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Analysis of Meatal Location in 500 Men: Wide Variation Questions Need for Meatal Advancement in All Pediatric Anterior Hypospadias Cases
Qo22-5347/95/1542-0833$03.00/0 %E JOURNAL OF UROLOGY fipyright 0 1995 by h E R l C A V UROLOGICAL ASSOCIATION, INC
Vol. 154,833-834. A w t 1995 Princed in U S A
ANALYSIS OF MEATAL LOCATION IN 500 MEN: WIDE VARIATION QUESTIONS NEED FOR MEATAL, ADVANCEMENT IN ALL PEDIATRIC ANTERIOR HYPOSPADIAS CASES JAN FICHTNER,* D. FILIPAS, A.M. MOTTRIE, G.E. VOGES
AND
R. HOHENFELLNER
From the Department of Urology, Maim University Medical School, Maim, Gennany
ABSTRACT
The high incidence (70%) of anterior hypospadias, mostly without penile curvature, in our pediatric hypospadias patients led us to study the meatal location in normal men to investigate if meatal advancement in all patients with anterior hypospadias can be justified when the wide variation of meatal locations in normal men is considered. The location of the external meatus was analyzed in 500 men (mean age 57 years) with classification of the meatal position in relation to the tip of the glans and corona. Quality of erections and sexual intercourse, presence or absence of penile curvature, urinary stream and ability to void in a standing position were assessed in an interview. Of the 500 men only 275 (55%)were normal with the meatus in the distal third of the glans, while 65 (13%) had anterior hypospadias (glanular in 49,coronal in 15 and subcoronal in 1).In 160 men (32%) the urethral meatus was located in the mid third of the glans. Analyzing coronal and subcoronal hypospadias further, all but 6 patients were not aware of any penile anomaly, all but 1 homosexual patient have fathered children and only 1 had penile curvature (subcoronal hypospadias). However, all patients participated in sexual intercourse without problems and were able to void in a standing position with a single stream. In our study of 500 %ormal’’ men the meatal location varied widely with only 55% of all meatus at the tip of the glans and significant hypospadias in patients without complaints about cosmetic or functional as-. We believe that these observations might question the need for meatal advancement in cases of anterior hypospadias without associated penile curvature. Kcl WORDS: penis, hypospadias
a high precision caliper ruler with 111111. intersections. The quality of erections and sexual intercourse, presence or absence of penile curvature, urinary stream and ability to void in a standing position were assessed in an interview.
Current surgical techniques for the correction of hypospadias share the objects of constructing a straight penis and positioning the meatus as close as possible to the so-called “normal site.”’ The normal site in this context is usually regarded as the position a t the tip of the glans and all widely used techniaues, such as meatal advancement and danuloplasty2 and h e Mathieu procedure3 as well as the transverse preputial island flap (onlay or tube),* try to achieve this meatal position. However, it remains unclear whether the tip of the glans truly is the normal site. Therefore, we analyzed the meatal location in 500 unselected men. This question is crucial because approximately 65 to 70% of all hypospadias cases are anterior1 with little, if any, associated functional deficit. A major part of complications in the repair of more posterior hypospadias results from the final glans plasty or glans channeling in the attempt to achieve a meatal tip of the glans position.
RESULTS
Of the 500 men in whom meatal location was investigated 275 (55%) were “normal” with the urethral meatus in the distal third of the glans, 160 (32%)had the meatus in the mid third of the glans and 65 (13%) had anterior hypospadias, including 49 glanular (75%), 15 coronal (23%) and 1 subcoronal(2%).Interestingly, 10 of the 16 patients with coronal and subcoronal hypospadias as well as their sexual partners were not aware of any penile deformity and, thus, only 37% had noticed an abnormality. Of these 16 patients all except 1 homosexual patient have fathered children and only 1 had penile curvature (subcoronal hypospadias). All 16 patients
MATERIALS AND METHODS
The position of the external meatus was analyzed in 500 men (age 38 to 75 years, mean 57)admitted to our hospital between November 1993 and September 1994 for transurethral treatment of benign prostatic hyperplasia and superficial bladder cancer without any previous surgery to the penis. The exact location of the meatus in relation to the tip of the glans and corona was assessed. The distance from the corona to the tip of the glans was measured in each patient and the location of the meatus was classified as A (anterior thirdkip of the glans), B (mid third) or C (posterior third near the corona) in relation to the total corona tip of the glans distance (see figure). All measurements were performed with
* Re uests for reprints: Department of Urology, Maim University Medic3 School, Langenbeckstr. 1,56131, Mainz. Germany.
