring tissue rearrangement. Stricture length was measured in men undergoing substitution urethroplasty, whereas stricture length in men undergoing other forms of meatoplasty was not measured. In patients who required substitution meatoplasty, a circumcising incision was used to deglove the penis. The glans was then sharply incised through the proximal aspect of the urethral stricture to ventrally open the urethra. The urethral scar tissue was excised ventrally in non-LS strictures whereas total excision of the ventral and dorsal aspect of the urethral stricture was completed if LS was suspected. In men with suspected or confirmed LS on pathology, oral mucosa was used as the graft source, whereas patient preference of graft source was used in non-LS cases. Grafts in the non-LS cases were then sutured in a ventral onlay fashion using a 5–0 polyglactin 910 suture. If the dorsal urethral mucosa was removed in LS cases, graft tissue was quilted in the glans bed dorsally followed by ventral onlay of the remaining graft. Glans flaps were developed and used for tension-free coverage and support of the neourethra. A 16 F catheter was left in place for 2 weeks postoperatively in this cohort of men.

POSTOPERATIVE MANAGEMENT

Men were seen at 3 weeks postoperatively and then every 3 months for the first year followed by semi-annual and then annual follow-up. Men were screened for recurrence by subjective voiding symptoms in questionnaire form (often the AUA symptom score), urine culture and ultrasound postvoid residuals. Any increase in voiding difficulty or elevated postvoid residual urine volume resulted in flexible cysto-urethroscopy and calibration with sounds if a stricture recurred. Patients were considered to have a recurrence if they required dilatation or any further procedures.

A subset of men undergoing meatotomy in Arezzo answered a non-validated questionnaire about their procedure. The questionnaire was administered in Italian to 44 men, regardless of success of their procedure, all of whom completed the questionnaire. The survey was completed 6 months after surgery.

RESULTS

Men undergoing urethroplasty were on average 44.2 years of age. The identified causes of strictures were LS (42%), instrumentation (33%), unknown (33%), condyloma (7%), catheter related (4%) and external trauma (2%). Nearly half of patients (42%) had been treated previously (Table 1). Average (median) clinical follow-up for men undergoing urethroplasty was 50 months. The overall success rate of patients at last follow-up was 84% (78/93). Meatotomy was performed in 80% (74/93) of procedures with a success rate of 86% (64/74) (Table 1).

Table 1.  Demographic and procedure information
Mean age44.2
Cause of stricture 
 Trauma (%)2
 Catheter related (%)4
 Condyloma (%)7
 Instrumentation (%)9
 Unknown (%)33
 Lichen sclerosus (%)42
Prior procedure 
 Meatoplasty (%)9
 Urethrotomy (%)11
 Circumcision (%)13
 Meatotomy (%)14
 Dilatation (%)54
 None (%)58
Procedures 
 Meatotomy, n (%)73 (78)
 Meatoplasty, n (%)20 (22)
  De Sy3
  Blandy3
  Barcat1
  Substitution13
 Ventral onlay, penile skin4
 Ventral onlay,oral mucosa9

Meatoplasty was performed in 22% (20/93) including 13 substitution urethroplasty procedures. For men undergoing substitution urethroplasty, mean stricture length was 3.2 cm (range 2–6 cm). Onlay graft sources included oral mucosa 69% (9/13) and penile skin grafts 31% (4/13). The overall success rate of meatoplasty was 75% (15/20) (Table 2). Traditional meatoplasty using flap urethroplasty was highly successful (6/7, 85%) with De Sy (2/3, 66%), Blandy (3/3, 100%) and Barcat (1/1100%) repairs. Oral grafts were successful in 55% (5/9), while all four penile skin grafts were successful. The outcomes of patients with LS were compared with men without LS. Recurrence occurred in 20.5% of LS men, compared with 7.5% of men without LS (P= 0.04).

