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Gümüş K, Demir M. Effect of Haematological Parameters in the Development of Urethrocutaneous Fistula After Hypospadias Surgery. Cureus 2023; 15:e36033. [PMID: 36919113 PMCID: PMC10008427 DOI: 10.7759/cureus.36033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2023] [Indexed: 03/14/2023] Open
Abstract
Investigation of the relationship between urethrocutaneous fistula (UCF) development and haematological parameters after hypospadias surgery was aimed for in this study. Patients who underwent tubularized incised plate urethroplasty between January 2015 and June 2021 with the diagnosis of distal hypospadias were included in the study. We divided the participants into two groups based on UCF development. We compared haematological parameters, including neutrophil, lymphocyte, and platelet counts; neutrophil-lymphocyte ratio (NLR); platelet-lymphocyte ratio (PLR); and systemic immune inflammation index (SII) values between the two groups. A total of 78 patients were included in the study. Of the patients, 11 developed UCF. The mean age of the patients was 74.9 ± 42.8 months. Catheter diameter, operation time, neutrophil counts, NLR, and SII values were similar between those with and without UCF (p > 0.05). However, the UCF group had significantly higher lymphocyte and platelet counts than those without UCF (p < 0.05). Moreover, the PLR value was significantly lower in the UCF group (p < 0.05). Patients who developed UCF post hypospadias surgery had a significant association with altered blood cell counts, including increased lymphocytes and decreased PLR rate. The PLR can be used as a biological marker for UCF development.
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Affiliation(s)
- Kemal Gümüş
- Urology, Mehmet Akif Inan Education and Research Hospital, Şanlıurfa, TUR
| | - Mehmet Demir
- Department of Urology, Harran University, Şanlıurfa, TUR
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Bloesch S, Misra D, Mohd-Amin AT. Management of urethral fistula after hypospadias repair with particular reference to purse-string sutures: a 24-year review. Pediatr Surg Int 2022; 38:919-25. [PMID: 35286476 DOI: 10.1007/s00383-022-05109-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 10/18/2022]
Abstract
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.
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Bar-Yosef Y, Ben-Chaim J, Ekstein M, Ben-David R, Savin Z, Yossepowitch O, Mano R, Dekalo S. Concomitant repair of meatal stenosis and urethral fistula does not increase the risk of fistula recurrence post-hypospadias surgery. Urology 2021; 160:187-190. [PMID: 34896481 DOI: 10.1016/j.urology.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/23/2021] [Accepted: 11/29/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate whether meatal stenosis treated concomitantly with urethral fistula repair alters the results of fistula closure. METHODS A retrospective cohort study, included were all children who underwent local fistula closure following hypospadias repair between 2006-2017. Patients who underwent reoperative urethroplasty were excluded. Data were extracted from electronic records, and missing data were supplied by telephone interviews. Characteristics of patients and fistulas were compared between children who underwent fistula closure only and those who underwent meatoplasty for meatal stenosis during the same surgery. The primary endpoint was fistula recurrence. RESULTS In total, 106 local repairs of urethrocutaneous fistulas were performed during the study period, and 25 of them included concomitant meatoplasty for meatal stenosis. There was no difference in terms of location, size, and number of fistulas or the number of recurrent fistulas between the 81 patients who underwent fistula closure only and the 25 who underwent concomitant meatoplasty. The fistula recurrence rate was 17/81 (21%) for the fistula only group and 5/25 (20%) for the fistula and meatoplasty group after a median follow-up of 7 and 8 years, respectively. Meatoplasty was required in a subsequent procedure in 5/81 in the former group vs. 3/25 patients in the latter group. CONCLUSIONS The presence and repair of meatal stenosis does not alter the recurrence rate of urethrocutaneous fistulas repaired concomitantly following hypospadias repair.
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Affiliation(s)
- Yuval Bar-Yosef
- Pediatric Urology Department, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Jacob Ben-Chaim
- Pediatric Urology Department, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Margaret Ekstein
- Pediatric Urology Department, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Reuben Ben-David
- Pediatric Urology Department, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ziv Savin
- Pediatric Urology Department, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ofer Yossepowitch
- Pediatric Urology Department, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Mano
- Pediatric Urology Department, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Snir Dekalo
- Pediatric Urology Department, Dana-Dwek Children's Hospital, Tel-Aviv Medical Center, Tel-Aviv, Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Chen W, Ma N, Wang W, Ju M. The Application of Multilayer Direct Closure With a Longitudinal Relaxing Incision in Urethrocutaneous Fistula Repair. Ann Plast Surg 2020; 84:317-21. [PMID: 31633549 DOI: 10.1097/SAP.0000000000002056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The simple closure of a urethrocutaneous fistula is technically easy, but direct suture tension is associated with a higher urethral fistula recurrence rate. We describe a multilayer direct closure with a longitudinal relaxing incision in urethrocutaneous fistula repair, avoiding the tension associated with the direct suturing of the surgical skin wound. From March 2015 to January 2018, 46 urethrocutaneous fistulas in 34 patients were repaired at the Hypospadias Center of our hospital. During the operations, after the urethral fistula closure, a longitudinal penile skin incision was created 0.5 to 1.5 cm from the edge of the surgical wound. The penile skin wound was closed, and the longitudinal penile skin incision made during the operation was used as a relaxing incision to reduce the skin tension of the closed fistula area. The urethral fistula repairs were successful, and no signs of infection or poor healing were present at the closure sites of the penile skin wounds. The relaxing incisions gradually healed within 7 to 21 days after operation, and the residual scars were soft and did not significantly differ in color from normal skin. The key to increasing the success rate of urethrocutaneous fistula repair is creating a longitudinal relaxing penile skin incision. The technique aims to avoid the direct suture tension of the penile skin wound, thereby providing a favorable environment for the normal healing of the urethral fistula suture site.
