Management of urethrocutaneous fistula following hypospadias repair

Modified PATIO technique for urethrocutaneous fistula after hypospadias repair: Experience from a tertiary referral hospital

INTRODUCTION

Urethrocutaneous fistula (UCF) is a common complication after hypospadias repair with an incidence of 5-10%. Several techniques are described for its repair: small UCFs are frequently corrected by isolation, excision, and closure with apposition of a protective second layer. In 2008 Malone described the PATIO technique: the fistula tract is turned inside out in the urethral lumen preventing contact with passing urine without direct urethral sutures.

OBJECTIVE

Aim of our study is to present our outcomes using a modified version of the PATIO technique, with a more reproducible isolation of the tract and without its fixation at the urethral meatus.

STUDY DESIGN

We retrospectively reviewed all cases of UCFs corrected with a modified PATIO technique at our center between 2016 and 2020. Data collected from electronical clinical notes were age at UCF closure, location of UCF, presence of meatal stenosis and clinical outcomes. Data are presented as median and IQR.

RESULTS

In the study period we performed 425 urethroplasties for distal and mid penile hypospadias. The incidence of UCFs was 7% (30/425) and 25 patients underwent UCF correction with modified PATIO. Median age at repair was 4.5 years (IQR: 2.5-6.2). At a median follow-up of 3 years (IQR: 2-4) recurrence was observed in 5 cases out of 24 with one patient who was lost at follow-up (20.8%). One case was corrected successfully with re-do modified PATIO technique, while 4 are awaiting repair. One cases was lost at follow-up. UFC-recurrence was homogeneously distributed along the study period.

DISCUSSION

Risk factors for UCF recurrence are mostly the type of hypospadias, neo-urethral length, and quality of the urethral plate. Among the many existing techniques, we propose a modified version of Malone's PATIO repair. We believe that the use of four stay-suture to isolate the fistula allows a well-defined dissection of the tract along its surface, compared to the use of a single stay-suture. In our experience, there is no need to keep and fix the traction on the fistula tract to the urethral meatus, probably reflecting the efficacy of the fistula closure during the introflection, which is then maintained without traction. Limitations to our study include the retrospective nature of the review, the small sample size of the cohort and the absence of control groups.

CONCLUSIONS

Our results appear consistent with literature regarding the efficacy of PATIO principles in treating UCF. Modified PATIO seem to be particularly reproducible, showing encouraging results.

Clinical Classification of Urethrocutaneous Fistulas Developing after Hypospadias Repair

Background Clinical classification of the urethrocutaneous fistulas (UCFs) was designed to help the surgeons in (1) categorizing the fistulas, (2) selecting appropriate treatments, (3) keeping record at presentation and discharge, and (4) transferring information while referring a patient with recurrent fistula to a higher center.

Methods This retrospective study comprised of 68 patients with UCFs who reported in the “Hypospadias and VVFs Clinic” between 2004 and 2016. The study was performed to determine the incidence or etiology of the UCFs. It was rather performed to classify fistulas into different categories depending on the number of fistulas: A (5 fistulas), B (16 fistulas), C-a (28 fistulas), C-b (4 fistulas), D (4 fistulas), and E (11 fistulas). Category A fistulas healed conservatively. Category B fistulas underwent transection of the fistula tracts (tractotomy), purse-string closure, or multilayered closure (fistulorrhaphy). Category C-a fistulas were reenforced by preputial or penile skin flaps or waterproofing flaps. Category C-b fistulas underwent re-tubularization of their neourethral plates and eccentric closure of peno-preputial skin. The urethral plates of category D fistulas were re-tubularized after 3 to 6 months and cover was provided by the Cecil-Culp procedure. Category E fistulas had associated hairy urethra, stricture distal urethra, stricture with diverticulum, perifistular scar-induced chordee, long narrow urethral plate, balanitis xerotica obliterans (BXO), and short reconstructed neourethra. Accordingly, appropriate corrective measures were taken. Miscellaneous category F was excluded from the study.

Results Except for one in category D, none of the patients had any recurrence of fistula. One patient of category E had residual diverticulum.

Conclusion The designed clinical classification of UCFs is simple. Treatment was in accordance with reconstructive ladder wherein complexity of treatment paralleled with increasing complexity of fistulas.

EVALUATION OF VEST-OVER-PANT TECHNIQUE IN THE TREATMENT OF POST-HYPOSPADIAS URETHROCUTANEOUS FISTULA

OBJECTIVE

The aim: In this study, we present and evaluate the vest-over-pants technique as a simple way to correct urethrocutaneous fistulas after hypospadias.

