Assessment and management of urethrocutaneous fistula developing after hypospadias repair:

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.

EVALUATION OF VEST-OVER-PANT TECHNIQUE IN THE TREATMENT OF POST-HYPOSPADIAS URETHROCUTANEOUS FISTULA

OBJECTIVE

The aim: In this study, we present and evaluate the vest-over-pants technique as a simple way to correct urethrocutaneous fistulas after hypospadias.

PATIENTS AND METHODS

Materials and methods: Between October 2018 and June 2020, twenty male patients aged 5 to 20 years came to us with post hypospadias repair fistula, these patients underwent vest-over-pant repair of their fistula. The size of fistula was ranging between 2.5-5 mm. The distribution of fistula was coronal (3 patients), distal penile (9 patients), midshaft (2 patients) and proximal penile (6 patients). In 14 patients there were single fistula and 6 patients had more than one fistula. Eleven of patients were exposed to a previous failed fistula repair procedure.

RESULTS

Results: Six months after the operation, the fistula recurred only in 2 patients, and our operation was successful in 90% of cases without complications.

CONCLUSION

Conclusions: The vest-over-pants technique is a simple and effective way to treat penile fistulas after hypospadias in properly selected patients. It is a technically simple procedure with a short learning curve and no major postoperative complications.

Analysis of influencing factors of multiple urethrocutaneous fistula after urethroplasty in children with hypospadias

Objective

The objective of this study was to investigate the influencing factors of multiple urethrocutaneous fistula (UF) after urethroplasty in children with hypospadias.

Methods

The clinical data of 195 children with UF after urethroplasty treated surgically in the Third Affiliated Hospital of Zhengzhou University from August 2015 to August 2022 were retrospectively analyzed and divided into the single UF group (n = 134) and the multiple UF group (n = 61) according to whether multiple UF occurred after urethroplasty. The possible correlated factors were collected and compared between the two groups, including hypospadias degree, length of formed urethra, time of urethroplasty, pre-urethroplasty weight, age at urethroplasty, urethroplasty style, season of urethroplasty, the first fistula repair method, season of the first fistula repair, diameter of the largest fistula of the first fistula repair, time of the first fistula repair surgery, and other 13 factors.

Results

By univariate analysis, statistically significant differences were found between the two groups in age at urethroplasty, length of the formed urethra, method of urinary drainage after urethroplasty, whether or not purulent urethral drainage after first fistula repair was present, the first fistula repair method, and diameter of the largest fistula of the first fistula repair (P < 0.05). After multifactorial analysis, the independent risk factors associated with multiple UF after urethroplasty were determined to be use of a vesicostomy tube as the urinary drainage method after urethroplasty (P < 0.05, OR = 6.574, 95% CI: 2.720-15.891) and the presence of purulent urethral drainage after first fistula repair (P < 0.05, OR = 2.723, 95% CI: 1.214-6.109).

Conclusions

A catheter as the drainage method after urethroplasty is an independent protective factor for multiple urethrocutaneous fistula, and the existence of purulent urethral secretions after the first fistula repair is an independent risk factor.

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.

Tunica vaginalis graft for recurrent urethrocutaneous fistula repair after hypospadias surgery

OBJECTIVES

To evaluate the outcomes of recurrent urethrocutaneous fistula repair using tunica vaginalis graft as an intermediate protective layer.

METHODS

We retrospectively reviewed the data of 45 children with recurrent urethrocutaneous fistula who underwent tunica vaginalis graft repair between February 2011 and January 2019. The repair was carried out at least 6 months after a previous fistula repair. Follow up at an outpatient clinic was scheduled on a weekly basis for 1 month, then monthly for 6 months and then annually. During follow up, every patient was evaluated by history taking. The site of repair and the act of micturition were inspected. Urine analyses together with culture and sensitivity tests were carried out if required. Successful repair was defined as the absence of recurrence, with good force and caliber of the urinary stream.