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Abdullaev Z, Agzamkhodjaev S, Chung JM, Lee SD. Risk factors for fistula recurrence after urethrocutaneous fistulectomy in children with hypospadias. Turk J Urol 2020; 47:237-241. [PMID: 33263516 DOI: 10.5152/tud.2020.20323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 11/10/2020] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Zafar Abdullaev
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Pediatric Urology, National Children's Medical Center, Tashkent, Uzbekistan
| | - Saidanvar Agzamkhodjaev
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Pediatric Urology, National Children's Medical Center, Tashkent, Uzbekistan
| | - Jae Min Chung
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Urology, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Don Lee
- Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Urology, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Hyuga T, Hashimoto D, Matsumaru D, Kumegawa S, Asamura S, Suzuki K, Katayama KI, Nakamura S, Nakai H, Yamada G. Evaluation of surgical procedures of mouse urethra by visualization and the formation of fistula. Sci Rep 2020; 10:18251. [PMID: 33106510 DOI: 10.1038/s41598-020-75184-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/12/2020] [Indexed: 11/08/2022] Open
Abstract
Visualization of the surgically operated tissues is vital to improve surgical model animals including mouse. Urological surgeries for urethra include series of fine manipulations to treat the increasing number of birth defects such as hypospadias. Hence visualization of the urethral status is vital. Inappropriate urethral surgical procedure often leads to the incomplete wound healing and subsequent formation of urethro-cutaneous fistula or urethral stricture. Application of indocyanine green mediated visualization of the urethra was first performed in the current study. Indocyanine green revealed the bladder but not the urethral status in mouse. Antegrade injection of contrast agent into the bladder enabled to detect the urethral status in vivo. The visualization of the leakage of contrast agent from the operated region was shown as the state of urethral fistula in the current hypospadias mouse model and urethral stricture was also revealed. A second trial for contrast agent was performed after the initial operation and a tendency of accelerated urethral stricture was observed. Thus, assessment of post-surgical conditions of urogenital tissues can be improved by the current analyses on the urethral status.
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Misra D, Amin AM, Vareli A, Lee L, McIntosh M, Friedmacher F. Urethral fistulae following surgery for scrotal or perineal hypospadias: A 20-year review. J Pediatr Urol 2020; 16:447.e1-447.e6. [PMID: 32654895 DOI: 10.1016/j.jpurol.2020.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/04/2020] [Accepted: 06/12/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Urethral fistulae (UF) following hypospadias surgery can be a frustrating complication with reports of even 15 attempts to close a difficult fistula (Richter 2003). UF occurring in scrotal or perineal hypospadias (SPH) pose a further challenge because of the under-virilised penis. OBJECTIVE To review the outcomes of a single surgeon's experience over 20 years of managing UF in SPH. To analyse the traditional approach of fistula closure and three alternative techniques. MATERIALS AND METHODS A prospectively maintained database of patients who underwent hypospadias surgery for SPH from January 1997 to September 2018 was reviewed. Patients with UF were identified and their data recorded. The techniques of fistula closure were: a-Traditional approach. b Purse-string closure. c. Right angle intersection technique where the skin and urethra are closed at right angles to each other. d Anchoring skin to corpora away from the fistula closure. RESULTS 32 patients with 41 fistulae were identified. Follow-up ranged from 1 to 18 years. 10/32 (31%) had concomitant meatal stenosis or urethral strictures. The sites of UF were: penoscrotal 19/41 (46%), midpenile 14/41 (34%), coronal or subcoronal in 8/41 (20%). One fistula resolved spontaneously after a single urethral dilatation. 4 patients with a coronal fistula were laid open to the glandular meatus creating a coronal hypospadias, with redo-urethroplasty later (in 2 a buccal graft was used). Of the rest, 29 fistulae were cured after one surgery, while 7 needed two attempts. No patient needed more than two surgeries to close the fistula. The recurrence rates were as follows- Purse-string suture: 10%, Right angle intersection technique: 14.3%, Anchoring skin to corpora: 16.7%, Traditional approach: 21.7%. Although the purse-string suture technique had the lowest recurrence rate, the figures did not reach statistical significance (P-0.95). CONCLUSION Urethral fistulae occurring in SPH pose challenges because of the under-virilised penis. A third of patients may have meatal stenosis or urethral strictures which must be identified and dealt with. The three novel techniques we employed helped drive down our recurrence rate. Purse string sutures reduce the weak area to a dot and are an excellent way to deal with small fistulae (<5 mm). Other innovations include offsetting the skin suture line by anchoring it to the penile shaft well away from the fistula repair or closing the fistula and skin at right angle to each other. The fact that no patient needed more than two operations to lose the UF, was gratifying.
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Affiliation(s)
- Devesh Misra
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK.
| | - Amir Mohd Amin
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Anastasia Vareli
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Leonie Lee
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Mikhailia McIntosh
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Florian Friedmacher
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
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Eryilmaz R, Şimşek M, Aslan R, Beger B, Ertaş K, Taken K. The effect of plasma rich platelet graft on post-operative complications in mid-penile hypospadias. Andrologia 2020; 52:e13652. [PMID: 32436309 DOI: 10.1111/and.13652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/26/2020] [Accepted: 04/29/2020] [Indexed: 01/01/2023] Open
Abstract
Hypospadias is one of the most common penile congenital anomalies, which often requires a surgical approach. After the hypospadias is repaired, urethral fistula can occur in around 20% of patients. In this study, we used platelet-rich plasma (PRP) to reduce the urethral fistula and other post-operative complications after hypospadias repair. Only patients with primary mid-penile hypospadias were included study. Patients with forms other than mid-penile hypospadias and cases with previous hypospadias surgery were excluded from the study. A total of 40 hypospadias patients were included in this study. These patients were divided into groups A and B with 20 patients in each group. Hypospadias repair was performed with the Snodgrass TIPU technique on both groups. PRP was used with group A, and PRP was not use with group B. These two groups were compared in terms of early and long-term post-operative complications. Both early and long-term post-operative UCF, urethral stenosis and post-operative infection rates were lower in the group using PRP, group A. PRP has the potential to prevent post-operative complications occurring after hypospadias repair, particularly post-operative infection.