Type A: anterior third TypeB: mid third Type C: posterior third
of distance between corona and tip of the glans
Classification of meatal loeation in relation to tip of slam and corona. 833
834
MEATAL LOCATION IN 500 MEN
with coronal and subcoronal hypospadias reported sexual intercourse without problems and were able to void in a standing position with a straight, single and not downward deflected stream. These findings were also true for the remaining 49 patients with glanular hypospadias in whom meatal location was classified as position C with a meatus only somewhat distal to the corona (average 3 mm.). Thus, there was a 13% incidence of glanular, coronal and subcoronal hypospadias (65 of 500 patients), while only 55% (275) had the urethral meatus in the distal third of the glans. Glans fusion proximal to the meatus was noted in all cases classified as A or B meatal position, as opposed to the remaining 65 patients with anterior hypospadias in whom there was no glana fusion. DISCUSSION
In a prospective study of 500 men we demonstrated that the meatal location has a signiscant variation in socalled "normal adults" with only 55%having the meatus truly at the tip of the glans and an observed 13% with anterior hypospadias (subcoronal, coronal or glanular) without asciated functional comdaints. This observation seems to auestion the need for meatal advancement in all cases of i c r i o r hypospadias since functional deficits are only rarely encountered in this condition. Thus, an operation designed only for improved cogmesis becomes questionable when 45% of our investigated adult patients do not have the meatus at the tip of the glans, which is the desired location in all current surgical techniques for hypospadias repair. Since 63% of our adult hypospadias patients are unaware of any penile anomaly and they have a normal sexual history, reproductive function and ability to void in the standing position with a single stream, the object of moving the meatus to the tip of the glans is further questioned. With newer surgical techniques for hypospadias repair developed during the last 2 decades an effort has been made to move the meatus to the tip of the glans in all cases, as opposed to older 2-stage techniques in which the neomeatus was left at the level of the corona.5 However, these newer, mostly 1-stage techniques for the repair of more severe hypospadias (other than anterior) have a significant complication rate, which is in part directly related to extensive disSection of the glans. Mobilization of the glans wings and positioning of the neomeatus to the tip of the glans possibly result in meatal stenosis and subsequent fistula formation, which might be reduced by leaving the neomeatus at the level of the corona. Because our adult patients with anterior hvpospadias were able to void in astanding position with-a
forward directed, single stream, the "stream" indication for moving the meatus to the tip of the glans seems to be questionable. We have similarly observed that children with more severe repaired hypospadias in whom the neomeatus was left at the level of the corona were also able to void standing with a straight stream. Pediatric urologists should be aware of the observed "normal distribution" of meatal positions in men since the aim of reconstructive surgery should be to restore the individual to normal. However, pure esthetic surgery would try to surpass the normal. It appears from our study that this is the case in many patients with hypospadias in whom the surgeon attempts to place the meatus in a position where it would not be found in 45% of so-called normal men. Thus, in obtaining informed consent parents have to be thoroughly informed about the o h n pure cosmetic indication in anterior hypospadias without associated functional deficits. To our knowledge an analysis of the precise metal location in normal adults has not been reported previously. Thus, our study creates a standard of the "normal distribution" to which our surgical goals in reconstructive surgery of hypospadias should be related. Our data have led us to narrow our indication for meatal advancement in children with anterior hypospadias. In reconstructive surgery of more severe hypospadias using a DreDutial island onlav flaD or buccal mucosa ohlay6 we do-noi Gist on advanchithe meatus beyond the corona in all instances when it is not easily feasible. This strategy may reduce complications associated with glans plasty and meatal advancement without impairing functional and cosmetic results. REFERENCES
1. Duckett, J. W.:Hypospadias. In: Campbell's Urology, 6th ed. Editad by P. C. Walsh. A. B. htik, T. A. Stamey and E. D. Vaughan, Jr. Philadelphia:W. B. Saunders Co., vol. 2, chapt. 50, pp. 1893-1919,1992. 2. Duckett, J. W.: MAGPI (meatoplasty and glanuloplasty):a procedure for subcoronal hypospadias. Urol. Clin. N. h e r . , 8: 513,1981. 3. Mathieu, P.:Traitement en un temps de I'hypospadiasbalanique et juxtabalanique.J. Chir., 3 9 481, 1932. 4. Duckett, J. W., Jr.: Transverse preputial island flap technique for repair of severe hypospadias.Urol. Clin. N. h e r . , 1: 423, 1980. 5. Browne, D.: An operation for hypospadias.Lancet, 1: 141, 1936. 6. Biirger, R.A, Miiller, S. C., El-Damanhoury,H., Tschakaloff, A, Riedmiller,H. and Hohenfellner,R.: The buccal mucosal graft for urethral reconstruction:a oreliminarv .reoort. , . J. Urol.. 141: 662, 1992.