PATIENTS AND METHODS

Materials and methods: Between October 2018 and June 2020, twenty male patients aged 5 to 20 years came to us with post hypospadias repair fistula, these patients underwent vest-over-pant repair of their fistula. The size of fistula was ranging between 2.5-5 mm. The distribution of fistula was coronal (3 patients), distal penile (9 patients), midshaft (2 patients) and proximal penile (6 patients). In 14 patients there were single fistula and 6 patients had more than one fistula. Eleven of patients were exposed to a previous failed fistula repair procedure.

RESULTS

Results: Six months after the operation, the fistula recurred only in 2 patients, and our operation was successful in 90% of cases without complications.

CONCLUSION

Conclusions: The vest-over-pants technique is a simple and effective way to treat penile fistulas after hypospadias in properly selected patients. It is a technically simple procedure with a short learning curve and no major postoperative complications.

Management of urethral fistula after hypospadias repair with particular reference to purse-string sutures: a 24-year review

PURPOSE

To review our management of urethral fistulae following hypospadias repair over a 24-year period. To showcase our innovations, particularly the purse-string closure technique.

METHODS

We reviewed our prospectively maintained database from 1997 to 2020 to identify patients with fistula. Two main surgical techniques were used: traditional linear closure and purse-string suture. Other innovations included anchoring skin to corpora and intersectional skin closure.

RESULTS

Sixty two patients presented with 73 urethral fistulae after hypospadias repair. 55/62 were operated: 28-purse-string technique, 23-linear closure, 4-redo urethroplasty. Cure after the first attempt was achieved in 26/28 (93%) in the purse-string group and 16/23 (70%) in the linear group (p = 0.015). Spontaneous resolution occurred in 6/62 patients (9.6%), in 3 spontaneously and in 3 after a single dilation. 1 patient awaits surgery. Closure after first fistula repair was 22/24 (92%) in distal hypospadias and 20/27 (74%) in proximal hypospadias (p = 0.051).

CONCLUSION

Remarkably, conservative management was succesful in almost 10% of urethral fistulae, either spontaneously or after a single dilation. Purse-string closure, rarely described in the literature, coupled with our other innovations, helped bring down our recurrence rates significantly with no patient needing more than two surgeries for cure.

Comparative Study of Modifying Meatal Advancement Glandular with Release Chordi versus Snodgrass Surgical Methods Regarding the Repair of Distal Hypospadias

BACKGROUND

Hypospadias is one of the most common congenital anomalies of the external genitalia of boys. No single technique can be recommended for the repair of hypospadias in its various forms. We aimed to compare modify meatal advancement glandular with release chordi versus Snodgrass surgical methods in the repair of distal hypospadias.

METHODS

In this study, conducted from Apr 2018 to the end of Sep 2020, all boys who underwent one of the two methods of Snodgrass and modify meatal advancement glanuplasty with release chordi in Imam Khomeini and Abuzar Hospitals of Ahvaz, Southern Iran, were enrolled.

RESULTS

Forty-five patients underwent Snodgrass (group S) and 55 patients underwent modified meatal advancement glandular with release chordi (group M). The mean age of patients and duration of surgical wound healing in the two groups did not differ significantly. There was no significant difference between the two groups in terms of complications, including Bleeding, Hematoma, Meatus stricture, Wound infection, detachment of the wound edge, chordi after surgery, Balanitis and Urethral stricture but the incidence of fistula in patients undergoing Snodgrass repair was significantly higher than the group modify meatal advancement glandular with release chordi (P<0.05).

CONCLUSION

The method of modify meatal advancement glandular with release chordi compared to Snodgrass method is associated with fewer complications due to surgery, although further studies are recommended.

Promising results for hypospadias repair using alloderm® (Regen): A randomized controlled trial

INTRODUCTION;: Hypospadias is a congenital disorder of urethra in which meatus is not at its correct place and occurs in 1 of 250 live male birth. Many techniques have been used for the repair of hypospadias and to decrease the incidence of fistula. Alloderm has been recently used for the repair of urologic congenital defects, and reconstructive surgeries, but not used in hypospadias in a randomized controlled trial. Therefore, the aim of this study was to assess the efficacy of Alloderm® (Regen) to reduce fistula rate in hypospadias repair.