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Affiliation(s)
- Recep Eryilmaz
- Department of Urology, Yuzuncu Yil University, School of Medicine, Van, Turkey
| | - Metin Şimşek
- Department of Pediatric Surgery, Van Education and Research Hospital, Van, Turkey
| | - Rahmi Aslan
- Department of Urology, Yuzuncu Yil University, School of Medicine, Van, Turkey
| | - Burhan Beger
- Department of Pediatric Surgery, Yuzuncu Yil University, School of Medicine, Van, Turkey
| | - Kasım Ertaş
- Department of Urology, Yuzuncu Yil University, School of Medicine, Van, Turkey
| | - Kerem Taken
- Department of Urology, Yuzuncu Yil University, School of Medicine, Van, Turkey
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Pescheloche P, Parmentier B, Hor T, Chamond O, Chabaud M, Irtan S, Audry G. Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: A 12-year experience. J Pediatr Urol 2018; 14:421.e1-421.e6. [PMID: 29859768 DOI: 10.1016/j.jpurol.2018.03.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/31/2018] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Fistulas are a common complication of hypospadias surgery; they are more frequent after mid-shaft and posterior hypospadias repair. Surgical treatment of fistula still remains challenging with a significant failure rate. The basic principle is to add layers between skin and neourethra in order to decrease the incidence of recurrent urethrocutaneous fistula (UCF). We report our experience of UCF repair using a vascularized tunica vaginalis flap (TVF) after posterior and mid-shaft hypospadias surgery. MATERIAL AND METHODS A retrospective review of all patients operated on using TVF for UCF in our institution between December 2005 and July 2017 was performed. RESULTS Among 36 cases, TVF was used at a first attempt in 22 patients; 14 children had a prior attempt to close the fistula, and four of them had two surgeries before TVF repair. UCF was respectively penoscrotal (n = 3, 8%), posterior (n = 19, 53%), midshaft (n = 9, 25%) and anterior (n = 5, 14%). The size of the fistula was more than 5 mm in 26 patients. The UCF was treated successfully in every case after one single procedure. In the three children with two fistulas, both fistulas were successfully treated by the same TVF. After an average follow-up time of 45 months there was no recurrence of the initial UCF. In four cases of undescended testis, it was possible to dissect the flap through an inguinal incision and perform an orchydopexy in the same time. One patient presented a testicular atrophy after undescended testis surgery. DISCUSSION Area review of published series shows excellent results in UCF repair including recurrent fistula (Table). TVF can aspire to some advantages with regard to a dartos flap (DF). First of all, a nearly 2.5-fold lower incidence of fistula after fistula repair with TVF than with DF (5.1% vs. 12.2%) has been shown. Secondly, TVF allows treating multiple fistulas, and can also be brought to the anterior part of the penis until the balano preputial furrow, allowing curing anterior fistula. Furthermore, it doesn't lead to aesthetic complications such as penile rotation or distal skin necrosis, which can occur during DF procedures. CONCLUSION TVF is a simple and reproductive technique for UCF repair, with a high success rate. The risk of testicular atrophy has to be considered in case of associated undescended testis surgery, and careful attention must be given to the TVF dissection. This technique should be considered as first choice treatment for any UCF.
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Affiliation(s)
- Pierre Pescheloche
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France.
| | - Benoit Parmentier
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Thevy Hor
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Olivier Chamond
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Maud Chabaud
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Sabine Irtan
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
| | - Georges Audry
- Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, Sorbonne Universités, Paris, France
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Han W, Zhang W, Sun N. Risk factors for failed urethrocutaneous fistula repair after transverse preputial island flap urethroplasty in pediatric hypospadias. Int Urol Nephrol 2018; 50:191-5. [PMID: 29282594 DOI: 10.1007/s11255-017-1773-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We review our experience in urethrocutaneous fistula (UCF) repair after transverse preputial island flap urethroplasty (Duckett) in pediatric hypospadias to investigate the risk factors for unsuccessful outcome. METHODS Two hundred and nineteen UCFs repairs conducted in our center from January 2015 to December 2016 after Duckett technique were retrospectively reviewed and 182 had a follow-up for more than 6 months. The age of patients, size, localization and numbers of UCFs, interval time of two operations, length of neourethra, times of UCFs repairs, complications other than UCFs, hospital of primary surgery and postoperative infection were analyzed as potential risk factors. Stratified analysis and assessment of additive interaction were performed to have a better understanding of the relation between the risk factors. Logistic regression analysis was used for multivariate analysis. RESULTS UCF repairs were succeeded in 121 (66.5%) and failed in 61 (33.5%) at first operation. In the univariate analysis, size and numbers of UCFs (P = 0.01 and P = 0.035, respectively), interval time of two operations (P = 0.042) and hospital of primary surgery (P = 0.02) were statistically related with the outcome. In the multivariate analysis, UCF ≥ 2 (OR 2.71, 95%, CI 1.095-6.692, P = 0.031), size ≥ 2 mm (OR 2.45, 95% CI 1.267-4.757, P = 0.08) and primary surgery not at our hospital (OR 2.21, 95% CI 1.094-4.126, P = 0.026) were identified as independent risk factors for unsuccessful outcome. In the stratified analysis, multiplicative interaction between the 3 risk factors was not found. CONCLUSIONS Our study suggested that UCF repairs after transverse preputial island flap urethroplasty were easier to fail if the UCF was ≥ 2 mm, the numbers of UCFs was ≥ 2, or the surgeon had less experience. The age of patients, site of UCFs, interval time of two operations, length of neourethra, times of UCFs repairs, complications other than UCF and postoperative infection were not significantly related to the success rate of UCF repair.
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Kranz J, Brinkmann OA, Brinkmann B, Steffens J, Malone P. [Patio repair for urethrocutaneous fistulae : Results of a multicentre retrospective study]. Urologe A 2017; 56:1282-1288. [PMID: 28819828 DOI: 10.1007/s00120-017-0490-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Urethrocutaneous (UC) fistulae are common complications after hypospadias surgery and they have been a serious problem for surgeons since the repair was first attempted. We present the results of our multicentre retrospective study for repairing UC fistulae using the Patio ("preserve the tract and turn it inside out") repair described by Malone. MATERIALS AND METHODS A total of 16 boys (Eschweiler 2, Lingen 4, Reading 10) at the ages of 1-10 years were treated for UC fistulae. Instead of excising the fistula tract, it is preserved and turned inside out, this creates a flap valve inside the urethral lumen. After a circumferential incision around the skin and meticulous dissection of the fistula tract, a 2/0 nylon suture is passed down the tract and brought out through the external urinary meatus. As a result, the fistula tract is inserted into the urethral lumen. In order to keep the fistula tract inverted, it is sutured to the tip of the external urinary meatus, or fixed by an angler lead (modification from Lingen). Due to the narrow base, the excess tissue atrophies postoperatively and leads to an appealing cosmetic result. RESULTS A total of 9 fistula repairs were performed on an outpatient basis without using a transurethral catheter; 7 boys were treated on an inpatient basis with an average length of stay in the hospital for 1-2 days with/without catheterization. During a mean follow-up of up to 4.5 years, only one fistula recurrence occurred; no other complications were observed. CONCLUSION The Patio repair for urethrocutaneous fistula is an outpatient, simply reproducible surgical technique without the necessity of transurethral catheterization. The short-term results are impressive; long-term results of a larger patient cohort will follow.
