'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.

Urethrocutaneous fistula repair following hypospadias surgery using the PATIO technique for small fistulae: A single centre experience

INTRODUCTION

Urethrocutaneous fistula (UCF) development following primary hypospadias repair is a common complication with high rates of recurrence despite attempts at repair. A novel technique for the management of these fistulae, the PATIO (preserve the tract and turn it inside out) repair, has been described and has shown encouraging outcomes in previous reports.

OBJECTIVE

The aim of this study was to evaluate fistula repair outcomes in patients undergoing the PATIO technique compared with standard repair.

STUDY DESIGN

A retrospective chart-based review was performed for pediatric patients undergoing UCF repair from January 2005 to July 2018. Data including: age, follow-up, meatal location, meatal stenosis, number of fistulae and repairs, UCF location, complications, and outcomes was obtained. Cases were categorized into PATIO repair, standard repair, and PATIO repair following prior standard repair. Surgical outcome with respect to freedom from fistula recurrence was determined.

RESULTS

In total, 586 patients underwent hypospadias surgery with 44 patients developing 52 UCF cases that required repair during the study period for a fistula rate of 8.9%. Mean age at repair was 19 months. Median follow-up time was 28 months. For PATIO repair alone, 21/26 (81%) had success. For standard repair alone, 8/18 (44%) had success and for standard repair followed by PATIO repair, 8/8 (100%) were successful. A statistically significant difference was noted for success when comparing standard repair with PATIO repair (p = 0.023, p < 0.05) and PATIO repair following standard repair (p = 0.010, p < 0.05). There was a statistically non-significant difference between PATIO repair and PATIO repair following standard repair (p = 0.309, p < 0.05). Failure following PATIO repair was found in cases where the procedure was early in implementation and experience was limited.

DISCUSSION

UCF repair using the PATIO technique has shown encouraging results in the short-term, with a majority of patients achieving a successful outcome compared with standards techniques. As this procedure continues to be used and experience develops, a larger sample of cases will become available for analysis and longer follow-up will prove necessary in examining the long-term outcomes of this procedure. The outcomes examined have demonstrated consistency with previously reported outcomes in the literature. Limitations include small sample size, short-term follow up, and the retrospective nature of the review.

CONCLUSIONS

The findings of this study have provided further support to the use of this technique in conventional UCF repair as a means to decrease the risk of recurrence and provide durable results in the short-term. Ongoing follow up will prove necessary to examine success in the long-term.

Austrian Experience with Lixisenatide Under Real-Life Conditions: A Prospective Observational Study

INTRODUCTION

Lixisenatide has been studied extensively in randomized clinical trials; however, data on its use in the real-life practice are scarce.

METHODS

This study was a prospective, 26-week, multicenter, observational study conducted in Austrian diabetes centers and office-based practices to evaluate efficacy and safety of lixisenatide under real-life conditions in patients with type 2 diabetes.

RESULTS

Out of 144 patients (mean BMI 36.4 kg/m², disease duration 12.4 years), 113 completed the documentation at 6 months and 42% received basal insulin with or without oral antidiabetic drugs. The HbA1c declined from 8.7% (72 mmol/mol) to 7.9% (63 mmol/mol) and at study end 24.8% of the patients reached an HbA1c level below 7%. Fasting and postprandial glucose after lixisenatide administration were reduced by 27 ± 58 mg/dl and 45 ± 67 mg/dl, respectively. At study end body weight (- 4.5 ± 5.4 kg), triglycerides (- 10.8 ± 105 mg/dl), systolic blood pressure (- 4.8 ± 17.1 mmHg), and LDL cholesterol (- 3.7 ± 25 mg/dl) were reduced. The most commonly reported adverse events were gastrointestinal disorders (18.8%). Forty-three patients (30%) discontinued prematurely, mostly caused by lack of efficacy, occurrence of gastrointestinal disorders, and missing reimbursement. The average dose of insulin decreased slightly by 1.5 units (from 29.4 to 27.9).

CONCLUSION

Lixisenatide demonstrated a similar efficacy and safety profile under real-life conditions as previously shown in randomized clinical trials.

FUNDING

sanofi-aventis GmbH Austria.