Interposing fascial pedicle flap for the repair of urethral fistulae after hypospadias surgery

Soft tissue interposition is effective for protecting the neourethra during hypospadias surgery and preventing postoperative urethrocutaneous fistula: a single surgeon's experience of 243 cases

PURPOSE

Soft tissue interposition (STI) during hypospadias repair (HR) purportedly prevents postoperative urethrocutaneous fistula (PUF) by supporting the neourethra. We report our experience.

METHODS

Data from 243 hypospadias patients treated by a single surgeon from 1997 to 2014 by urethroplasty (UP) with STI (n = 229; UP + STI) and UP without STI (n = 14; UP-STI) were collated prospectively and compared for incidence of PUF. Re-operative UP were excluded.

RESULTS

Hypospadias was distal (n = 55), mid-shaft (n = 59), proximal/penoscrotal (n = 109), scrotal (n = 15), and perineal (n = 5). UP was single-staged in 86, multi-staged in 157; mean age at UP was 3.1 ± 2.4 years. Soft tissue used for STI was prepucial inner dartos fascia (inner dartos: n = 88), ventral dartos fascia (ventral dartos: n = 15), pedicled external spermatic fascia (ESF: n = 84), adipose tissue surrounding the spermatic cord (pericordal: n = 9), scrotal adipose tissue (n = 8), or a combination of tissues (combined: n = 25). Mean follow-up was 6.4 ± 4.6 (range 0.6-16.8) years. Overall incidence of PUF was 10/243 (4.1 %); 7/229 (3.1 %) for UP + STI and 3/14 (21.4 %) in UP-STI (p < 0.05); incidence versus type of hypospadias was 1/55 for distal (1.8 %), 3/59 for mid-shaft (5.1 %), 5/109 for proximal/penoscrotal (4.6 %), 0/15 for scrotal (0 %), and 1/5 for perineal (20 %); incidence versus type of STI was 7/88 for inner dartos, 0/15 for ventral dartos, 0/84 for ESF, 0/9 for pericordal adipose tissue, 0/8 for scrotal adipose tissue, and 0/25 for combined. All PUF were repaired successfully. Satisfaction with penile cosmesis was acceptable (10.3 %) or good (89.7 %) without any testicular complications or scrotal deformity.

CONCLUSION

STI, especially ESF, would appear to effectively prevent PUF in HR.

A novel technique for reinforcing the neourethra in hypospadias associated with bilateral undescended testis: use of the gubernaculum

The authors present 3 cases of proximal hypospadias associated with bilateral undescended testes (UDT) in which the gubernaculum was used to reinforce the neourethra to prevent urethrocutaneous fistula. This is the first report of the gubernaculum being used to reinforce the neourethra. The technique is simple and should be applicable to any hypospadias patient with concomitant UDT, especially in severe hypospadias. Good outcome is likely because of the excellent blood supply of the gubernaculum.

Fascia lata grafts for closure of secondary urethral fistulas

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.

Management of recurrent urethral fistulas after hypospadias repair

OBJECTIVES

To report on our experience in the management of recurrent urethrocutaneous fistulas in order to understand the etiology and outcome of secondary repair of the failed fistula closure.

METHODS

We reviewed the records of 28 patients between 28 months and 19 years of age, who underwent surgery between January 1990 and December 1998. In all patients, urethrocutaneous fistulas developed postoperatively, and the number of operations for their closure ranged from 2 to 15 attempts. In 17 children, a single large fistula was present, and in 11 children, multiple fistulas were present. The causes of failure were believed to be the awkward fistula site in 12 (coronal fistulas), urethral diverticula in 7, and distal urethral strictures in 4. In 5 children, the cause of fistula formation was unclear.

RESULTS

The 12 coronal fistulas were converted into coronal hypospadias. Thereafter, the urethral plate was tubularized using a wider strip (Thiersch tube) with (n = 3) or without (n = 9) a relaxing midline incision (Reddy-Snodgrass). Of the 12 repairs, 11 were successful; 1 child developed wound separation, resulting in a megameatus that was subsequently corrected. In 7 children, the cause of the fistula was a urethral diverticulum, which was excised and closed in multiple layers. All were successful (voiding well and no stricture or fistula). In 4 children (1 with multiple fistulas), the distal urethra was stenotic, and repair of the fistula included repair of the stricture using an island onlay flap in 2 and a buccal mucosal graft in 2. All 4 patients achieved a successful outcome. Dartos flaps were used to cover the repair in 18 patients, and tunica vaginalis flaps were used in 6 children.

CONCLUSIONS

Recurrent urethral fistula after hypospadias repair may be a manifestation of another problem, such as urethral stricture and/or urethral diverticulum. Intraoperative calibration of the distal urethra and distension of the repaired hypospadias to search for a diverticulum are recommended. Coronal fistulas are best repaired by converting them into coronal hypospadias, followed by tubularization of the urethral plate with or without a dorsal midline relaxing incision. In resurfacing the operative site, the traditional transposition flaps (Y-V and advancement) may be unreliable, because their vascularity may be compromised by previous surgery. The hairless scrotal island or rotation scrotal flap is more reliable for these cases.

Pedicled external spermatic fascia flap for urethroplasty in hypospadias and closure of urethrocutaneous fistula

PURPOSE

To prevent the development of urethrocutaneous fistula after urethroplasty for hypospadias or recurrence after closure of a urethrocutaneous fistula, the authors developed a new simple technique wherein the readily available external spermatic fascia (ESF) surrounding the testis and cord is used as a pedicled blanket flap to cover the neourethra or the site of closure of a urethrocutaneous fistula.

RESULTS

In three patients who had urethroplasty for hypospadias incorporating our ESF flap procedure, no urethrocutaneous fistula developed. It was also effective for closure of urethrocutaneous fistula in five patients, some of whom had had recurrent fistula formation.