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Affiliation(s)
- J Kranz
- Klinik für Urologie und Kinderurologie, St.-Antonius-Hospital Eschweiler, Akademisches Lehrkrankenhaus der RWTH Aachen, Dechant-Deckers-Straße 8, 52249, Eschweiler, Deutschland.
| | - O A Brinkmann
- Klinik für Urologie und Kinderurologie, Bonifatius Hospital Lingen, Lingen, Deutschland
| | - B Brinkmann
- Klinik für Urologie und Kinderurologie, Bonifatius Hospital Lingen, Lingen, Deutschland
| | - J Steffens
- Klinik für Urologie und Kinderurologie, St.-Antonius-Hospital Eschweiler, Akademisches Lehrkrankenhaus der RWTH Aachen, Dechant-Deckers-Straße 8, 52249, Eschweiler, Deutschland
| | - P Malone
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, Großbritannien
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Feng J, Yang Z, Tang Y, Chen W, Zhao MX, Ma N, Wang WX, Xu LS, Li YQ. Risk Factors for Urethrocutaneous Fistula Repair After Hypospadias Surgery: A Retrospective Study. Ann Plast Surg 2017; 79:e41-4. [PMID: 28570466 DOI: 10.1097/SAP.0000000000001128] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Saavedra-Belaunde JA, Soto-Aviles O, Jorge J, Escudero K, Vazquez-Cruz M, Perez-Brayfield M. Can regional anesthesia have an effect on surgical outcomes in patients undergoing distal hypospadia surgery? J Pediatr Urol 2017; 13:45.e1-45.e4. [PMID: 27956108 DOI: 10.1016/j.jpurol.2016.09.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/24/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Caudal and penile blocks are the most popular regional anesthetic techniques used in infants and children undergoing urological surgery. A recent report has suggested that penile venous pooling resulting from caudal blocks could affect surgical outcomes after hypospadias operations. OBJECTIVE The aim was to report our experience in patients with distal hypospadias undergoing repair with caudal versus penile block. STUDY DESIGN A retrospective clinical database was constructed for patients who underwent distal hypospadias repair by a single surgeon (M.P.B.) at our sponsoring institutions for the time period 2008-2013 (n = 192). Collected data included hypospadias classification (glanular, coronal, subcoronal), chordee status, perioperative anesthesia (caudal vs. penile), and assessment of postoperative complications (fistula and meatal stenosis). RESULTS Risk ratio (RR) analysis for all distal hypospadias cases revealed that there is a higher risk of developing complications in patients who underwent caudal anesthesia than in patients who underwent penile block RR for a complication was 3.70 (95% CI 1.05-13.03; p < 0.04) (Figure). DISCUSSION Similar to other papers in the literature, we found that patients who underwent caudal anesthesia had more complications than those who underwent penile block. The limitations of this study include not adjusting the results according to the severity of hypospadias. CONCLUSION The main goal of this study was accomplished by demonstrating that, in our series, caudal anesthesia is associated with a higher risk of fistula formation after undergoing distal hypospadias repair than penile block.
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Affiliation(s)
| | - Omar Soto-Aviles
- Department of Urology, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | - Juan Jorge
- Department of Urology, University of Puerto Rico School of Medicine, San Juan, PR, USA
| | | | | | - Marcos Perez-Brayfield
- Department of Urology, University of Puerto Rico School of Medicine, San Juan, PR, USA; HIMA San Pablo, Bayamon, PR, USA
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Rathod K, Loyal J, More B, Rajimwale A. Modified PATIO repair for urethrocutaneous fistula post-hypospadias repair: operative technique and outcomes. Pediatr Surg Int 2017; 33:109-112. [PMID: 27696000 DOI: 10.1007/s00383-016-3983-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2016] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
| | - Jaskiren Loyal
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Bharat More
- University Hospitals of Leicester NHS Trust, Leicester, UK
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15
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Appiah KA, Gyasi-Sarpong CK, Azorliade R, Aboah K, Laryea DO, Otu-Boateng K, Baah-Nyamekye K, Maison PO, Arthur D, Antwi IO, Frimpong-Twumasi B, Yenli EM, Togbe SK, Amoah G. Circumcision-related tragedies seen in children at the Komfo Anokye Teaching Hospital, Kumasi, Ghana. BMC Urol 2016; 16:65. [PMID: 27825332 DOI: 10.1186/s12894-016-0183-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 10/27/2016] [Indexed: 11/25/2022] Open
Abstract
Background Circumcision is a common minor surgical procedure and it is performed to a varying extent across countries and religions. Despite being a minor surgical procedure, major complications may result from it. In Ghana, although commonly practiced, circumcision-related injuries have not been well documented. This study is to describe the scope of circumcision-related injuries seen at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Methods The study was conducted at the Urology Unit of the Komfo Anokye Teaching Hospital in Kumasi. Consecutive cases of circumcision-related injuries seen at the unit over an 18 month period were identified and included in the study. Data was collected using a structured questionnaire. Data was entered and analysed using SPSS version 16. Charts and tables were generated using Microsoft Excel. Results A total of 72 cases of circumcision-related injuries were recorded during the 18 month period. Urethrocutaneous fistula was the commonest injury recorded, accounting for 77.8 % of cases. Other injuries recorded were glans amputations (6.9 %); iatrogenic hypospadias (5.6 %), and epidermal inclusion cysts (2.8 %). The majority of children were circumcised in health facilities (75 %) and nurses were the leading providers (77.8 %). The majority of circumcisions were conducted in the neonatal period (94.7 %). Conclusion Circumcision-related injuries commonly occurred in the neonatal period. Most of the injuries happened in health facilities. The most common injury recorded was urethrocutaneous fistula but the most tragic was penile amputation. There is the need for education and training of providers to minimise circumcision-related injuries in Ghana.
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Fahmy O, Khairul-Asri MG, Schwentner C, Schubert T, Stenzl A, Zahran MH, Gakis G. Algorithm for Optimal Urethral Coverage in Hypospadias and Fistula Repair: A Systematic Review. Eur Urol 2016; 70:293-8. [DOI: 10.1016/j.eururo.2015.12.047] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 12/29/2015] [Indexed: 11/30/2022]
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Benlice C, Yildiz M, Baghaki S, Erguner I, Olgun DC, Batur S, Erdamar S, Ambarcioglu P, Hamzaoglu I, Karahasanoglu T, Baca B. Fistula tract curettage and the use of biological dermal plugs improve high transsphincteric fistula healing in an animal model. Int J Colorectal Dis 2016; 31:291-9. [PMID: 26310797 DOI: 10.1007/s00384-015-2374-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2015] [Indexed: 02/07/2023]
Abstract
PURPOSE The treatment of high transsphincteric fistula is a complex procedure, which may be associated with the risk of recurrence and fecal incontinence. In this study, we used an animal model to compare different types of sphincter-preserving treatments for transsphincteric fistula. METHODS Sixteen female New Zealand rabbits, weighing 2.8-4.8 kg underwent a surgical creation of high transsphincteric fistula. After 6 weeks, magnetic resonance imaging (MRI) was performed in order to confirm fistula formation and measure the fistula diameter. The rabbits were divided into three groups. Group 1 received no plug treatment (control). Autologous dermal graft and acellular dermal matrix were used as a plug in groups 2 and 3, respectively. Five weeks after treatment, fistula tract healing was determined by measuring the largest fistula diameter with MRI. All rabbits were euthanized and the anorectum excised en bloc for histopathological examination. RESULTS According to the MRI findings, all groups showed significant healing after the treatment (p < 0.05). The healing rate of fistula diameters after treatment was 40, 66, and 29% in the control, dermal graft, and acellular dermal matrix groups, respectively. In terms of negative healing parameters such as neutrophil, eosinophil, lymphocyte, and plasmocyte accumulation, dermal graft and acellular dermal matrix groups showed significantly lower results than those in the control group (p < 0.05). CONCLUSION According to MRI and histopathological results, fistula tract curettage and fistula orifice closure improved transsphincteric anal fistula healing. Additionally, in this study, plug treatment favoring autologous dermal graft resulted in better healing.
