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Lu Q, Liu W, Chen L. Contrast-Enhanced Ultrasound: A Real-Time, Noninvasive, Radiation-Free Method for Intraoperative Male Urethral Fistula Assessment. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 39096110 DOI: 10.1002/jum.16525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 06/25/2024] [Accepted: 06/30/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES To evaluate the feasibility of intraoperative transurethral contrast-enhanced ultrasound for the assessment of male urethral fistulas. METHODS Patients in a prospective database who underwent intraoperative two-dimensional ultrasound, transurethral saline-enhanced ultrasound, and contrast-enhanced ultrasound between January 2017 and July 2022 were included. All patients were clinically diagnosed with urethral fistulae (UF) in the outpatient setting based on clinical presentations, traditional two-dimensional ultrasound, and/or other imaging modalities and confirmed during surgical repair. Dynamic videos of the scans were independently analyzed by two experienced ultrasonologists. RESULTS Thirty-nine patients with an average age of 51 years were included. The UF were located in the anterior urethra in 22 (56.4%) patients and in the bulbar urethra in 14 (63.6%) patients. UF were located in the posterior urethra in 17 (436%) patients and in the prostatic urethra in 13 (76.5%) patients. Contrast-enhanced ultrasonography revealed UF in all patients. In patients with anterior UF, saline-enhanced ultrasound images did not show a UF in 15 (68.2%, 15/22) patients, 13 (86.7%, 13/15) of whom had fistulae with diameters <3 mm. Saline-enhanced ultrasound images did not reveal posterior UF in 13 (76.5%, 13/17) patients. The fistula diameters in eight (61.5%, 8/13) patients were <3 mm. The duration for contrast-enhanced ultrasonography was approximately 3 minutes. The duration for surgical repair was approximately 2 hours. CONCLUSIONS Transurethral contrast-enhanced ultrasound is a real-time, noninvasive, and radiation-free method that allows intraoperative imaging and accurate assessment of male UF. Its sensitivity is higher than that of both two-dimensional ultrasound and transurethral saline-enhanced ultrasound. The location, size, and course of the fistulae can be clearly seen due to greater contrast during contrast-enhanced ultrasound.
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Affiliation(s)
- Qijie Lu
- Department of Ultrasound in Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Liu
- Department of Ultrasound in Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Ultrasound in Medicine, Shanghai, China
| | - Lei Chen
- Department of Ultrasound in Medicine, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Institute of Ultrasound in Medicine, Shanghai, China
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Choudhury P, Phugat S, Jain V, Yadav DK, Dhua AK, Verma V, Verma A, Anand S, Singh S, Goel P. Defining the Indications of PATIO Technique for Urethrocutaneous Fistula Repair. J Indian Assoc Pediatr Surg 2023; 28:375-386. [PMID: 37842208 PMCID: PMC10569280 DOI: 10.4103/jiaps.jiaps_25_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/21/2023] [Accepted: 03/08/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Despite the advancements in technique and technology, urethrocutaneous fistula (UCF) formation continues to be the most common complication after hypospadias repair. Objective The objective of the current synthesis is to define the indications of PATIO technique for UCF repair. Materials and Methods The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Scopus, Ovid, Embase, Web of Science, and Google Scholar were interrogated for studies presenting primary data upon UCF repair by the PATIO technique. Data analysis was performed on MedCalc and R software. Results Eighteen studies were identified relevant to the current context: inversion of UCF tract has been described in 13 and ligation in 5. There were 2 duplications (abstract and manuscript). The overall success for PATIO is 88.2% (314/356). The success rate was variable between classic PATIO (inversion at 87.2%), ligation-inversion at 86.9%, and ligation alone at 88.9%. The success rate was not improvised upon by supplementing inversion of UCF tract with ligation (p = 0.957) or addition of a waterproofing layer (p = 0.622). PATIO has been used for single or multiple UCFs post hypospadias repair, genital piercing, and genitoplasty in cis- or transgender population for UCF up to 5 mm in size. The success rates were best for UCF <2 mm and worst for those approaching 5 mm. The results were, however, unaffected by the location of UCF along the penile shaft. Besides, the use of urethral catheter is optional and may be eliminated with shorter hospitalization. Conclusions PATIO repair may be considered for repair of UCFs (a) with diverse etiologies, (b) located anywhere along the penile shaft included coronal UCF, (c) preferably <4 mm in size, (d) single or multiple in number; multiple PATIOs may be done in the same setting, (e) in patients unwilling for prolonged hospitalization, (f) in patients unwilling for a urethral catheter, and (g) in hypospadias cripples wherein mobilization of distant tissues such as tunica vaginalis flap or a buccal mucosal graft may be required for supplementing the UCF repair.