Vol. 154,833-834. A w t 1995 Princed in U S A
ANALYSIS OF MEATAL LOCATION IN 500 MEN: WIDE VARIATION QUESTIONS NEED FOR MEATAL, ADVANCEMENT IN ALL PEDIATRIC ANTERIOR HYPOSPADIAS CASES JAN FICHTNER,* D. FILIPAS, A.M. MOTTRIE, G.E. VOGES
AND
R. HOHENFELLNER
From the Department of Urology, Maim University Medical School, Maim, Gennany
ABSTRACT
The high incidence (70%) of anterior hypospadias, mostly without penile curvature, in our pediatric hypospadias patients led us to study the meatal location in normal men to investigate if meatal advancement in all patients with anterior hypospadias can be justified when the wide variation of meatal locations in normal men is considered. The location of the external meatus was analyzed in 500 men (mean age 57 years) with classification of the meatal position in relation to the tip of the glans and corona. Quality of erections and sexual intercourse, presence or absence of penile curvature, urinary stream and ability to void in a standing position were assessed in an interview. Of the 500 men only 275 (55%)were normal with the meatus in the distal third of the glans, while 65 (13%) had anterior hypospadias (glanular in 49,coronal in 15 and subcoronal in 1).In 160 men (32%) the urethral meatus was located in the mid third of the glans. Analyzing coronal and subcoronal hypospadias further, all but 6 patients were not aware of any penile anomaly, all but 1 homosexual patient have fathered children and only 1 had penile curvature (subcoronal hypospadias). However, all patients participated in sexual intercourse without problems and were able to void in a standing position with a single stream. In our study of 500 %ormal’’ men the meatal location varied widely with only 55% of all meatus at the tip of the glans and significant hypospadias in patients without complaints about cosmetic or functional as-. We believe that these observations might question the need for meatal advancement in cases of anterior hypospadias without associated penile curvature. Kcl WORDS: penis, hypospadias
a high precision caliper ruler with 111111. intersections. The quality of erections and sexual intercourse, presence or absence of penile curvature, urinary stream and ability to void in a standing position were assessed in an interview.
Current surgical techniques for the correction of hypospadias share the objects of constructing a straight penis and positioning the meatus as close as possible to the so-called “normal site.”’ The normal site in this context is usually regarded as the position a t the tip of the glans and all widely used techniaues, such as meatal advancement and danuloplasty2 and h e Mathieu procedure3 as well as the transverse preputial island flap (onlay or tube),* try to achieve this meatal position. However, it remains unclear whether the tip of the glans truly is the normal site. Therefore, we analyzed the meatal location in 500 unselected men. This question is crucial because approximately 65 to 70% of all hypospadias cases are anterior1 with little, if any, associated functional deficit. A major part of complications in the repair of more posterior hypospadias results from the final glans plasty or glans channeling in the attempt to achieve a meatal tip of the glans position.
RESULTS
Of the 500 men in whom meatal location was investigated 275 (55%) were “normal” with the urethral meatus in the distal third of the glans, 160 (32%)had the meatus in the mid third of the glans and 65 (13%) had anterior hypospadias, including 49 glanular (75%), 15 coronal (23%) and 1 subcoronal(2%).Interestingly, 10 of the 16 patients with coronal and subcoronal hypospadias as well as their sexual partners were not aware of any penile deformity and, thus, only 37% had noticed an abnormality. Of these 16 patients all except 1 homosexual patient have fathered children and only 1 had penile curvature (subcoronal hypospadias). All 16 patients
MATERIALS AND METHODS
The position of the external meatus was analyzed in 500 men (age 38 to 75 years, mean 57)admitted to our hospital between November 1993 and September 1994 for transurethral treatment of benign prostatic hyperplasia and superficial bladder cancer without any previous surgery to the penis. The exact location of the meatus in relation to the tip of the glans and corona was assessed. The distance from the corona to the tip of the glans was measured in each patient and the location of the meatus was classified as A (anterior thirdkip of the glans), B (mid third) or C (posterior third near the corona) in relation to the total corona tip of the glans distance (see figure). All measurements were performed with
* Re uests for reprints: Department of Urology, Maim University Medic3 School, Langenbeckstr. 1,56131, Mainz. Germany.