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Nozohoor Ekmark A, Svensson H, Arnbjörnsson E, Hansson E. Failed hypospadias repair: An algorithm for secondary reconstruction using remaining local tissue. J Plast Reconstr Aesthet Surg 2015. [PMID: 26195272 DOI: 10.1016/j.bjps.2015.06.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Salvage hypospadias surgery is performed after failed primary reconstruction. Several treatment strategies have been suggested, all with pros and cons. The aim of this study was to evaluate our treatment algorithm for primary hypospadias repair applied to secondary cases in which a salvage procedure is indicated and, most importantly, local tissue is present. The algorithm was applied to 36 consecutive patients who had undergone a total of 109 surgical procedures before referral. In accordance with the algorithm, 12 patients without ventral curvature achieved a satisfactory result with one procedure by the use of local skin flaps. Six patients with moderate ventral curvature underwent orthoplasty, fistula closure, and/or urethral reconstruction using local skin flaps in one session. Eighteen patients with a severe ventral curvature or a proximal meatus were reconstructed in two stages using Byars' technique. After a median of two salvage procedures (range: 1-4), all patients but one, who awaits splitting of a skin bridge in the meatus, were successfully reconstructed. Two patients in active follow-up have potential problems requiring further surgery. Our findings indicate that failed hypospadias repairs are often due to an underestimation of the ventral curvature at the initial repair. Therefore, reevaluation of the degree of curvature is important. One-stage salvage repairs can be used, provided that none or minimal curvature remains. In cases of marked curvature, however, a meticulous resection of the chordee and ventral scarring is crucial. The subsequent repair of the large ventral defect and the long urethral reconstruction can, in most cases, be safely managed in a two-stage procedure.
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Affiliation(s)
- Ann Nozohoor Ekmark
- Departments of Clinical Sciences in Malmö, Lund University, Lund, Sweden; Paediatric Surgery, Skåne University Hospital, Lund, Sweden.
| | - Henry Svensson
- Departments of Clinical Sciences in Malmö, Lund University, Lund, Sweden; Departments of Plastic and Reconstructive Surgery, Skåne University Hospital, Sweden
| | - Einar Arnbjörnsson
- Clinical Sciences Lund, Lund University, Lund, Sweden; Paediatric Surgery, Skåne University Hospital, Lund, Sweden
| | - Emma Hansson
- Departments of Clinical Sciences in Malmö, Lund University, Lund, Sweden; Departments of Plastic and Reconstructive Surgery, Skåne University Hospital, Sweden
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Ochi T, Seo S, Yazaki Y, Okawada M, Doi T, Miyano G, Koga H, Lane GJ, Yamataka A. Traction-assisted dissection with soft tissue coverage is effective for repairing recurrent urethrocutaneous fistula following hypospadias surgery. Pediatr Surg Int 2015; 31:203-7. [PMID: 25520268 DOI: 10.1007/s00383-014-3652-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Urethrocutaneous fistula (UCF) complicating hypospadias surgery is associated with compromised tissue and perfusion at the UCF site, especially if recurrent. We report our technique for UCF repair. METHODS Between 1997 and 2014, we treated 35 UCF in 26 postoperative hypospadias patients; 12 UCF were recurrent (mean 2.5; range 1-5). Mean age at UCF repair was 9.3 years (range 2-22). Our repair involves making a superficial incision 3-5 mm around the fistula orifice, placing multiple stay sutures in the outer edge of this incision and dissecting only the epidermis under traction for 7-10 mm. This technique does not compromise underlying connective tissue or tissue perfusion. The skin layer of the inner edge of the circumferential incision is trimmed completely and the fistula closed using 7/0 absorbable interrupted sutures. A pedicled external spermatic fascia, or tunica vaginalis flap is then mobilized to cover the repair site through a subcutaneous tunnel and the skin closed. A urethral catheter is placed and removed the next day. Duration of follow-up was calculated as the period from discharge home until the last outpatient clinic attendance. RESULTS Repair was successful in all cases. Penile cosmesis was acceptable to good without any testicular complications or scrotal deformity. At mean follow-up of 7.4 years (range 0.4-17.3) there have been no recurrences. CONCLUSIONS Our technique allows UCF to be repaired effectively and is also indicated for recurrences.
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Ambriz-González G, Aguirre-Ramirez P, García-de León JM, León-Frutos FJ, Montero-Cruz SA, Trujillo-Trujillo XAR, Fuentes-Orozco C, Macías-Amezcua MD, del Socorro Álvarez-Villaseñor A, Cortés-Flores AO, Chávez-Tostado M, González-Ojeda A. 2-octyl cyanoacrylate versus reintervention for closure of urethrocutaneous fistulae after urethroplasty for hypospadias: a randomized controlled trial. BMC Urol 2014; 14:93. [PMID: 25416602 PMCID: PMC4246544 DOI: 10.1186/1471-2490-14-93] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 11/10/2014] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Urethrocutaneous fistulae (UCFs) represent one of the most frequent causes of morbidity after urethroplasty. Hypospadias can be repaired using different surgical techniques, but-regardless of technique-the incidence of UCF ranges between 10% and 40%. Surgical repair of UCF remains the treatment of choice, even if some patients need further surgery because of recurrences. Cyanoacrylates have been used as skin suture substitutes, and some evidence suggests a beneficial effect when these adhesives are used as an adjuvant in the management of UCF. Here we describe the results of management of UCF using 2-octyl cyanoacrylate (OCA) compared with surgical repair. METHODS A randomized clinical trial conducted from January 2008 to December 2012 included 42 children with UCF complications after urethroplasty for hypospadias. Twenty-one children were assigned to receive OCA as ambulatory patients and 21 were treated surgically. The main outcome variable was closure of the UCF. The estimated costs of both treatments were also calculated, as were absolute risk reduction (ARR), relative risk reduction (RRR) and number needed to treat (NNT) to prevent a surgical intervention. RESULTS The mean numbers of UCF were 1.3 in the OCA group (n = 28) and 1.1 in the surgical group (n = 25) with no statistically significant difference. The external orifices measured were 2.96 ± 1.0 mm and 3.8 ± 0.89 mm, respectively (NS). Sixty per cent of the UCFs treated with cyanoacrylate were completely closed and 68% of the surgical group healed completely (NS). More than one reoperation to improve complications was needed in the surgical group (3.5 ± 1.2). The clinical significance of the therapeutic usefulness of OCA was demonstrated by an ARR of 0.08, RRR of 0.25 and NNT of 12 to avoid further surgical treatment. The total costs of adhesive applications and reoperations were $US 14,809.00 and $US 158,538.50, respectively. CONCLUSIONS The results showed a similar success rate for both treatments. However, sealant use should be considered before surgical treatment because this is a simple outpatient procedure with a reasonable success rate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02115191. Date: April 13, 2014.