Table 2.  Outcomes of urethroplasty by surgical technique
OutcomesSuccess rate
Overall79/93 (85%)
Meatotomy64/73 (87%)
Meatoplasty15/20 (75%)
Ventral onlay, oral mucosa5/9 (56%)
Ventral onlay, penile skin4/4 (100%)
Other meatoplasty6/7 (86%)

A proportion of men (44/74, 59%) from the Center for Reconstructive Urethral Surgery in Arezzo who underwent meatotomy completed a postoperative survey regarding their satisfaction with the operation (Table 3). Most (84%) were either satisfied or very satisfied with the results and 82% described their outcomes as good or excellent. All but two (4.5%) reported they would have the operation again if necessary. Of those men that had problems after surgery (15/44, 34%), most reported problems with urinary symptoms including ‘fluttering’ (subjective stuttering intermittency of urine flow caused by distal obstruction or strength of stream) (58.4%), irregular stream (33.3%) or deviation of stream (8.3%).

Table 3.  Patient response to meatotomy procedure
Q1. Are you pleased with the results of surgery? 
 Dissatisfied1 (2.3%)
 A little satisfied6 (13.6%)
 Satisfied15 (34.1%)
 Very satisfied22 (50%)
Q2. How would you evaluate these results? 
 Negative1 (2.3%)
 Fair/passable6 (13.6%)
 Good16 (36.4%)
 Excellent21 (47.7%)
Q2A. If you answered ‘Negative’ or ‘Fair/passable’ to Q2 was it 
 Because my urination problem has not resolved7 (100%)
 Because the operation created problems I didn’t have before0
Q3. Would you have this operation again? 
 Yes42 (95.5%)
 No2 (4.5%)
Q3A. If you answered no to Q3 was it 
 Due to pain 
 Due to psychological problems 
 Because the results were not what I expected2 (100%)
Q4. Would you like to have a second-stage urethroplasty to restore micturition through the apex of the glans? 
 Yes12 (27.3%)
 No32 (72.7%
Q5. Has the meatotomy caused any problems 
 Yes15 (34.1%)
 No29 (65.9%)
Q5A. If you answered ‘Yes’ to Q5 were they 
 Psychological problems1 (6.7%)
 Urination problems12 (80%)
 Sexual activity problems2 (13.3%)
Q5B. If you answered ‘psychological problems’ were they 
 Problems with sexual activity1 (6.7%)
Q5C. If you answered ‘urination problems’ were they 
 Deviation of stream1 (8.3%)
 Irregular stream4 (33.3%)

DISCUSSION

Strictures of the FN are a unique reconstructive challenge [5]. Anatomically, the fossa is surrounded by limited ventral spongiosum, but receives additional support dorsally from the glans. In addition to physiological voiding, the meatus requires considerable cosmetic attention to achieve patient satisfaction. As the gateway to the urinary system, the fossa navicularis is susceptible to inflammatory changes from LS, infection and instrumentation [1]. Men requiring repeated cysto-urethroscopy and transurethral procedures are at a higher risk of developing FN strictures with rates reported as high as 10–20% previously and in 33% of our cases [5]. Despite the aetiology, the spectrum of distal urethral stricture disease can range from limited meatal involvement to extensive disease requiring a tailored approach for each patient based on endoscopic and radiographic staging.

Several procedures using penile skin flaps have been popularized for the management of FN strictures. Jordan [3] described the use of a transverse island skin flap for the management of FN strictures. An updated report from Jordan et al. [6] describing the long-term results of this repair yielded a durable 17% recurrence rate. Similarly Armenakas and McAninch [7] described a modified ventral transverse island fasciocutaneous flap in men with resistant strictures with a recurrence rate of 5.3% with the addition of a glanuloplasty at an average of 43 months of follow-up. Onol et al. [8] describe a correspondingly low recurrence rate using the same repair in men after radical prostatectomy with an average of 30 months of follow-up.