Type A: anterior third TypeB: mid third Type C: posterior third
of distance between corona and tip of the glans
Classification of meatal loeation in relation to tip of slam and corona. 833
834
MEATAL LOCATION IN 500 MEN
with coronal and subcoronal hypospadias reported sexual intercourse without problems and were able to void in a standing position with a straight, single and not downward deflected stream. These findings were also true for the remaining 49 patients with glanular hypospadias in whom meatal location was classified as position C with a meatus only somewhat distal to the corona (average 3 mm.). Thus, there was a 13% incidence of glanular, coronal and subcoronal hypospadias (65 of 500 patients), while only 55% (275) had the urethral meatus in the distal third of the glans. Glans fusion proximal to the meatus was noted in all cases classified as A or B meatal position, as opposed to the remaining 65 patients with anterior hypospadias in whom there was no glana fusion. DISCUSSION
In a prospective study of 500 men we demonstrated that the meatal location has a signiscant variation in socalled "normal adults" with only 55%having the meatus truly at the tip of the glans and an observed 13% with anterior hypospadias (subcoronal, coronal or glanular) without asciated functional comdaints. This observation seems to auestion the need for meatal advancement in all cases of i c r i o r hypospadias since functional deficits are only rarely encountered in this condition. Thus, an operation designed only for improved cogmesis becomes questionable when 45% of our investigated adult patients do not have the meatus at the tip of the glans, which is the desired location in all current surgical techniques for hypospadias repair. Since 63% of our adult hypospadias patients are unaware of any penile anomaly and they have a normal sexual history, reproductive function and ability to void in the standing position with a single stream, the object of moving the meatus to the tip of the glans is further questioned. With newer surgical techniques for hypospadias repair developed during the last 2 decades an effort has been made to move the meatus to the tip of the glans in all cases, as opposed to older 2-stage techniques in which the neomeatus was left at the level of the corona.5 However, these newer, mostly 1-stage techniques for the repair of more severe hypospadias (other than anterior) have a significant complication rate, which is in part directly related to extensive disSection of the glans. Mobilization of the glans wings and positioning of the neomeatus to the tip of the glans possibly result in meatal stenosis and subsequent fistula formation, which might be reduced by leaving the neomeatus at the level of the corona. Because our adult patients with anterior hvpospadias were able to void in astanding position with-a
forward directed, single stream, the "stream" indication for moving the meatus to the tip of the glans seems to be questionable. We have similarly observed that children with more severe repaired hypospadias in whom the neomeatus was left at the level of the corona were also able to void standing with a straight stream. Pediatric urologists should be aware of the observed "normal distribution" of meatal positions in men since the aim of reconstructive surgery should be to restore the individual to normal. However, pure esthetic surgery would try to surpass the normal. It appears from our study that this is the case in many patients with hypospadias in whom the surgeon attempts to place the meatus in a position where it would not be found in 45% of so-called normal men. Thus, in obtaining informed consent parents have to be thoroughly informed about the o h n pure cosmetic indication in anterior hypospadias without associated functional deficits. To our knowledge an analysis of the precise metal location in normal adults has not been reported previously. Thus, our study creates a standard of the "normal distribution" to which our surgical goals in reconstructive surgery of hypospadias should be related. Our data have led us to narrow our indication for meatal advancement in children with anterior hypospadias. In reconstructive surgery of more severe hypospadias using a DreDutial island onlav flaD or buccal mucosa ohlay6 we do-noi Gist on advanchithe meatus beyond the corona in all instances when it is not easily feasible. This strategy may reduce complications associated with glans plasty and meatal advancement without impairing functional and cosmetic results. REFERENCES
1. Duckett, J. W.:Hypospadias. In: Campbell's Urology, 6th ed. Editad by P. C. Walsh. A. B. htik, T. A. Stamey and E. D. Vaughan, Jr. Philadelphia:W. B. Saunders Co., vol. 2, chapt. 50, pp. 1893-1919,1992. 2. Duckett, J. W.: MAGPI (meatoplasty and glanuloplasty):a procedure for subcoronal hypospadias. Urol. Clin. N. h e r . , 8: 513,1981. 3. Mathieu, P.:Traitement en un temps de I'hypospadiasbalanique et juxtabalanique.J. Chir., 3 9 481, 1932. 4. Duckett, J. W., Jr.: Transverse preputial island flap technique for repair of severe hypospadias.Urol. Clin. N. h e r . , 1: 423, 1980. 5. Browne, D.: An operation for hypospadias.Lancet, 1: 141, 1936. 6. Biirger, R.A, Miiller, S. C., El-Damanhoury,H., Tschakaloff, A, Riedmiller,H. and Hohenfellner,R.: The buccal mucosal graft for urethral reconstruction:a oreliminarv .reoort. , . J. Urol.. 141: 662, 1992.