RESULTS

This study included 45 patients with recurrent urethrocutaneous fistula who were managed with a tunica vaginalis graft as a second layer. The mean age of patients was 6.7 ± 2.8 years. The mean postoperative hospital stay was 5.5 ± 0.7 days. The repair was successful for 43 (95.6%) patients, and urethrocutaneous fistula recurrence was reported for two (4.4%) patients, which were repaired after 6 months. In all patients, the cosmetic appearance of the penis was satisfactory without torsion or ventral chordee.

CONCLUSION

Tunica vaginalis graft is a simple and fast procedure that is highly effective as a protective second layer for recurrent urethrocutaneous fistula repair.

Risk factors for failed urethrocutaneous fistula repair after transverse preputial island flap urethroplasty in pediatric hypospadias

OBJECTIVES

We review our experience in urethrocutaneous fistula (UCF) repair after transverse preputial island flap urethroplasty (Duckett) in pediatric hypospadias to investigate the risk factors for unsuccessful outcome.

METHODS

Two hundred and nineteen UCFs repairs conducted in our center from January 2015 to December 2016 after Duckett technique were retrospectively reviewed and 182 had a follow-up for more than 6 months. The age of patients, size, localization and numbers of UCFs, interval time of two operations, length of neourethra, times of UCFs repairs, complications other than UCFs, hospital of primary surgery and postoperative infection were analyzed as potential risk factors. Stratified analysis and assessment of additive interaction were performed to have a better understanding of the relation between the risk factors. Logistic regression analysis was used for multivariate analysis.

RESULTS

UCF repairs were succeeded in 121 (66.5%) and failed in 61 (33.5%) at first operation. In the univariate analysis, size and numbers of UCFs (P = 0.01 and P = 0.035, respectively), interval time of two operations (P = 0.042) and hospital of primary surgery (P = 0.02) were statistically related with the outcome. In the multivariate analysis, UCF ≥ 2 (OR 2.71, 95%, CI 1.095-6.692, P = 0.031), size ≥ 2 mm (OR 2.45, 95% CI 1.267-4.757, P = 0.08) and primary surgery not at our hospital (OR 2.21, 95% CI 1.094-4.126, P = 0.026) were identified as independent risk factors for unsuccessful outcome. In the stratified analysis, multiplicative interaction between the 3 risk factors was not found.

CONCLUSIONS

Our study suggested that UCF repairs after transverse preputial island flap urethroplasty were easier to fail if the UCF was ≥ 2 mm, the numbers of UCFs was ≥ 2, or the surgeon had less experience. The age of patients, site of UCFs, interval time of two operations, length of neourethra, times of UCFs repairs, complications other than UCF and postoperative infection were not significantly related to the success rate of UCF repair.

Modified PATIO repair for urethrocutaneous fistula post-hypospadias repair: operative technique and outcomes

BACKGROUND

To describe a modification of PATIO repair for urethrocutaneous fistula repair and evaluate its outcome.

METHODS

We studied 15 boys who underwent modified PATIO repair from Jan 2010 to Sept 2015. Parameters studied included age, type of hypospadias, age at first urethroplasty, hypospadias repair technique, number of urethroplasties required, location of fistula, time gap between urethroplasty and fistula repair, method of fistula repair, and outcome of fistula repair.

RESULTS

Mean age of the studied patients was 67.6 months (38-139). Type of hypospadias was Coronal = 3, subcoronal = 8, mid-penile = 2, prominal penile = 1, and penoscrotal = 1. Ten patients had single urethroplasty, while two patients had two urethroplasties, details not available for three patients. Average age at urethroplasty was 43.4 months (18-110). 12 patients had Snodgrass repair, Mathieu = 1 patient, tubularised plate repair = 1 patient, and unknown = 1 patient. Location of fistula was coronal in nine patients and subcoronal in six patients. Average operative time was 47.2 min (30-68). Follow-up is available for 12 patients out of which 2 patients had recurrent fistula, one of which was successfully treated by the redo modified PATIO method.

CONCLUSION

Modified PATIO method is technically easy method for urethrocutaneous fistula repair, with less operating time and good postoperative outcomes.