Early Closure of Fistula After Hypospadias Surgery Using N-butyl Cyanoacrylate: Preliminary Results

Role of Long-Chain Cyanoacrylate as an Adjunct Interposition Layer in Repair of Hypospadias and Urethrocutaneous Fistula in Children: A Novel Technique

Purpose Hypospadias is an anomaly wherein the urethral opening is ectopically located on the ventral aspect of the penis. The most common complications after hypospadias repair are urethrocutaneous fistula (UCF) and meatal stenosis. Long Chain Cyanoacrylate (LCCA) tissue adhesive promises safety, feasibility, and durability due to its tensile strength and bacteriostatic and hemostatic properties. We conducted this study to ascertain whether LCCA tissue adhesive can prove a more effective adjunct to traditional suturing techniques. Methods Patients were divided into two groups. Group A underwent surgery with conventional reconstruction of the neourethral tube along with the buttressing layer using Buck's fascia or Tunica Vaginalis. In addition to the traditional procedure of Group A, Group B patients were administered a layer of LCCA tissue adhesive as an adjunct between the neourethral suture line and the buttressing layer. Patients were followed up for six months and were evaluated for complications like UCF, meatal stenosis, hematoma, skin infection, glans dehiscence, and flap necrosis. Results Thirty-eight children in the age group 1-6 years were studied, of which 20 were in Group A and 18 in Group B. Among patients of Group A seven (35%) developed complications. In contrast, only four (22.2%) patients developed complications in Group B. The statistical significance in the complication rates between the two groups could not be achieved due to the modest sample size. However, the numerical and proportional reduction in the number of complications was noted. Conclusion LCCA adhesive as an adjunct numerically reduces the number of complications compared to traditional suturing alone in patients undergoing surgery for hypospadias and UCF.

Can sealing promote healing?: A systematic review and meta-analysis highlighting the adjunctive role of tissue sealant application during urethroplasty for hypospadias

BACKGROUND

A significant proportion of children require multiple surgeries for successful repair of hypospadias. This is not only a source of a financial burden to the family but also causes long-term social and psychosexual issues. Tissue sealant application can provide additional coverage to the suture line and subsequently prevents operative failure. However, a consensus statement regarding its usage during urethroplasty is lacking. This systematic review and meta-analysis aims to compare the outcomes of hypospadias surgery, in terms of its complications, in children with and without tissue sealant application.

METHOD

The authors systematically searched the databases PubMed, EMBASE, Web of Science and Scopus through September 2020. The occurrence of overall complications, and specific complications (including urethrocutaneous fistula, wound-related complications, flap-related complications, complications involving the neo-urethral tube and meatal stenosis) were the primary and secondary outcomes, respectively. Statistical analysis was performed using a random-effects model, and pooled risk ratio (RR) and heterogeneity (I²) were calculated. The methodological quality of the studies was assessed utilizing the Downs and Black scale.

RESULT

Four comparative studies were included in the meta-analysis. The different types of tissue sealants such as fibrin glue, cyanoacrylate glue, BioGlue and cryocalcium glue were used in these studies. As compared to without sealant application, hypospadias repair performed with sealant application showed no significant difference in the incidence of overall postoperative complications (RR 0.63; 95% CI 0.34-1.14, p = 0.13). However, a significant reduction in some specific complications including urethrocutaneous fistula (RR 0.37; 95% CI 0.19-0.72, p = 0.003), wound-related complications (RR 0.57; 95% CI 0.38-0.86, p = 0.008) and complications involving the neo-urethra (RR 0.15; 95% CI 0.04-0.54, p = 0.004) was observed with sealant usage. The average Downs and Black scale scores ranged from 16 to 18, with all studies having a moderate risk of bias. Kappa statistics showed a value of 0.962 (p < 0.001), highlighting an almost perfect agreement among the two observers.

CONCLUSION

The present meta-analysis revealed no additional benefit of the repair of hypospadias performed with tissue sealants as compared to without sealants in terms of reducing the overall postoperative complications. However, a significant reduction in the occurrence of some specific complications, including UCF, wound-related complications and complications involving the neourethra was observed with sealant application. The level of evidence of the published comparative studies is limited. Therefore, further studies need to be conducted for optimal comparison between the sealant and no sealant (or placebo), and different types of sealants.

