Successful Meatoplasty for Subcoronal Hypospadias in a 52 Y.O. Male with Diabetes Mellitus

PACE Hospital’s expert Urology team successfully performed a Cystoscopy with Meatoplasty on a 52-year-old male patient diagnosed with subcoronal hypospadias, with a history of BMG urethroplasty for Balanitis xerotica obliterans (BXO)-related pan-anterior urethral stricture, with the aim of evaluating the urethral passage and correcting the urethral opening to improve urinary flow, reduce urine stream splaying, and prevent soiling of clothes, thereby enhancing overall urinary function and quality of life.

Chief Complaints

A 52-year-old male patient with a body mass index (BMI) of 22 presented to the Urology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of splaying of the urine stream and associated with soiling of clothes.

The patient had a known history of subcoronal hypospadias and had previously undergone buccal mucosal graft (BMG) urethroplasty for Balanitis xerotica obliterans (BXO)-related pan-anterior urethral stricture. He was also a known case of diabetes mellitus and was on regular medication. There was no documented history of other major chronic illnesses or significant surgical interventions apart from the prior urethral surgery.

On examination, the patient was conscious, coherent, and oriented, with stable vital signs. General and systemic physical examinations were normal. Abdominal assessment was normal. Genital examination revealed a subcoronal urethral meatus consistent with hypospadias.

Upon admission to PACE Hospitals, the patient was thoroughly evaluated by the Urology team, including a detailed review of his medical history and a comprehensive clinical examination. He presented with splaying of the urine stream and soiling of clothes, raising clinical suspicion of urethral stricture and hypospadias complications.

The patient underwent diagnostic investigations. Ultrasonography of the abdomen revealed a liver of normal size with increased echogenicity suggestive of grade I fatty liver, a well-distended urinary bladder with diffuse wall thickening and sediments, normal kidneys, normal prostate, normal pancreas, and normal spleen. X-ray chest showed linear fibrotic opacity in the right upper zone with otherwise normal heart size, lung fields, hila, and costophrenic angles.

Laboratory investigations included thyroid function testing which showed a normal thyroid stimulating hormone, renal function tests showing elevated serum creatinine and blood urea, liver function tests which were within normal limits, lipid profile showing borderline triglycerides, undesirable HDL cholesterol, and borderline LDL cholesterol, fasting and post-prandial blood sugar which were elevated, random blood sugar within normal range, serum electrolytes which were within normal limits, and C-reactive protein which was elevated. Viral screening for HIV, Hepatitis B, and C was negative. Urine culture grew Klebsiella pneumoniae with variable antibiotic sensitivity.

Based on these confirmed findings, the patient was advised to undergo Subcoronal Hypospadias Treatment in Hyderabad, India, along with post-buccal mucosal graft urethroplasty for Balanitis Xerotica Obliterans (BXO) related pan-anterior urethral stricture under the expert care of the Urology Department.

After a detailed consultation with Dr. Abhik Debnath, Consultant Laparoscopic Urologist, a comprehensive evaluation was conducted focusing on the patient’s presentation of splaying of urine stream and soiling of clothes, along with his history of post-buccal mucosal graft urethroplasty for BXO-related pan-anterior urethral stricture. Clinical and diagnostic findings, including retrograde urethrogram, ultrasonography of the urinary tract, and urine culture, confirmed the presence of subcoronal hypospadias with a previously grafted urethral segment and no evidence of acute infection obstructing the urinary tract.

Laboratory investigations showed elevated fasting and post-prandial blood sugar, borderline lipid profile, elevated serum creatinine and blood urea, and elevated C-reactive protein. Viral screening for HIV, Hepatitis B, and C was negative. Urine culture grew Klebsiella pneumoniae with variable antibiotic sensitivity.

It was determined that cystoscopy with meatoplasty was identified as the most appropriate intervention to restore urinary flow, correct the urethral meatus configuration, and prevent further complications such as recurrent urinary tract infections, urinary retention, or stricture recurrence.

The patient and family were informed about the diagnosis, planned surgery, associated risks, and expected benefits to relieve symptoms and prevent complications.

Following the decision, the patient was scheduled to undergo a Cystoscopy with Meatoplasty Surgery in Hyderabad at PACE Hospitals, under the expert care of the urology department.

The procedure involved the following steps:

• Anesthesia and Preparation: The patient was administered spinal and general anesthesia for optimal surgical comfort and immobilization. The genital area was prepared under sterile conditions. A 12 Fr Foley catheter was inserted to maintain urinary drainage during the procedure.

• Assessment of Urethra: Cystoscopy was performed to evaluate the anterior urethra. The urethra was found to be roomy with no evidence of stricture, confirming patency and guiding the reconstruction.

• Incision and Plate Preparation: The urethral plate in the glans was incised to prepare the recipient site for grafting. The glans was spatulated, and the narrow urethral plate measured 8 mm in diameter, with the meatus located subcoronally.

• Graft Placement and Layering: A buccal mucosal graft (TV flap) was harvested and placed as a Snodgrass-type flap over the incised urethral plate. A second layer was created using a local dartos flap to provide additional support and reinforcement, reducing the risk of fistula formation.

• Glansplasty and Completion: Glansplasty was performed to reconstruct the glans around the new urethral meatus, ensuring a cosmetically acceptable and functional outcome. The Foley catheter remained in situ for urinary drainage postoperatively.
  

After surgery, the patient was closely monitored and remained stable throughout the hospital stay. His intraoperative and postoperative course was uneventful, with no complications observed. He received medications for pain relief, infection prevention, and supportive care. The catheter and surgical site were carefully managed to ensure proper healing and urine drainage. The patient was discharged in stable condition with instructions for follow-up and catheter care.

Upon discharge, the patient was prescribed medications to prevent infection, control pain, reduce inflammation, support tissue healing, improve circulation, and manage diabetes. He was also instructed on proper catheter care and daily local dressing to ensure optimal healing and prevent complications.

The patient was advised to follow a diabetic diet and maintain proper catheter care as instructed to ensure optimal recovery and prevent complications.

The patient was instructed to contact the emergency ward at PACE Hospitals in the event of an emergency or if symptoms such as fever, catheter block, or pain in the groin or penis.

The patient was advised to have the catheter removed in their hometown after 7 days under the supervision of a doctor and to return for a follow-up visit with the Urologist in Hyderabad at PACE Hospitals after 10 days for dressing and drain removal.

This case highlights subcoronal hypospadias with post-BMG urethroplasty for BXO-related pan-anterior urethral stricture, managed with cystoscopy and meatoplasty. The procedure was successful, with no intraoperative or postoperative complications. The patient was discharged in stable condition with appropriate medications, catheter care, and follow-up instructions to ensure proper recovery and monitoring.