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

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

INTRODUCTION

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Concomitant repair of meatal stenosis and urethral fistula does not increase the risk of fistula recurrence post-hypospadias surgery

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.