Risk factors for fistula recurrence after urethrocutaneous fistulectomy in children with hypospadias

Application of the modified Byars staged procedure for severe hypospadias repair

ABSTRACT

This study aimed to introduce a modified Byars staged procedure and investigate its application value in patients with severe hypospadias. We retrospectively analyzed the clinical data of patients with severe hypospadias admitted to the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, China) between October 2012 and October 2022. In total, 31 patients underwent the conventional Byars procedure (conventional group), and 45 patients underwent the modified Byars staged procedure (modified group). Our modified strategy was built upon the standard Byars procedure by incorporating glansplasty during the first stage and employing a Y-shaped flap in conjunction with a glandular tunnel for urethroplasty during the second stage. Notably, there were no statistically significant differences in the preoperative baseline characteristics, duration of surgery, amount of blood loss, or occurrence of postoperative complications, including urethral fistula, stricture and diverticulum, or penile curvature, between the conventional and modified groups. However, there was a significantly lower incidence of coronal sulcus fistula (0 vs 16.1%, P = 0.02) and glans dehiscence (0 vs 12.9%, P = 0.02) in the surgical group than that in the conventional group. In addition, the modified group exhibited a notably greater rate of normotopic urethral opening (100.0% vs 83.9%, P = 0.01) and a higher mean score on the Hypospadias Objective Penile Evaluation (HOPE; mean ± standard error of mean: 8.6 ± 0.2 vs 7.9 ± 0.3, P = 0.02) than did the conventional group. In conclusion, the modified Byars staged procedure significantly reduced the risks of glans dehiscence and coronal sulcus fistula. Consequently, it offers a promising approach for achieving favorable penile esthetics, thereby providing a reliable therapeutic option for severe hypospadias.

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.

Current perspectives in hypospadias research: A scoping review of articles published in 2021 (Review)

Hundreds of papers are written about hypospadias every year referring to all aspects of the pathology, being one of the most common congenital malformations. The present study conducted a scoping review of articles published in 2021 to present the main issues and summarize current perspectives and achievements in the field. It searched for the keyword 'hypospadias' in the three most popular databases (PubMed, Scopus and Web of Science). After the analysis of the publications, they were categorized into different domains. The present review was performed respecting the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA ScR) guidelines. A total of 284 articles were included. These were published in 142 different journals. The most accessed was the Journal of Paediatric Urology with 54 articles. The main identified domains were related to surgical techniques, postoperative care, complications, anesthesia, anatomical factors, genetics, environmental factors, endocrinology, associated malformations, questionnaires and recommendations, management, biological materials, animal models, retrospective studies of centers, social media, bibliometrics, small gestational age, neoplasm, or fertility. Promising modifications of existing surgical techniques were presented with improved outcomes for both the proximal and distal types of hypospadias. Relevant anatomical and etiological, and also genetic factors were clarified. Aspects of the peri- and postoperative management referring to the antibiotherapy, analgesia, dressing techniques, and the future use of novel bioengineering agents to prevent, reduce or treat the occurring complications were discussed.

'Waterproofing layers' for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis

OBJECTIVE

To summarize the available evidence and to quantitatively evaluate the global results of different waterproofing layers in substantiating the UCF repair.

MATERIAL AND METHODS

After defining the study protocol, the review was conducted according to the PRISMA guidelines by a team comprising experts in hypospadiology, systematic reviews and meta-analysis, epidemiology, biostatistics and data science. Studies published from 2000 onwards, reporting on the results of UCF closure after hypospadias repair were searched for on PUBMED, Embase and Google Scholar. Study quality was assessed using Joanna Briggs Checklist (JBI) critical appraisal tool. The results with different techniques were compared with the two samples independent proportions test with the help of Microsoft Excel, MedCalc software and an online calculator.

RESULTS

Seventy-three studies were shortlisted for the synthesis; the final analysis included 2886 patients (71 studies) with UCF repair failure in 539. A summary of various dimensions involved with the UCF repair has been generated including time gap after last surgery, stent-vs-no stent, supra-pubic catheterization, suture material, suturing technique, associated anomalies, complications, etc. The success rates associated with different techniques were calculated and compared: simple catheterization (100%), simple primary closure (73.2%), dartos (78.8%), double dartos flaps (81%), scrotal flaps (94.6%), tunica vaginalis (94.3%), PATIO repair (93.5%), biomaterials or dermal substitutes (92%), biocompatible adhesives (56.5%) and skin-based flaps (54.5%). Several techniques were identified as solitary publications and discussed.

CONCLUSIONS

Tunica vaginalis and scrotal flaps offer the best results after UCF closure in the synthesis. However, it is not possible to label any technique as ideal or perfect. Almost all popular waterproofing layers have depicted absolute (100%) success sometimes. There are a vast number of other factors (patient's local anatomy, surgeon's expertise and technical perspectives) which influence the final outcome.

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.

Long-term follow-up study of loose combined cutting seton surgery for patients with high anal fistula

BACKGROUND

The treatment of high anal fistula (HAF) is still difficult for clinical surgeons. Our previous study demonstrated the short-term benefit of loose combined cutting seton (LCCS) for patients with HAF. This study aimed to evaluate the long-term effectiveness of LCCS for treating HAF patients.

METHODS

We retrospectively enrolled consecutive HAF patients who received LCCS therapy in our hospital between March 2014 and July 2017. After enrollment, all patients were followed up by clinical review. The patients' clinical information and most recent follow-up results were collected. Pain was assessed by the visual analog scale (VAS), and the severity of fecal incontinence was assessed by the Wexner Continence Grading Scale. We also assessed the patients' quality of life (QOL) using a the MOS item short from health survey (SF-36) questionnaire. HAF healing was considered the primary outcome, while the fistula recurrence rate, severity of fecal incontinence, and QOL were the secondary outcomes.

RESULTS

In total, 22 patients (18 male, four female) were enrolled in the final analysis. The mean duration of follow-up was 3.65 years (interquartile range: 3.55-4.22; range, 3.50-5.43). All patients were cured and there was no recurrence during the follow-up period. Eight patients reported a Wexner score of 1, while the remaining patients reported a score of 0 at the final follow-up. Furthermore, one patient had a VAS score of 1, while the remaining patients had a VAS score of 0, which indicated almost no postoperative pain. The QOL of all patients improved significantly.

CONCLUSIONS

LCCS is an effective method to treat HAF patients. Large, multicenter randomized controlled trials are warranted.