Men with LS have a significantly higher rate of failure following urethroplasty for distal urethral strictures [9]. When men have FN strictures clinically suspicious for LS, it appears that the use of penile skin for reconstruction increases the likelihood of stricture recurrence. Venn and Mundy [9] described a 100% recurrence rate when penile skin flaps were used with LS compared with only a 6% recurrence rate with oral grafts. Importantly, in long-term follow-up using fasciocutaneous flaps for FN strictures, success was only 50% (6/12) in men with LS compared with 100% (23/23) in men without LS [6]. Identification of LS of the penile skin and urethra is becoming more recognized with an incidence rate as high as 10.3% from a cohort of 251 men evaluated in a multicentre study [10]. In our series, the overall rate of recurrence was significantly higher in men with LS (20.5% vs 7.5%, P= 0.04). Although the use of oral mucosa grafts for FN strictures has been included in the outcomes of larger series, this small subgroup is not specifically described and therefore the challenges and outcomes of oral mucosa grafts placed in the FN remain unknown [4]. These tube grafts are generally reserved for very small segments and perhaps would be better approached in multiple stages. Thus, the present series describes the largest cohort of men with substitution urethroplasty of the FN with an overall success rate of 67% (5/8), and 75% (3/4) in men with LS. While encouraging, these results are limited to a small cohort of patients and need to be studied on a larger scale.

The men in the present study represent a difficult cohort to reconstruct, with most having either LS or a history of previous urethroplasty or multiple dilatations. The success rate of oral mucosa grafts in our series was lower than that observed in penile skin grafts. The reason for this may be secondary to the relatively small sample size and underpowered analysis, or the fact that oral mucosa grafts were used in the most difficult procedures involving strictures with increased scar tissue, poor vascularity and the presence of LS. Although substitution urethroplasty is highly valued, some men with complex, recurrent stricture disease may prefer extended meatotomy for relatively shorter strictures or perineal urethrostomy for extended, complex stricture disease [4,11].

Meatal stenosis is also common in men after genitourinary procedures. Yet, to our knowledge our series is the largest to date describing meatotomies in 73 of our 93 procedures (78% of our cohort) treated at two separate institutions. The 87% success rate is comparable to all strictures performed in the last decade [12]. The majority of men who were surveyed (84%) with meatal stenosis reported satisfaction with their meatotomy and 95% would have the procedure again if required. Interestingly, despite the urologist’s fixation with restoring urination to the distal urethra, only 27% of men would elect to undergo a follow-up procedure (such as meatal advancement) to achieve this result. The most bothersome urinary complaints were urinary ‘fluttering’, followed by an irregular stream. Despite genital surgery, only two patients (13.3%) complained of a sexual activity problem after meatotomy and only one patient (6%) complained of psychological problems after meatotomy. To our knowledge, this may be the first patient-reported outcome of meatotomy evaluating the patient’s perception of the penis and the effect of urethroplasty on sexual function. Although this questionnaire has not been validated, it provides useful information for the urologist regarding patient satisfaction, patient expectations and functional outcomes.

Several limitations of the present study deserve mention. First, the study is limited in size and retrospective in nature. Second, the causes of urethral stricture in this series range from iatrogenic to LS. A larger patient population may reveal the suitability of this technique for a specific cause (e.g. LS) if subset analysis could be performed; however, we were compelled to report these data based on the relative dearth of information regarding the use and type of graft for isolated FN strictures. Finally, our questionnaire, while providing informative data, has not been externally validated.

In the majority of men, meatotomy is successful for the management of meatal stenosis. Men requiring meatoplasty, by flap or graft, have a greater chance of stricture recurrence. The use of tissue grafts for repair of urethral stricture disease primarily involving the FN resulted in reasonable overall success including cases of LS; however, men with LS have a higher rate of stricture recurrence. In men with LS, complete excision of involved tissue along with the use of non-genital tissue, namely oral mucosa, should be considered.

CONFLICT OF INTEREST

None declared. Source of funding: J. J. Meeks is an AUA Research Scholar with a grant from the AUA Foundation with contributions from Sanofi-Aventis.

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