METHODS & MATERIALS

This was a randomized controlled trial. Sixty patients were divided into two groups, 30 children underwent surgery using Alloderm® (Regen) as the Alloderm group and 30 without using it as controls. In the Alloderm group, 21 underwent primary surgery (12 mid-shaft hypospadias who underwent concurrent chordee correction and urethroplasty, and 9 penoscrotal who underwent 2 stage surgery, chordee was first corrected and then 6 months later TIP was performed), and 9 underwent fistula repair due to previous surgeries. In the control group, 24 patients underwent primary surgery (15 mid-shaft, and 9 penoscrotal) and 6 fistula repair the same as the Alloderm group but without using Alloderm.

RESULTS

There was no meaningful difference between the two groups regarding age (P = 0.634). There was no meaningful difference regarding the operation type between the two groups (P = 0.371). There was no meaningful difference regarding the meatal location between the two groups (P = 0.781). There were no significant post-operative complications in the both groups. No bleeding or diverticulum occurred. Recurrence of fistula occurred in one patient in the Alloderm group after fistula repair and in 2 in the control group. Overall, In the Alloderm group, 3 (2 after TIP and 1 after fistula repair) patients and in the control group 8 (6 after TIP, 2 after fistula repair) patients developed fistulas after surgery (10% vs 26.7%). There was a statistically meaningful difference regarding fistula formation between the two groups using Chi-square test (P = 0.014).

CONCLUSION

Alloderm® (Regen) can be used for hypospadias and fistula repair with very few complications and good results. Fistula was less probably occurred in the Alloderm group compared to the standard repair of hypospadias.

Risk factors for fistula recurrence after urethrocutaneous fistulectomy in children with hypospadias

OBJECTIVE

This study aimed to investigate the risk factors of fistula recurrence after primary urethrocutaneous fistulectomy in children with hypospadias.

MATERIAL AND METHODS

The study included 63 children who underwent fistulectomy for urethrocutaneous fistula (UCFs) that occurred after urethroplasty for hypospadias, between February 2009 and December 2018. The patients were divided into 2 groups: successful group 1 and failed group 2. For data analysis, we included the demographics of the patients, the details of the previous urethroplasty (the type of hypospadias and the location of the meatus after complete chordectomy), the presence of meatal stenosis or urethral stricture after urethroplasty, and the size of the UCFs. The Student t-test and the chi-square test were performed to analyze the data using the Statistical Package for Social Sciences software.

RESULTS

The overall success rate of primary urethrocutaneous fistulectomy was 81.0% (51/63 children). The most common location of a secondary fistula was the penoscrotal area 5 (41.6%). There were no statistically significant differences in age (p=0.501), weight (p=0.063), body mass index (p=0.924), history of low birth weight (p=0.454), and history of prematurity (p=0.381). The type of hypospadias (p=0.007) and urethral defect length (p=0.021) were identified as independent risk factors for failed urethrocutaneous fistulectomy. There were no statistically significant differences in meatal stenosis (p=0.431), postoperative stricture (p=0.587), fistula location (p=0.173), multiplicity (p=0.588), and fistula size (p=0.530).

CONCLUSION

The type of hypospadias and the length of the urethral defect are the significant risk factors for secondary fistula recurrence after primary urethrocutaneous fistulectomy.

Dermal regeneration sheet Integra® in management of recurrent Urethrocutaneous fistula after hypospadias surgery

BACKGROUND

Urethrocutaneous fistula UCF is the most common complication following surgical repair of hypospadias. Currently, the surgical technique mostly used to prevent recurrence employs preputial dartos or testicular tunica vaginalis flaps as a urethral covering. However, autologous tissues are limited in patients with multiple surgeries, and the use of biomaterials as a urethral coverage may represent a good alternative.

OBJECTIVE

The goal of the present study is to assess the results and complications of recurrent UCF correction using a dermal bovine regeneration sheet as a urethral covering.

MATERIALS AND METHOD

From May 2016 to January 2019, all patients with recurrent UCF of the authors center were repaired using this technique. The inclusion criteria were patients who had undergone one or more unsuccessful UCF repair surgeries and the absence of preputial tissue. The informed consent has been signed by all the patients. Patients were examined in outpatient consultations where their urinary stream was evaluated and a physical examination of the penis was conducted.

RESULTS

A total of 12 patients and 13 UCFs were included in the study. The median follow-up was 18 months, (range: 4-26), and only two patients (15%) developed a recurrence of UCF. No complications were observed in the remaining patients (85%) during their evolution. No patient developed a fibrosis increase or loss of elasticity of the tissues in contact with the dermal matrix.