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Affiliation(s)
- Prativa Choudhury
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shivani Phugat
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vishesh Jain
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Kumar Yadav
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Kumar Dhua
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Verma
- Department of Biostatistics, Assam University, Silchar, Assam, India
| | - Ajay Verma
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sachit Anand
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sanchita Singh
- Department of Health Research, Indian Council of Medical Research, New Delhi, India
| | - Prabudh Goel
- Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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Choudhury P, Saroya KK, Jain V, Yadav DK, Dhua AK, Anand S, Mawar S, Verma V, Kapahtia S, Acharya SK, Shah R, Bajpai M, Goel P. 'Waterproofing layers' for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis. Pediatr Surg Int 2023; 39:165. [PMID: 37010625 DOI: 10.1007/s00383-023-05405-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 04/04/2023]
Abstract
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.
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Affiliation(s)
- Prativa Choudhury
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Komal Kaur Saroya
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vishesh Jain
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Kumar Yadav
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Anjan Kumar Dhua
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sachit Anand
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Shashi Mawar
- College of Nursing, All India Institute of Medical Sciences, New Delhi, India
| | | | - Siddharth Kapahtia
- Division of Non-Communicable Diseases, Indian Council of Medical Research, New Delhi, India
| | | | - Rasik Shah
- Department of Paediatric Surgery, SRCC Children's Hospital, Mumbai, India
| | - Minu Bajpai
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Prabudh Goel
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India.
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Misra D, Amin AM, Vareli A, Lee L, McIntosh M, Friedmacher F. Urethral fistulae following surgery for scrotal or perineal hypospadias: A 20-year review. J Pediatr Urol 2020; 16:447.e1-447.e6. [PMID: 32654895 DOI: 10.1016/j.jpurol.2020.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/04/2020] [Accepted: 06/12/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Urethral fistulae (UF) following hypospadias surgery can be a frustrating complication with reports of even 15 attempts to close a difficult fistula (Richter 2003). UF occurring in scrotal or perineal hypospadias (SPH) pose a further challenge because of the under-virilised penis. OBJECTIVE To review the outcomes of a single surgeon's experience over 20 years of managing UF in SPH. To analyse the traditional approach of fistula closure and three alternative techniques. MATERIALS AND METHODS A prospectively maintained database of patients who underwent hypospadias surgery for SPH from January 1997 to September 2018 was reviewed. Patients with UF were identified and their data recorded. The techniques of fistula closure were: a-Traditional approach. b Purse-string closure. c. Right angle intersection technique where the skin and urethra are closed at right angles to each other. d Anchoring skin to corpora away from the fistula closure. RESULTS 32 patients with 41 fistulae were identified. Follow-up ranged from 1 to 18 years. 10/32 (31%) had concomitant meatal stenosis or urethral strictures. The sites of UF were: penoscrotal 19/41 (46%), midpenile 14/41 (34%), coronal or subcoronal in 8/41 (20%). One fistula resolved spontaneously after a single urethral dilatation. 4 patients with a coronal fistula were laid open to the glandular meatus creating a coronal hypospadias, with redo-urethroplasty later (in 2 a buccal graft was used). Of the rest, 29 fistulae were cured after one surgery, while 7 needed two attempts. No patient needed more than two surgeries to close the fistula. The recurrence rates were as follows- Purse-string suture: 10%, Right angle intersection technique: 14.3%, Anchoring skin to corpora: 16.7%, Traditional approach: 21.7%. Although the purse-string suture technique had the lowest recurrence rate, the figures did not reach statistical significance (P-0.95). CONCLUSION Urethral fistulae occurring in SPH pose challenges because of the under-virilised penis. A third of patients may have meatal stenosis or urethral strictures which must be identified and dealt with. The three novel techniques we employed helped drive down our recurrence rate. Purse string sutures reduce the weak area to a dot and are an excellent way to deal with small fistulae (<5 mm). Other innovations include offsetting the skin suture line by anchoring it to the penile shaft well away from the fistula repair or closing the fistula and skin at right angle to each other. The fact that no patient needed more than two operations to lose the UF, was gratifying.
