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

A three-step repair of post circumcision coronal fistula: A glans flap, urethral closure, and dartos flap interposition

PURPOSE

To evaluate the outcomes of patients who underwent a post-circumcision coronal fistula repair by means of a three-step repair technique: glans flap, urethral closure, and dartos flap interposition.

MATERIALS AND METHODS

We retrospectively reviewed the outcomes of 23 patients with postcircumcision urethrocutaneous fistulas who were treated at our institution between January of 2014 and December of 2018. The patients included in this review had exclusively a coronal fistula with an adequate glans bridge between the fistula and the urethral meatus and underwent surgical repair at least 6 months after the initial injury. We excluded from the study patients who had multiple level fistulas, glans dehiscence and patients that were lost to follow-up less than 6 months post fistula repair.

RESULTS

The median age at the time of the repair was 9.2 (range: 6.3 to 31) months. The fistulas were classified according to their size as small (ranging from pinpoint to ≤4 mm; n = 19) or large (>4 mm; n = 4). The overall success rate was 87% (20 of 23 patients). The success rates for the small and the large fistulas were 94.7% (18 of 19) and 50% (2 of 4), respectively. An indwelling urethral stent was used in all patients, except in those with pinpoint fistulas. The mean follow-up was 19.9 (6-60) months.

CONCLUSIONS

Post-circumcision coronal urethrocutaneous fistulas less or equal to 4 mm in diameter without glans dehiscence can be successfully repaired using a three-step repair technique, with a recurrence rate of less than 6%. For larger fistulas, a formal urethroplasty is recommended due to high recurrence rate of the three-step repair technique.

LEVEL OF EVIDENCE

Case Series (Level IV).

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.

In Support of a Simple Urethrocutaneous Fistula Closure Technique Following Hypospadias Repair

OBJECTIVE

To evaluate the success rates of a simple posthypospadias urethrocutaneous fistula repair.

STUDY DESIGN

We evaluated children who underwent urethrocutaneous fistula closure by means of a simple standard technique in which the fistula tract was dissected to its base and resected and the urethral defect closed with a single layer of continuous sutures and covered with local subcutaneous tissue. No urethral stents or catheters were used, and the patients were discharged on the same day. Excluded were children who underwent fistula repair by a different technique, revision hypospadias repair for fistula, or concomitant meatoplasty for meatal stenosis. Study endpoints were fistula recurrence and the need for further penile surgery other than fistula repair.

RESULTS

Seventy-two children underwent 81 repairs. The mean follow-up was 7.9 years. Recurrence occurred in 17 cases (21%). Seven children (9%) underwent penile surgery other than fistula repair, including meatoplasty (n = 5) and re-do hypospadias repair for a diagnosis other than fistula recurrence (n = 2). There was no significant difference in recurrence rate between large and small fistulas, coronal or more proximal fistulas, or children w/wo prior fistula repairs.

CONCLUSION

Standard fistula closure solely by adjacent tissues yielded success rates of 79% after long-term follow-up. This repair can be safely offered with the expectation of similar results for a variety of urethrocutaneous fistulas in children.

The effect of plasma rich platelet graft on post-operative complications in mid-penile hypospadias

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.

Our urethrocutaneous fistula repair results in adults after hypospadias surgery

INTRODUCTION

Our aim was to evaluate and share our urethrocutaneus fistula repair results in adult patients who had been operated for hypospadias in their childhood.

MATERIAL AND METHODS

The data of totally 48 patients who had been treated for urethrocutaneous fistula after hypospadias surgery in our department from May 2008 to January 2015 analyzed retrospectively. Patients' age at fistula repair, age at first hypospadias surgery, fistula size, localization and number, distal urethral obstruction status and surgical outcomes of fistula repairs were recorded. All patients were controlled three months after the repair for surgical outcomes.

RESULTS

Fistula repair performed in 45 patients. Mean age was 21.46 (20-26). Nineteen patients (42.2%) underwent first hypospadias surgery under the age of 7 years; 8 patients (17.7%) between 7 and 15 years, 18 patients between 15 and 20 years. Tubularized incised plate urethroplasty (TIPU) was performed in 40 patients (88.9%), extragenital tissue was used in 5 patients (11.1%). Twenty two patients (48.9%) had 1 or 2 operations, 17 patients (37.8%) had 3-5 operations and 6 patients (13.3%) had 6 or more operations. Thirteen (28.9%) coronal, 24 (53.3%) subcoronal, 6 (13.3%) penile and 2 (4.4%) penoscrotal fistulas were observed. While a single fistula was observed in 35 patients, multiple fistulas were seen in 10 patients. A fistula diameter les than 5mm was detected in 37 patients, and larger than 5mm in 8 patients. Fistula recurrence was observed in 3 patients at follow-up examinations carried out at 3 months postoperatively. The number of operations was more than 5, the fistula diameter was larger than 5mm and the fistulas were coronal in all three recurrent fistulas.

CONCLUSION

According to our results fistula size, previous surgery and well-vascularised, one or two layer tissue were the important factors in the success of fistula repair after hypospadias surgery.

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.