CONCLUSION

The use of an Integra® sheet as a urethral covering during urethral fistula surgery appears to be a safe, effective, and easily reproducible option. However, prospective studies with larger numbers of patients should be performed to corroborate these results.

Risk Factors for Urethrocutaneous Fistula Repair After Hypospadias Surgery: A Retrospective Study

OBJECTIVES

We review our experience in urethrocutaneous fistula (UCF) repair after hypospadias surgery to investigate the risk factors for unsuccessful outcome.

METHODS

Two hundred eleven patients had undergone UCF repair in our department from January 2005 to December 2015. This study included 185 patients who were followed up for more than 6 months. The age of patients, size, site and number of UCFs, number of UCF repairs, urethral complications other than UCF, and postoperative infection were included as potential risk factors. Binary logistic regression analysis was used for multivariate analysis. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. Stratified analysis and assessment of additive interaction were performed to have a better understanding of the relation between the risk factors.

RESULTS

Urethrocutaneous fistula repairs failed in 38 patients (20.5%) at first attempt. In the univariate analysis, size of UCFs (P = 0.012), times of UCF repair (P = 0.008), and postoperative infection (P = 0.044) were statistically related with the outcome of surgery. In the multivariate analysis, only the size of UCFs (P = 0.030; adjusted OR, 2.42; 95% CI, 1.09-5.36) and times of repair (P = 0.008; adjusted OR, 3.09; 95% CI, 1.35-7.07) were identified as risk factors for unsuccessful outcome. We had consistent results in the stratified analysis. No additive or multiplicative interaction between the 2 risk factors was found.

CONCLUSIONS

Our study suggested that UCF repairs after hypospadias surgery were easier to fail if one of the UCFs was larger than 2 mm or it had been repaired repeatedly. But when both factors existed, the increase of the risk was not statistically significant. The age of patients, site and number of UCFs, complications other than UCF, and postoperative infection were not significantly related to the success rate of UCF repair.

Modified PATIO repair for urethrocutaneous fistula post-hypospadias repair: operative technique and outcomes

BACKGROUND

To describe a modification of PATIO repair for urethrocutaneous fistula repair and evaluate its outcome.

METHODS

We studied 15 boys who underwent modified PATIO repair from Jan 2010 to Sept 2015. Parameters studied included age, type of hypospadias, age at first urethroplasty, hypospadias repair technique, number of urethroplasties required, location of fistula, time gap between urethroplasty and fistula repair, method of fistula repair, and outcome of fistula repair.

RESULTS

Mean age of the studied patients was 67.6 months (38-139). Type of hypospadias was Coronal = 3, subcoronal = 8, mid-penile = 2, prominal penile = 1, and penoscrotal = 1. Ten patients had single urethroplasty, while two patients had two urethroplasties, details not available for three patients. Average age at urethroplasty was 43.4 months (18-110). 12 patients had Snodgrass repair, Mathieu = 1 patient, tubularised plate repair = 1 patient, and unknown = 1 patient. Location of fistula was coronal in nine patients and subcoronal in six patients. Average operative time was 47.2 min (30-68). Follow-up is available for 12 patients out of which 2 patients had recurrent fistula, one of which was successfully treated by the redo modified PATIO method.

CONCLUSION

Modified PATIO method is technically easy method for urethrocutaneous fistula repair, with less operating time and good postoperative outcomes.

Coronal fistula repair under the glans without reoperative hypospadias glansplasty or urinary diversion

BACKGROUND

Coronal fistulas present a potential dilemma in management. Successful closure requires reoperative glansplasty when there is only a thin band of tissue separating the urethral meatus from the fistula, indicating glans dehiscence. However, we avoided reoperative glansplasty during coronal fistula repair when the glans wings remained well-fused, given the increased risk for complications, including recurrent fistula, following reoperative glansplasty.

PURPOSE

We report coronal fistula closure without reoperative glansplasty in patients with preserved fusion of the glans wings. We also compare this closure done with versus without postoperative urinary diversion. The primary outcome was recurrent fistula.

MATERIALS

Consecutive patients with coronal fistula and no glans dehiscence (Figure) underwent repair by dissecting the fistula tract under the glans rather than re-opening the glans wings. A midline incision facilitated creation of a ventral dartos barrier flap, used in all cases, as well as selective skin revision when needed. Initial patients had postoperative urinary diversion, whereas later consecutive patients did not. Data was recorded prospectively at the time of service into a database.

