Repairing urethrocutaneous fistula in adults: is a catheter necessary?

A Systematic Review of Loco-Sedative Anesthesia for Urologic Surgery

OBJECTIVE

To perform a systematic review of the characteristics and outcomes of conscious sedation and local anesthesia for various urologic procedures. Urologic care has much to gain from the routine integration of ambulatory surgery via loco-sedative anesthetic techniques for both surgeon and patient.

METHODS

A comprehensive systematic literature search was conducted on PubMed, and Scopus databases following PRISMA criteria from June to August 2021. Articles were included if they were English, prospective, randomized, or nonrandomized controlled trials that used local anesthetic or conscious sedation for urologic interventions in adult patients. Additionally, included studies provided primary data on the use loco-sedative anesthesia and the efficacy and complications. All studies included were further reviewed to assess the biases and conflicts of interests.

RESULTS

Thirty-two studies with 6897 patients were included in the review. Mean patient age was 46.4years. The most common anesthetic and analgesic relief was the use of local anesthetic with 1% lidocaine. The majority used lidocaine as an injection, whereas the second most common route of administration was a topical cream. However, there was significant heterogeneity in the type of local or conscious sedation method and whether a combination was used. 44.4% of the studies used the visual analog scale as their primary endpoint. All the studies reported an 83%-100% successful procedure rate without note of significant sedation-related complications.

CONCLUSION

Given the high efficacy rates, loco-sedative anesthesia is a promising technique for urologic interventions and should be further investigated to determine whether it may become be the standard of care.

Clinical Classification of Urethrocutaneous Fistulas Developing after Hypospadias Repair

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

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

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

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

Application of Tunica Vaginalis Flap for Epispadias Repair in the Epispadias-Exstrophy Complex

OBJECTIVE

To describe long-term outcomes and experience with the tunica vaginalis flap (TVF) as a tissue augment for complex epispadias repair.

METHODS

A prospectively maintained institutional database was reviewed for patients who underwent epispadias repair with TVF from 2010 to 2021. Evaluation of patient characteristics between those who developed dehiscence or UCF and those who did not was performed via Mann-Whitney U, Kruskal-Wallis, or Fisher's exact test, as appropriate.

RESULTS

A total of 47 male patients were identified, of whom, 1 (2.1%) had cloacal exstrophy, 38 (80.9%) had classic bladder exstrophy or a variant, and 8 (17.0%) had epispadias as their primary exstrophy-epispadias complex diagnosis. The median age at epispadias repair was 13 months (IQR 11 - 19). The overall rate of fistula or dehiscence development was 19.1% (9 patients), of whom, 7 developed urethrocutaneous fistulae, 1 dehiscence, and 1 both. Notably, 0 of the 5 patients who had undergone prior epispadias repair and 0 of the 8 patients with a diagnosis of isolated epispadias developed a UCF or dehiscence after repair with TVF. Differences in age at repair, primary EEC diagnosis, prior epispadias repair, pre-repair testosterone, fibrin sealant utilization, closure layers, stent removal time, and bladder capacity at repair were not statistically significant (P>.05) CONCLUSION: Our expanded evaluation indicates that utilization of the tunica vaginalis as an adjunct to epispadias repair may provide durable protection against fistula development in EEC patients who have undergone prior epispadias repair and in primary repair of patients with isolated epispadias.

Diagnosis and management of urethro-cavernosal fistulas

Objective:

To present a case series of urethro-cavernosal fistulas evaluating their diagnostic work-up and management.

Methods:

A literature search was performed using key words including “urethro-cavernosal fistula,” “urethral fistula,” and “cavernosal fistula.”

Results:

In total 10 case reports were identified and reviewed for information regarding clinical diagnosis, management, and long-term outcomes including success rates and complications.

Conclusion:

Urethro-cavernosal fistula is a rare urological condition. With few cases reported to date, there is considerable variation in diagnostic work-up and management. Both conservative and surgical approaches can be utilized in the management of urethro-cavernosal fistulas with good long-term outcomes.

Level of evidence:

Not applicable for this multicentre audit.

Les fistules péniennes urétrocutanées postcirconcision: à propos de 85 cas

Buts

Analyser les aspects cliniques et thérapeutiques des cas de fistules péniennes liés à une circoncision et pris en charge dans notre pratique quotidienne urologique.

Patients et méthodes

Étude rétrospective des dossiers des patients admis pour fistule pénienne postcirconcision de la période allant de 1990 à 2007.

Résultats

Quatre-vingt-cinq cas ont été notés avec une moyenne d’âge de 10,7 ans (15 mois et 38 ans). La circoncision était réalisée par un personnel paramédical dans la majorité des cas. Le délai de consultation était en moyenne de 4,1 ± 5,3 ans (1 semaine-28 ans). La fistule était associée à une amputation partielle du gland dans un cas et une sténose du méat urétral dans trois cas. Le traitement chirurgical a consisté surtout à un dédoublement urétrocutané. Avec un recul moyen de 3,35 ans (2 mois-8 ans), nous avions noté 81,2 % de bons résultats.

Conclusion

La fistule pénienne postcirconcision est fréquente dans nos régions. Sa prise en charge est assez codifiée, mais le risque d’échec n’est pas négligeable, d’oú l’intérêt de la prévention.