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Affiliation(s)
- Devesh Misra
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK.
| | - Amir Mohd Amin
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Anastasia Vareli
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Leonie Lee
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Mikhailia McIntosh
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
| | - Florian Friedmacher
- Department of Paediatric Urology and Paediatric Surgery, Royal London Hospital, London, E1 1BB, UK
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Risk factors for failed urethrocutaneous fistula repair after transverse preputial island flap urethroplasty in pediatric hypospadias. Int Urol Nephrol 2017; 50:191-195. [PMID: 29282594 DOI: 10.1007/s11255-017-1773-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 12/12/2017] [Indexed: 10/18/2022]
Abstract
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.
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Tokgoz H, Tetik G, Yalcinkaya S, Yildiz A, Savas M. Urethroplasty Using A Turnover Flap for Correctıon of Problematıc Urethrocutaneous Fıstula: A Case Report. World J Plast Surg 2017; 6:230-232. [PMID: 28713716 PMCID: PMC5506360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Urethral fistula formation after urethroplasty for hypospadias is a frequent complication. Repeated failures can occur even after multiple attempts at repair. A surgical procedure is described for a problematic resistant urethrocutaneous fistula (UF) with the transverse turnover flap using the Buck's fascia of the corpus cavernosum. A 23-year-old male was admitted to our hospital with recurrent coronal UF. We placed a suprapubic catheter in the bladder and operated the patient with the flap technique combined with glanuloplasty. In 3rd month follow up, the patient had no fistula with normal voiding.
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Affiliation(s)
- Husnu Tokgoz
- Corresponding Author: Husnu Tokgoz, MD; Department of Urology, Antalya Training and Research Hospital, Antalya, Turkey. E-mail:
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Salehipour M, Monabbati A, Ensafdaran MR, Adib A, Babaei AH. The effect of zinc on healing of renal damage in rats. J Nephropathol 2017; 6:157-162. [PMID: 28975095 PMCID: PMC5607977 DOI: 10.15171/jnp.2017.27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/30/2016] [Indexed: 12/12/2022] Open
Abstract
Background:
Several studies have previously been performed to promote kidney healing after injuries. Objectives: The aim of this study was to investigate the effect of zinc on renal healing after traumatic injury in rats.
Materials and Methods:
Forty healthy female rats were selected and one of their kidneys was incised. Half of the incisions were limited only to the cortex (renal injury type I) and the other ones reached the pelvocalyceal system of the kidney (renal injury type II). All the rats in the zinc treated group (case group) received 36.3 mg zinc sulfate (contained 8.25 mg zinc) orally. After 28 days, the damaged kidneys were removed for histopathological studies.
Results:
In the rats with type I injury, kidney inflammation of the case group was significantly lower than that of the control group. However, the result was not significant in rats with type II injury. Tissue loss and granulation tissue formation were significantly lower in the case group than the control group in both type I and II kidney injuries.
Conclusions:
Overall, Zinc can contribute to better healing of the rat’s kidneys after a traumatic injury.
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Affiliation(s)
- Mehdi Salehipour
- Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Monabbati
- Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Ali Adib
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Hossein Babaei
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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