RESULTS

WS performed 122 fistula repairs from 2001 to 2013, of which 78 were coronal. Of these, 33 had glans dehiscence with only a thin band of skin separating the fistula from the distal meatus and underwent reoperative hypospadias repair. The other 45 met inclusion criteria with maintained glans wings fusion and had only fistula closure. These 45 patients all had fistulas </= 3 mm, and none had evidence of meatal stenosis, defined as calibration <8 Fr in prepubertal and <12 Fr in pubertal males. Median age at fistula closure was 3 y (1-51), and mean follow up in 37 of the 45 patients was 18 m (1.6-84). Recurrent fistulas occurred in 2 (5%), with no difference in those with versus without urinary diversion.

DISCUSSION

There was a 5% fistula recurrence rate after dissecting under the glans and closing the urethral defect without reopening the glans in patients with well-fused glans wings. All patients had a ventral dartos barrier flap which covered the urethral defect. There was no difference in outcomes based on use of urinary diversion or not, and so we no longer use postoperative catheter drainage. Ours is the first report on fistula repair using a standardized protocol in consecutive patients, and it is difficult to compare our results to other published series which included fistulas in various locations, heterogeneity in decision-making based on "simple vs "complex" designations, and varied use of urinary diversion. Other reported recurrence rates vary from 4% to 30%. All our patients had primary fistulas <3 mm in size, and so we cannot comment on use of this technique for recurrent fistulas and/or larger defects. We report outcomes during a mean of 18 months follow up, and it is possible there will be additional recurrences with longer follow up.

CONCLUSIONS

This study is the first on fistula repair using a standardized procedure in consecutivepatients with prospectively recorded data. We found coronal fistulas ≤3 mm under well-fused glans wings can be repaired with low risk for recurrence by elevating the glans rather than re-opening the wings for reoperative glansplasty. Postoperative urinary diversion did not impact the recurrence rate and so is no longer used.

Repair of hypospadias fistula using a penile skin advancement flap with penile dartos interposition

OBJECTIVE

We aim to report a single surgeon's experience of using a penile skin advancement flap with penile dartos interposition for hypospadias fistula repair.

PATIENTS & METHODS

All hypospadias fistula repairs performed in our unit by this paediatric urologist between 2000 and 2012 were identified from a prospectively recorded database. Patients' case-notes were reviewed retrospectively gathering data on surgical technique, post-operative care and fistula recurrence on follow-up. Only those boys having repair by this advancement flap technique were included. A urethral catheter was left in situ in all patients for 5-7 days. Repairs performed using other techniques were excluded.

RESULTS

20 consecutive patients had fistula repair by the advancement flap technique. This was the primary repair in 19 boys, and was repair of a third fistula occurrence in one. The median age at fistula repair was 3.7 years (1.6-15.3). The median follow-up was 4 months (3-73). One boy failed to attend any follow-up. No recurrence has yet been identified in any of the 20 patients.

CONCLUSION

The penile skin advancement flap with dartos interposition technique was very successful in our series in both primary fistula repair, and in a patient who had multiple previous operations.

Urethrocutaneous fistula after hypospadias repair: outcome of three types of closure techniques

OBJECTIVE

To evaluate the outcomes of three surgical techniques for the closure of urethrocutaneous fistula (UCF) after hypospadias repair.

MATERIALS AND METHODS

Fifty-one patients (mean age 6.5 years) who underwent UCF closure between June 1998 and February 2008 were divided in to three groups depending on fistula size; group I had <2 mm and (n = 17, 33.4%), group II had 2-4 mm (n = 21, 41.2%) and group III had >4 mm or multiple fistulas (n = 13, 25.4%). Group I patients were treated by excision and simple closure. Patients in group II and III were treated with flip flap technique along with the wrapping of repaired area with scrotal dartos flap and tunneled tunica vaginalis flap (TVF), respectively.

RESULTS

Mean surgical time was 45 min (range 30-55), 60 min (range 50-75) and 80 min (range 60-100) in three techniques, respectively. The mean follow-up was 3.5 years (range 6 months-10 years). No patient had recurrence of fistula in group III, while 2 (9.5%) and 4 (25.4%) patients in groups II and I, respectively, had recurrent UCF. No postoperative complications were encountered in the testis or the scrotum. No patient had torsion or deviation of penis.

CONCLUSION

Simple fistula closure carries a higher risk of recurrence even in small sized fistulas. The application of scrotal dartos or TVF for wrapping the repaired area gives excellent results and they are easy to harvest with no harmful effects on the scrotum or testis.