Jordan Flap Meatoplasty

the skin alone. The ventral penile skin is dissected from the fascial pedicle in the plane between the superficial fascial plexus and the deep subdermal plexus of the skin (□ Fig. 17.5). With the skin island oriented transversely, the broad dartos fascial pedicle is created from the entire

□ Fig. 17.4. The ventral transverse skin island as described by Jordan. A urethrostomy defect is created to the level of normal urethra. The dimensions of the skin island is outlined transversely on the ventral penile skin. (From [11])
Meatoplasty Penis
□ Fig. 17.5. The lateral glans wings are dissected. The skin island is then elevated on dartos fascia, transposed and inverted into the remaining dorsal midline strip (From [11])

penile ventrum, and elevation of the fascial flap should be sufficient for a tension-free flap transposition.

The lateral glans flaps are dissected in the relatively avascular plane between the tips of the corpora cavernosa and the glanular spongy erectile tissue. The small amount of bleeding that occurs during this dissection is easily controlled with bipolar electrocautery forceps and injection of the glans with diluted epinephrine. Tension or narrowing of the urethra of the glans caused by ventral fusion is avoided by wide elevation of the glans flaps, and the appearance of the glans after fusion is normal in most patients.

The skin island is transposed and inverted into the external urethrotomy defect without requiring aggressive advancement of the ventral dartos fascia after elevation (□ Fig. 17.6). Flap transposition permits mechanically efficient mobilization of the fascia. The onlay is secured with tacking sutures (# 5-0 PDS with knots inside the urethral lumen) and a running subepithelial suture (#6-0 PDS).

The glans is closed ventrally over the neofossa with a #28-Fr sound through the area of reconstruction after the patch onlay is complete. A deep layer of #4-0 or #5-0 monofilament absorbable suture and small (usually #6-0) PGA sutures are used to bring the skin into everted apposition is used for glans closure. The sound is replaced with a small urethral stent. Suprapubic diversion was performed early in our series; however, some of our patients currently are diverted by placing a feeding

□ Fig. 17.6. The skin island is sutured into the defect. Note the glans wings have not been fused ventrally yet (From [11])
Jordan Flap Meatoplasty
□ Fig. 17.7. The appearance of the glans when re-fused ventrally with the flap harvest site closed (From [11])

tube through a splent, to allow voiding (through the splent) on the 3rd postoperative day. The flap donor site is closed by transposition of the preputial skin into the defect and development of Burrow's triangles to excise the small »dog ears« at the corners of the closure (□ Fig. 17.7).

17.2.3 Stricture Associated with Early Balanitis Xerotica Obliterans

Although BXO in children is normally seen with a redundant prepuce, phimosis and balanitis, it has been suggested that BXO begins as a perimeatal process. In patients with BXO who present early in the disease course with a meatal or fossa stricture, high intraurethral pressures appear to be generated during voiding, which leads to intravasation of urine into the glands of Littre. This intravasation may cause inflammation and microabscess formation, ultimately leading to a progressive and severe urethral stricture. It has been our experience that panurethral stricture disease is avoided if early aggressive reconstruction is offered to these patients while the stricture process is confined to the meatus or distal fossa navicularis.

While the meatus and fossa are generally the site of greatest functional limitation in BXO, the glanular skin is also a problem. Most patients will respond to topical steroids up to three times daily for 6-8 weeks, tapered to once daily. Generally after patients are reduced to a once daily regimen, they begin to use it on an as-needed regimen. In addition, BXO-associated inflammation seems to respond favorably to daily doxycycline. However, dermatologists commonly regard BXO as a premalignant condition, and a biopsy is therefore recommended in patients with BXO, who do not respond as expected to treatments, as squamous cell carcinoma may present with what appears to be severe BXO of the glans.

In addition to the one-staged procedures described above for strictures of the fossa navicularis, some surgeons prefer a staged approach for reconstruction of the fossa navicularis in BXO. Devine's procedure (i.e., resurfacing of the fossa navicularis) has been used for BXO, and when there is concern that the BXO would recur involving the graft, a tubed buccal mucosa graft could be used alternately. Another application would be to place a buccal graft open as a first stage followed by a second stage in which the graft is tubed [7].

17.3 Stricture of the Fossa Navicularis with Redundancy of Dorsal Penile Skin

Occasionally a patient will present with stenosis of the fossa navicularis or distal urethral stricture disease, who has redundant skin on the dorsum of the penis. This can be reconstructed using a transverse skin island elevated on the dorsal dartos fascia from the redundant dorsal skin, with the deep dissection in the layer immediately superficial to the outer lamina of Buck's fascia [8].

To produce a tension-free fusion of the glans around the neomeatus and neofossa navicularis, the dorsal transverse island procedure requires wide elevation of the lateral glans flaps similar to the other techniques described above. Some patients, particularly those who have undergone multiple procedures, do not have enough redundancy to elevate a dorsal transverse island without torsion. However, in most cases the torsion resolves over time, and leaving some torsion in exchange for a good functional result is generally acceptable. If the surgeon suspects in advance that this might occur, the patient should be informed before the surgery is performed.

17.4 Results

Several procedures for reconstruction of true strictures of the fossa navicularis provide excellent aesthetic and functional results. The largest series of patients in which a single technique has been used for reconstruction of the fossa navicularis was reported by DeSy, using a longitudinally oriented skin island mobilized on the dartos fascia. The ventral transverse island technique has also been used in large numbers by several reconstructive surgeons, including the author, with excellent results.

References

1. Cohney BC (1963) A penile flap procedure for the relief of meatal strictures. Br J Urol 35:182

2. Blandy JP, Tresidder GV (1967) Meatoplasty. Br J Urol 39:623

3. Brannen GE (1976) Meatal reconstruction. J Urol 116:319-321

4. DeSy WA (1984) Aesthetic repair of meatal stricture. J Urol 132:678-679

5. Devine CJ Jr (1986) Surgery of the urethra. In Walsh PC, Gittes RF, Perlmutter AD et al (eds) Campbell's Urology, edn 5. WB Saunders, Philadelphia, p 2853

6. Jordan GH (1987) Reconstruction of the fossa navicularis. J Urol 138:102-104

7. Venn SN, Mundy AR (1998) Urethroplasty for balanitis xerotica obliterans. Br J Urol 81:735-737

8. Duckett JW (1981) The island flap technique for hypospadias repair. Urol Clin North Am 8:503-511

9. Jordan GH, Schlossberg SM (2002) Surgery of the penis and urethra. In Campbell's Urology, 8th Edn. Vol 4, Chap. 110, Saunders, Philadelphia

10. Jordan GH (1987) Management of anterior urethral stricture disease. problems in urology, Vol 1. Philadelphia, JB Lippincott

11. Jordan GH (1999) Reconstruction of the meatus-fossa navicu-laris using flap techniques. In: Schreiter F, Bartsch (eds) Plastic-Reconstructive Surgery in Urology. George Thieme, Stuttgart, 1999

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