Urethral Meatotomy Under Local Anesthesia Only
Ezekiel H. Landau, MD, Jacob Ben Chaim, MD, Ofer N. Gofrit, MD, PhD, Vladimir Yutkin, MD, Mordechai Duvdevani, MD, Dov Pode, MD, Guy Hidas, MD, MSc.
Hadassah Hebrew University Medical Center, Jerusalem, Israel.
BACKGROUND:Urethral meatal stenosis (UMS) occurs in 5-10% of children undergoing neonatal ritual circumcision (NRC). In countries, where NRC is executed routinely, the number of children requiring urethral meatotomy (UM) is significant. UM under local anesthesia only (UML), avoids the potential complications of general anesthesia/sadation, the pain associated with penile block, the necessity for fasting, and saves anesthesiologist and operating room time.
We present our experience with UML, using EMLA (lidocaine prilocaine 5%) cream, emphasizing success rate of local anesthesia.
A retrospective review of all children undergoing UM between 2011
and 2015 was executed. Indications for meatotomy included history of a narrow urinary stream, directed outside the toilet, dysuria, frequency and urgency, combined with the establishment of UMS by a pediatric urologist. They were divided into those who underwent UM with EMLA only (group 1), and those who required sedation by a pediatric anesthesiologist (group 2). The patients in whom EMLA failed (group 1), were called again, fasting, and underwent UM under sedation. Indications for sedation (group 2), included G6PDD, age above 9 years, and hyperactive behavior during pre-operative clinic visit.
Technique: EMLA cream was applied on the glans penis 50-60
minutes, prior meatotomy. The glans was then covered with an adhesive tape. The cream was cleansed at the time of meatotomy. A longitudinal meatal incision was performed towards the ventrum of the glans, for 2-4 mm following crash. Meatotomy was performed, without touching the patient at all, and with parents' presence. If the child did not cooperate, the procedure was cancelled, and the child underwent UM under sedation, at a later date, considering failure of UML. Parents were advised to apply 5% Chloramphenicol ointment (by inserting the tip of the tube into the urethral meatus), 3 times daily, for 14 days, followed by a clinic visit. Subjective improvement of voiding symptoms, described by the parents, and assessment of urethral meatus by the surgeon were obtained during
this visit. Surgical failure was defined by the necessity for re-meatotomy due to re-stenosis defined by lack of voiding improvement, and by physician assessment of the meatus.
The study was approved by the institutional IRB.
RESULTS:The study groups comprised 642 patients (aged 3-14 years, average 4.1). Group 1 included 591 patients, while group 2 included 51 children (G6PDD-7, age-20, hyperactivity-24). UML was successful in 568 (96.1%) in group 1, while sedation was successful in 100% of the patients, in group 2 (p=0.25). No EMLA or sedation related complications, were encountered. Meatotomy was successful in 550 (96.7%) patients in group 1. Eighteen patients underwent successful re-UM under sedation. Meatotomy was successful in all (100%) patients in group 2 (p=0.62).
CONCLUSIONS:UM with EMLA alone is very efficient, avoids sedation, saves operating room time and money, and has comparable outcome with meatotomy under sedation. We recommend on UML whenever possible.
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