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Affiliation(s)
- Gabriela Ambriz-González
- />Pediatrics Surgery Department, Medical Unit of High Specialty, Pediatrics Hospital of the Western Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco México
- />Pediatrics Urology Department, Medical Unit of High Specialty, Pediatrics Hospital of the Western Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco México
| | - Pedro Aguirre-Ramirez
- />Pediatrics Urology Department, Medical Unit of High Specialty, Pediatrics Hospital of the Western Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco México
| | - José Manuel García-de León
- />Pediatrics Surgery Department, Medical Unit of High Specialty, Pediatrics Hospital of the Western Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco México
- />Pediatrics Urology Department, Medical Unit of High Specialty, Pediatrics Hospital of the Western Medical Center, Mexican Institute of Social Security, Guadalajara, Jalisco México
| | | | | | | | - Clotilde Fuentes-Orozco
- />Research Unit in Clinical Epidemiology, Medical Unit of High Specialty, Specialties Hospital of the Western Medical Center, Mexican Institute of Social Security, Avenida Belisario Domínguez 1000, Colonia Independencia, CP 44340 Guadalajara, Jalisco México
| | - Michel Dassaejv Macías-Amezcua
- />Research Unit in Clinical Epidemiology, Medical Unit of High Specialty, Specialties Hospital of the Western Medical Center, Mexican Institute of Social Security, Avenida Belisario Domínguez 1000, Colonia Independencia, CP 44340 Guadalajara, Jalisco México
| | | | - Ana Olivia Cortés-Flores
- />Research Unit in Clinical Epidemiology, Medical Unit of High Specialty, Specialties Hospital of the Western Medical Center, Mexican Institute of Social Security, Avenida Belisario Domínguez 1000, Colonia Independencia, CP 44340 Guadalajara, Jalisco México
| | - Mariana Chávez-Tostado
- />Research Unit in Clinical Epidemiology, Medical Unit of High Specialty, Specialties Hospital of the Western Medical Center, Mexican Institute of Social Security, Avenida Belisario Domínguez 1000, Colonia Independencia, CP 44340 Guadalajara, Jalisco México
| | - Alejandro González-Ojeda
- />Research Unit in Clinical Epidemiology, Medical Unit of High Specialty, Specialties Hospital of the Western Medical Center, Mexican Institute of Social Security, Avenida Belisario Domínguez 1000, Colonia Independencia, CP 44340 Guadalajara, Jalisco México
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Karakuş OZ, Ateş O, Tekin A, Hakgüder G, Olguner M, Akgür FM. Tubularized incised plate urethroplasty for the treatment of penile fistulas after hypospadias repair. J Pediatr Urol 2014; 10:455-8. [PMID: 24309516 DOI: 10.1016/j.jpurol.2013.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 10/29/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Urethrocutaneous fistula is the most common complication of hypospadias repair. Tubularized incised plate urethroplasty (TIPU) has been used for the management of distal fistulas. This study reports the usage of TIPU in the treatment of large penile fistulas. MATERIALS AND METHODS Between April 2002 and September 2012, 15 patients with large penile fistulas who were managed with TIPU were included in the study. The fistulas were sited along the penile shaft from proximal to distal penile localization. Glanular and coronal fistulas were excluded. The surgical technique was completed according to the standard TIPU technique. The surrounding scar tissue of the fistula was circumferentially excised, and the urethral plate at the level of the fistula was incised to provide performance of loose urethral tubularization. A urethral stent was kept for 5-7 days. RESULTS The mean age of the patients was 7.3 ± 3.1 years. Primary operation of these patients was tubularized preputial island flap (n = 6), on-lay preputial island flap (n = 4), and TIPU (n = 5). The sites of the hypospadias fistulas were as follows; penoscrotal (three), mid-penile (eight) and subcoronal (four). Fistulas recurred in two patients after fistula repair. The postoperative follow up of the patients was 12.4 ± 7.7 months. CONCLUSION TIPU may be used safely for the treatment of fistulas after hypospadias repair.
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Affiliation(s)
- O Z Karakuş
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey.
| | - O Ateş
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - A Tekin
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - G Hakgüder
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - M Olguner
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
| | - F M Akgür
- Department of Pediatric Surgery, Dokuz Eylül University, Medical School, Izmir, Turkey
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Soyer T, Ayva Ş, Boybeyi Ö, Aslan MK, Çakmak M. The effect of platelet rich fibrin on growth factor levels in urethral repair. J Pediatr Surg 2013; 48:2545-9. [PMID: 24314201 DOI: 10.1016/j.jpedsurg.2013.06.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 06/15/2013] [Accepted: 06/20/2013] [Indexed: 11/19/2022]
Abstract
AIM Platelet rich fibrin (PRF) is an autologous source of growth factors and promotes wound healing. An experimental study was performed to evaluate the effect of PRF on growth factor levels in urethral repair. MATERIALS AND METHODS Eighteen Wistar albino rats were included in the study. Rats were allocated in three groups (n:6): control (CG), sham (SG), and PRF (PRFG). In SG, a 5 mm vertical incision was performed in the penile urethra and repaired with 10/0 Vicryl® under a microscope. In PRFG, during the urethral repair as described in SG, 1 cc of blood was sampled from each rat and centrifuged for 10 minutes at 2400 rpm. PRF obtained from the centrifugation was placed on the repair site during closure. Penile urethras were sampled 24 hours after PRF application in PRFG and after urethral repair in SG. Transforming growth factor beta receptor (TGF-β-R-CD105), vascular endothelial growth factor (VEGF) and its receptor (VEGF-R), as well as endothelial growth factor receptor (EGFR), were evaluated in subepithelia of the penile skin and urethra. Groups were compared for growth factor levels and growth factor receptor expression with the Kruskal Wallis test. RESULTS TGF-β-R levels were significantly decreased in SG when compared to CG (p<0.05). In PRFG, TGF-β-R was increased in both subepithelia of penile skin and urethra with respect to SG (p<0.05). When VEGF levels and its receptor expression were compared between SG and PRFG, VEGF levels were found to be increased in penile skin subepithelium, whereas VEGF-R expressions were decreased in urethral subepithelia in PRFG (p<0.05). There was no difference between groups for EGFR levels (p>0.05). CONCLUSION Use of PRF after urethral repair increases TGF-β-R and VEGF expressions in urethral tissue. PRF can be considered as an alternative measure to improve the success of urethral repair.