Biocompatible alkyl cyanoacrylates and their derivatives as bio-adhesives

Cyanoacrylate adhesives and their homologues have elicited interest over the past few decades owing to their applications in the biomedical sector, extending from tissue adhesives to scaffolds to implants to dental material and adhesives, because of their inherent biocompatibility and ability to polymerize solely with moisture, thanks to which they adhere to any substrate containing moisture such as the skin.

Temporary re-catheterization as a treatment for early fistulas after hypospadias repair

OBJECTIVE

To present the results of temporary urethral re-catheterization in order to aid spontaneous closure of early fistulas after hypospadias repair.

METHODS AND TECHNIQUE

Children presenting with early fistulas (within 2 weeks of initial catheter removal) after hypospadias repair underwent urethral calibration and re-insertion of a urethral catheter under intravenous anesthesia. The catheter was removed after 2 weeks.

RESULTS

Nine children (age 1-9 years) with early fistulas had re-catheterization: six (66%) had spontaneous healing of the fistula by 2 weeks, which remained closed at subsequent follow-up.

CONCLUSION

The simple technique of urethral re-catheterization may allow spontaneous healing of some early fistulas after hypospadias repair.

Is It Possible to Eliminate Sutures in Open (Lichtenstein Technique) and Laparoscopic (Totally Extraperitoneal Endoscopic) Inguinal Hernia Repair? A Randomized Controlled Trial With Tissue Adhesive (n-Hexyl-α-Cyanoacrylate)

Background. The morbidity linked to the use of sutures in inguinal hernioplasty is well known. Tissue adhesives may be an alternative, so as to be able to improve levels of postoperative comfort, but clinical experience using them is limited. The aim of this study is to evaluate the efficiency of cyanoacrylate as a substitute for sutures in the treatment of inguinal hernias. Patients. Randomized clinical trial in abdominal wall unit. A total of 208 patients were operated upon for inguinal hernias of which 102 were unilateral hernias via open surgery using the Lichtenstein technique, randomized to receive prolene sutures (n = 52) or n-hexyl-α-cyanoacrylate glue (n = 50) and 106 were patients with bilateral inguinal hernias operated upon via totally extraperitoneal laparoscopy and randomized to receive either tackers (n = 54) or glue (n = 52). Main Outcome Measures. The primary endpoints were pain and recurrence. Secondary endpoints were operating time, postoperative morbidity, pain, and analgesic consumption. Results. No morbidity associated with the use of the glue existed. The use of glue significantly reduced the mean of surgical time (12 minutes in open surgery, 13 minutes in laparoscopic surgery), pain, and analgesics consumption, both via the open and laparoscopic approaches ( P < .001). After 1 year the adhesive did not change the recurrence rate in either of the approaches. The economic analysis shows potential yearly savings of 123 916.3 Euros. Conclusions. Substituting sutures with glue ( n-hexyl-α-cyanoacrylate) in open or laparoscopic inguinal hernioplasty is safe with less postoperative pain and the same possibilities of recurrence.

2-octyl cyanoacrylate versus reintervention for closure of urethrocutaneous fistulae after urethroplasty for hypospadias: a randomized controlled trial

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.

The use of octyl cyanoacrylate (superglue) in hypospadias repair including its use as a fixator for urethral stents

BACKGROUND

Octyl cyanoacrylate has been used for many years for simple skin closure, but its use in hypospadias repair and as a urethral stent fixator has not been previously reported. We report our experience.

METHOD

A retrospective study was performed of all children undergoing hypospadias surgery from July 2007 to July 2011. Octyl cyanoacrylate was used for skin closure after placing a few sutures to align the skin edges. No other dressing was used. A urethral stent, if used, was glued to the penis and removed after one week.

RESULTS

Seventy two procedures were performed on 37 patients. Eight distal hypospadias (22%) underwent single stage repair. Seventeen (46%) underwent staged repair for severe hypospadias, and twelve (32%) "hypospadiac cripples" underwent various salvage procedures. One patient (1/72) had partial dehiscence, and one stent dislodged. There were no wound infections. Four (4/25) tabularized urethroplasties developed a fistula (16%).

CONCLUSION

Octyl cyanoacrylate is easy to apply on difficult hypospadias contours. It forms a strong, waterproof adhesive bond which separates from epithelial surfaces in 7 to 10 days and makes it an effective urethral stent fixator and an ideal dressing for hypospadias surgery.