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Affiliation(s)
- Tutku Soyer
- Department of Pediatric Surgery, Hacettepe University, School of Medicine, Ankara, Turkey.
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Soyer T, Çakmak M, Aslan MK, Şenyücel MF, Kisa Ü. Use of autologous platelet rich fibrin in urethracutaneous fistula repair: preliminary report. Int Wound J 2012; 10:345-7. [PMID: 22568526 DOI: 10.1111/j.1742-481x.2012.00983.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Urethrocutaneous fistula (UCF) is one of the most common complications occurring after hypospadias repair. Despite the surgical advancement in hypospadias, multiple failed fistula closures are commonly referred to paediatric urologists. Although several techniques have been described to interpose a waterproof layer between urethral and skin closures, occurrence of urethrocutaneous fistula cannot be eliminated completely. In addition to several local tissue grafts, autologous and homologous fibrin sealants are used to prevent UCF. Platelet rich fibrin (PRF) is known as an autologous source of growth factors obtained from the sera of the patient. PRF supports collagen synthesis and tissue repair and accelerates wound healing. We aimed to present our initial experience about the use of autologous PRF in a 3-year-old boy with a UCF after hypospadias repair.
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Affiliation(s)
- Tutku Soyer
- Department of Pediatric Surgery, School of Medicine, Kırıkkale University, 71100 Kırıkkale, Turkey.
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Józsa T, Csízy I, Csiszkó A, Boros M, Roszer T, Nyirády P. Double unfurled dartos flap technique in the surgical treatment of recurrent urethrocutaneous fistulas. Urol Int 2011; 87:380-4. [PMID: 21849763 DOI: 10.1159/000329776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 05/30/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND The management of recurrent urethrocutaneous fistula (RUCF) is a challenging problem that poses a serious difficulty for the hypospadias surgeon. We report here a novel technique in which a double unfurled dartos subcutaneous flap is utilized in the treatment of patients with RUCF. METHODS We retrospectively reviewed the records of all our patients who underwent surgical treatment of urethrocutaneous fistula with this new operative method after previously failed fistula repair. The main novelty of this technique is the use of two opposite medium thickness flaps, unfurled from the inner surface of the dartos fascia and spread over the fistula and each other so as to cover the urethral suture line completely, and fixed to the surrounding corporal tissue. RESULTS Eight patients with 11 RUCFs (with localizations varying from subcoronal to penoscrotal fistula opening) underwent surgical correction with the new method. There had previously been at least 3 recurrences in 6 of these patients, and different closure techniques had been used. RUCF diameter was <4 mm in all patients. Surgery was performed at the earliest following a 6-month healing period since the last fistula repair attempt. All of the RUCFs were repaired successfully with the technique. After a follow-up of at least 6 months, none of the 8 patients had developed recurrence of the fistula, and there were no postoperative complications. CONCLUSION The double unfurled dartos subcutaneous flap method appears to be a simple and appropriate procedure with which to repair recurrent mid-shaft and proximal urethral fistulas after failed hypospadias repair.
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Affiliation(s)
- Tamás Józsa
- Institute of Pediatrics, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary. jozsa_tamas @ freemail.hu
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Kajbafzadeh AM, Abolghasemi H, Eshghi P, Alizadeh F, Elmi A, Shafaattalab S, Dianat S, Amirizadeh N, Mohseni MJ. Single-donor fibrin sealant for repair of urethrocutaneous fistulae following multiple hypospadias and epispadias repairs. J Pediatr Urol 2011; 7:422-7. [PMID: 20634140 DOI: 10.1016/j.jpurol.2010.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Accepted: 06/10/2010] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the efficacy of fibrin sealant for repair of urethrocutaneous fistula after multiple failed hypospadias and epispadias surgeries. MATERIALS AND METHODS The study population comprised 11 boys (mean age 12.18 years) with history of hypospadias or epispadias and at least two failed fistula repair operations leading to recurrent urethrocutaneous fistula. During the operation, single-donor fibrin glue, either from the patient (7) or a parent (4), was applied over the suture lines and beneath the skin. A urethral catheter was kept in place for 7-10 days. Follow up ranged from 6 to 24 months (mean 12.63 months). RESULTS Nine patients had an uneventful postoperative course. In one patient with a large fistula, partial wound dehiscence occurred. In another patient with complete hypospadias, hematoma formation caused skin dehiscence but the urethra remained intact. Both cases recovered after 6 months with no further intervention. No fistula recurrence was reported during follow up. CONCLUSION Single-donor fibrin glue could be a useful adjunct to surgical management of patients after multiple failed attempts at hypospadias or epispadias fistula repair. Moreover, this product improves the safety margin regarding the risk of disease transmission.
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Affiliation(s)
- Abdol-Mohammad Kajbafzadeh
- Pediatric Urology Research Center, Pediatric Center of Excellence, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
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Prestipino M, Bertozzi M, Nardi N, Appignani A. Outpatient department repair of urethrocutaneous fistulae using n-butyl-cyanoacrylate (NBCA): a single-centre experience. BJU Int 2011; 108:1514-7. [PMID: 21314816 DOI: 10.1111/j.1464-410x.2010.10083.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Marco Prestipino
- S.C. di Clinica Chirurgica Pediatrica, Università degli Studi di Perugia, Ospedale S. Maria della Misericordia, Perugia, Italy
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Abstract
OBJECTIVE To report the challenges and outcomes of hypospadias repair in a developing country such as Nigeria. PATIENTS AND METHODS This was a prospective study of children who underwent hypospadias repair at the University of Benin Teaching Hospital in 2003-2007. The challenges and outcome of repair were documented with photographs to assess cosmetic results. RESULT A total of 149 operations were performed on 127 children with hypospadias, aged between 9 days and 12 years (mean 2.3 years+/-2.1) with 33 (26.0%) presenting after circumcision; 118 (92.9%) were single and 9 (7.1%) multistage, while 13 had closure of post-hypospadias repair fistulae and redo surgery. Non-availability of suitable pediatric urethral catheters, special dressing materials and microsurgical instruments/sutures, presentation after circumcision, and lack of parents/caregivers' motivation were major challenges. Transurethral urinary diversion, dressing with petroleum jelly impregnated with antibiotic/chloramphenicol ointment, mosquito forceps, scrotal skin flaps, size 6/0 polyglactin sutures, and organized counseling/home visits were employed. Repair was successful in all the children: excellent cosmetic results in 121 (95.3%), fair in 5 (3.9%) and poor in 1 (0.9%). Urethrocutaneous fistula was the main complication with no mortality recorded. CONCLUSION Despite the challenges, improvising with available materials, counseling of parents/caregivers, adequate patient recruitment and appropriately timed repairs gave encouraging results.
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Affiliation(s)
- O David Osifo
- Paediatric Surgery Unit, Department of Surgery, University of Benin Teaching Hospital, Benin City, Nigeria.
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Affiliation(s)
- Peter R Malone
- Harold Hopkins Department of Urology, Royal Berkshire NHS Foundation Trust, Reading, Berks, UK.
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Abstract
The tubularized incised plate (TIP) urethroplasty or Snodgrass procedure has gained worldwide acceptance for distal hypospadias repair due to its low complication rate, good cosmetic result, and technical simplicity. As a result, several articles have been published concerning various aspects and subtle variations of this procedure. The aim of this review is to critically and systematically analyze the published complication rates of TIP repair for distal hypospadias in children. We also reviewed the surgical modifications that have been introduced to the original technique and discussed the potential impact on the final outcome of the Snodgrass procedure.
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Affiliation(s)
- Luis Henrique P. Braga
- Division of Urology and University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Armando J. Lorenzo
- Division of Urology and University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Joao L. Pippi Salle
- Division of Urology and University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
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Milla SS, Chow JS, Lebowitz RL. Imaging of hypospadias: pre- and postoperative appearances. Pediatr Radiol 2008; 38:202-8. [PMID: 18071684 DOI: 10.1007/s00247-007-0697-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2007] [Revised: 10/19/2007] [Accepted: 10/30/2007] [Indexed: 10/22/2022]
Abstract
Hypospadias is a common condition that is typically diagnosed and repaired in early life. Boys with hypospadias can present with complications from their surgery months to years later. Imaging in patients with hypospadias is usually accomplished by retrograde urethrography (RUG) and less commonly by voiding cystourethrography (VCUG). This pictorial essay demonstrates the fluoroscopic appearances of hypospadias preoperatively as well as the normal postoperative appearance and a variety of complications that can occur.
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Ayyildiz A, Celebi B, Akgül KT, Nuhoğlu B, Caydere M, Germiyanoğlu C. A comparison of free skin graft, fascia lata, alloderm, bovine pericardium and primary repair in urethrocutaneous fistulas without diversion: an experimental study. Pediatr Surg Int 2006; 22:809-14. [PMID: 16947026 DOI: 10.1007/s00383-006-1769-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2006] [Indexed: 11/28/2022]
Abstract
The purpose of this study is to compare primary repair procedure with those that use bio-concordant materials in the treatment of urethrocutaneous fistula. Twenty-five New Zealand rabbits were randomly placed into five groups (primary repair, free graft, allograft fascia lata, alloderm and bovine pericardium repair groups). A single dose of 20 mg/kg of ceftriaxon was applied intramuscularly as a prophylactic dose. Urethrocutaneous fistula was formed on midpenile level. Later, while primary repair was applied in one group, repair with free grafts and with other bio-concordant materials were performed in other groups. Urinary diversion was not used in any of the rabbits. The macroscopic observation was evaluated with urethrography obtained 21 days after the operation and then the rabbits were sacrificed. A total point was obtained by awarding a point to each good parameter in the histopathological evaluation and all the groups were compared. The urethrographic findings and macroscopic examinations were normal in all groups. In histopathological examinations, ranging from the best to worst results, bovine pericardium group (8 points) had a better total score than primary repair group (7 points), allograft fascia lata group (7 points) and alloderm group (7 points). The free graft group had the worst total point (6 points). Bio-concordant materials can be used in urethrocutaneous fistula repair as an alternative to primary repair or to the grafts obtained from body tissues.
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Affiliation(s)
- Ali Ayyildiz
- Second Urology Clinic, Ministry of Health Ankara Training and Research Hospital, 11. Sokak 18/4, 06500 Bahçelievler, Ankara, Turkey
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Snyder CL, Evangelidis A, Hansen G, St Peter SD, Ostlie DJ, Gatti JM, Gittes GK, Sharp RJ, Murphy JP. Management of complications after hypospadias repair. Urology 2005; 65:782-5. [PMID: 15833528 DOI: 10.1016/j.urology.2004.11.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2004] [Revised: 11/12/2004] [Accepted: 11/19/2004] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To review our experience with hypospadias complications (seen after 10%-15% of repairs) and to identify factors influencing outcome. METHODS We reviewed the available medical records of 113 patients who underwent repeat operation for hypospadias complications. Of the 113 patients, 40% had undergone the initial repair at our institution (internal referral); 60% had undergone the initial repair elsewhere before referral (external referral). The variables potentially affecting outcome were reviewed, including the severity of the defect, concomitant disease, age at the initial operation and revisions, type of complications and treatment, and the number of revisions. Outcomes were compared on the basis of specialty and experience. RESULTS Isolated hypospadias was present in 81% and other genitourinary abnormalities in 10%. External referral patients were older at the first revision (7.3 versus 4.2 years, P = 0.027). Complications included fistula (73%), stricture (12%), breakdown of repair (10%), and diverticulum formation (11%). Successful revision was independent of the initial defect. The first, second, and third revision was successful in 77%, 64%, and 67% of patients, respectively. The cumulative success rate was 77%, 92%, and 97% after each respective repair attempt. The success of the repair was independent of the patient's age at the initial operation/revision and of the interval from the initial repair to reoperation. Internal referral and external referral patients had similar results. Specific experience with the repair of hypospadias complications correlated with a successful outcome (P <0.001). CONCLUSIONS Complications after hypospadias repairs are common, with fistula accounting for approximately 75%. The outcome in our series was independent of hypospadias severity, patient age at repair, number of revisions, stent use, and referral status. Repairs performed by an experienced pediatric urologist were associated with improved outcomes (P <0.001).
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Affiliation(s)
- Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri 64108, USA.
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Abstract
OBJECTIVES To evaluate the efficacy of fascia lata graft in the repair of secondary urethral fistulas. Urethral fistulas may result from a complication of hypospadias repair. The treatment of urethral fistulas is quite challenging. METHODS This technique was used in 8 patients between 2000 and 2002. All patients had undergone hypospadias repair and had recurrent fistula formation. A 2 x 2-cm fascia lata graft was harvested from the lateral aspect of the thigh. After repair of the fistula, the fascia lata graft was placed between the urethra and skin. The mean age of the patients was 8 years (range 5 to 13). RESULTS During 8 to 22 months (average 11) of follow-up, no recurrence of urethral fistula was observed. No complications occurred, and patients were completely satisfied with the results. CONCLUSIONS The results of this study show that the fascia lata graft can be used for the closure of urethral fistula secondary to hypospadias repair. Additional studies are warranted.
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Affiliation(s)
- Eksal Kargi
- Department of Plastic and Reconstructive Surgery, Zonguldak Karaelmas University Faculty of Medicine, Kozlu, Zonguldak, Turkey
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