Effect of cyanoacrylic glue on penile fracture: an experimental study

PURPOSE

We investigated the effect of Glubran(R)2 cyanoacrylic glue on rat cavernous tissue after forming penile fractures experimentally as well as the histopathological effect. We also investigated its clinical use.

MATERIALS AND METHODS

Experimental penile fracture was formed by incising from the proximal dorsal side of the penis in 32 Wistar Albino rats. The rats were randomly assigned to 4 main groups of 8 each. In the control group the incision was not repaired and it was left to secondary healing. In the glue group cyanoacrylic glue was only applied to the incision region. In the primary repair group the incision was primarily repaired and in the final group cyanoacrylic glue was applied to the incision region following primary repair. Three weeks later penectomy materials were examined histopathologically.

RESULTS

When the control group was compared with the other groups, the differences in cavernous tissue healing with fibrosis and hyperemia-bleeding were statistically significant (p = 0.043 and 0.003, respectively). In the glue group fibrosis was observed in 2 rats. This group was the best according to cavernous healing. Although there was no significant difference between the control group and the other groups according to inflammation (p = 0.057), the glue group was better than the primary repair group (p = 0.026). No significant inflammation or hyperemia-bleeding was observed in the glue group. When the experimental groups were evaluated for histopathological parameters, it was observed that the best results were obtained in the glue group.

CONCLUSIONS

Cyanoacrylic glue can be used in cavernous surgery due to its hemostatic, adhesive and anti-inflammatory properties.

Cyanoacrylic glue: a minimally invasive nonsurgical first line approach for the treatment of some urinary fistulas

PURPOSE

We evaluated the adaptability and the efficacy of a cyanoacrylic glue for the conservative treatment of urinary fistulas of different etiologies using an endoscopic, percutaneous or endovaginal approach.

MATERIALS AND METHODS

From May 1998 to July 2004, 13 patients with long lasting iatrogenic and/or inflammatory urinary fistulas were treated conservatively with endoscopic, percutaneous or endovaginal application of 1 to 3 cc of cyanoacrylic glue.

RESULTS

The complication rate in this cohort of 13 patients was low. Occlusion therapy failed in 2 genitourinary fistulas which were wider (diameter greater than 1 cm) and short. In the remaining 11 cases urinary fistulas were successfully sealed and at a median followup of 35 months no relapses were observed.

CONCLUSIONS

Cyanoacrylic glue is suitable for endoscopic, percutaneous and endovaginal use. This occlusion therapy represents a safe and minimally invasive approach that might be offered as a first line option for the treatment of urinary fistulas, especially narrow and long tract fistulas.

The Effect of Cyanoacrylic Glue on Rat Testis, Urethra and Spongiosal Tissue: An Experimental Study

PURPOSE

We examined the effect of Glubran2 on the rat urethra and spongiosal tissue as well as the histopathological effect. We also investigated its clinical use.

MATERIALS AND METHODS

Eight control and 12 study group male Wistar rats were used in our study. The corpus spongiosum tissues, including the urethra and the tunica albuginea of the testis, were cut 0.5 and 0.2 cm long, respectively. Incision areas in the control group were sutured. In the study group Glubran2 was dripped on the area. Three weeks later all rats were sacrificed. The penile and testicular tissues were histopathologically investigated. One-way ANOVA and the t test were applied for statistical analysis.

RESULTS

When the study group was compared with the control group, the difference in urethral healing (p = 0.001), urethral lumen irregularity (p = 0.036), spongiosal tissue healing (p = 0.001), inflammation (p = 0.000), hyperemia-bleeding (p = 0.036) and total healing (p = 0.001) were statistically significant. When the study and control groups were compared, the difference in inflammation (p = 0.000), necrotic areas (p = 0.002), tunica albuginea irregularity (p = 0.005), Sertoli's and Leydig cell destruction (p = 0.005), and testicular spermatogenesis (p = 0.005) were statistically significant.

CONCLUSIONS

While perfect healing in the urethral and spongiosal tissues supports the clinical application, damage to the seminiferous tubules, decreased spermatogenesis at the operated site, tunica albuginea irregularity in a fourth of the testes and calcification in 1 testis were observed.