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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1223-1226

A simple procedure for management of urethrocutaneous fistula after hypospadias repair


Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India

Date of Submission16-Jul-2018
Date of Decision24-Aug-2018
Date of Acceptance26-Aug-2018
Date of Web Publication31-Dec-2019

Correspondence Address:
Aditya P Singh
Near the Mali Hostel, Main Bali Road Falna, Dist-Pali, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_213_18

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  Abstract 

Objective
The treatment of urethral fistula is quite challenging. We tried to evaluate the results of a simple procedure in urethral fistula repair.
Background
A urethrocutaneous fistula is a common complication of urethroplasty. These fistulae may be caused by a variety of factors and occur in different sizes at various sites of the previous repair.
Materials and methods
A variety of methods have been described in the literature for the repair of urethrocutaneous fistulae with variable results. In this study of 25 cases, we have successfully repaired urethrocutaneous fistulae using perifistula non-hair-bearing penile skin flaps for their closure in the period spanning from January 2005 to December 2015. The operation consists of the creation of perifistula non-hair-bearing penile skin-based flap after marking the site. It was created with one side being kept large as compared with the other side in any direction. We mobilized the flap and the larger sized flap was folded over the tube just like a hat of a box and sutured it with the other side of the flap. We did it in only midpenile and proximal fistulas, irrespective of the size of the fistulas, whether they were small, medium or large sized. We included recurrent as well as fistula after primary repair.
Results
The mean age of patients was 6 years. We have successfully repaired all urethrocutaneous fistulae using our protocol with a success rate of 100%.
Conclusion
Flap technique is an appropriate procedure for repair of midshaft and proximal urethral fistulae of any size.

Keywords: closure, fistula, flap, hypospadias, simple, urethrocutaneous


How to cite this article:
Singh AP, Shukla AK, Sharma P, Barolia DK. A simple procedure for management of urethrocutaneous fistula after hypospadias repair. Menoufia Med J 2019;32:1223-6

How to cite this URL:
Singh AP, Shukla AK, Sharma P, Barolia DK. A simple procedure for management of urethrocutaneous fistula after hypospadias repair. Menoufia Med J [serial online] 2019 [cited 2020 Feb 16];32:1223-6. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1223/274239




  Introduction Top


Urethrocutaneous fistula formation is the commonest complication of hypospadias repair with a reported incidence of 4–25% [1]. Unfortunately, there is no one single perfect technique to repair an urethrocutaneous fistula. Various techniques have been described for fistula repair but with disappointing results. Simple closure, although technically easy [2],[3], bears the potential risk of overlapping suture lines and recurrence rates. The aim of this study was to present a simple easy surgical technique for closure of the midpenile and proximal fistulas with any size of the fistula with promising results.


  Materials and Methods Top


The study was approved by the ethical Committee of the faculty of medicine Menoufia university and the patient gave an informed consent. We have operated upon a total of 25 cases during the period spanning from January 2005 to December 2015. All the patients underwent routine preoperative investigations. We calibrated the urethral meatus and distal passage with the infant feeding tube no 8 in every case. Most of the cases had normal passage and opening. In our study, most of the cases were operated by us. It is our practice to make a neourethra over a 10 Fr infant feeding tube; hence, we did not find any stenosis and stricture. There was no scarring around the fistula. We measured the size of the fistula in the maximum width, whether it was anteroposterior or side to side.

We did not use cautery or tourniquet for hemostasis. We used xylocaine and adrenalin solution in normal saline in a concentration of 1: 100 000. We infiltrated this solution at the incision site. Urethrocutaneous fistulae in our study were repaired after a minimum of 6–12 months after the last procedure so that the scar tissue was mature.

Surgical technique

The principle of the perifistula-based flap technique is tensionless repair of the fistula. Surgery was performed under general anesthesia with infiltration with 1: 100 000 xylocaine and adrenalin solution. Operative procedure initially involved placing a silastic nasogastric tube (NG) 8 Fr size and marking the flaps with the marker around the fistula site in any comfortable direction that created adequate size flaps. Flaps are dissected all round for adequate size. One flap is larger as compared with the other in our technique. The larger flap is folded over the tube and sutured with the other side flap. The tensionless repair was performed in two layers with polyglactin 6-0 suture, with the inner continuous and the outer interrupted. Thereafter, skin closure was carried out without superimposition over the repaired site. NG tube Fr 8 was replaced with the 6 Fr tube. 6 Fr NG tube was used as splint and for urinary diversion. The dressing was carried out on the seventh postoperative day. The catheter was removed on the 10th postoperative day. All patients were discharged on the 10th postoperative day after catheter removal and called to the follow-up clinic. Assessment of the patient was carried out at the time of dressing removal and catheter removal and in the follow-up clinic.

We had some cases with large fistula. We repaired them with the same technique and with adequate mobilization of the penile skin. We closed the fistula in two layers with two-layer closure of the skin without superimposing them.

Sample size calculation

We included 25 cases of urethrocutaneous fistula after hypospadias surgery.

Statistical analysis

We used simple statistics.


  Results Top


All 25 patients were operated in this series with the perifistula non-hair-bearing penile skin-based flap procedure. The age of the patients ranged from 4 to 12 years, with an average of 6 years [Table 1]. We operated after a minimum of 6 months after the primary hypospadias or fistula repair. The size of the fistulae in our study ranged from 4 to 14 mm. There was single fistula in 22 cases and multiple in three cases. Multiple fistulas were repaired by joining them. In our view, the most common cause of the fistula was infection and technical error. We had operated primary as well as recurrent fistula. All fistulae were located in the proximal and midpenile regions [Table 2]. We excluded distal penile (coronal and subcoronal) fistulas. In all patients, a catheter of size 6 Fr was kept as a stent for 10 days' duration postoperatively. In our study, there was no recurrence. We have successfully repaired all urethrocutaneous fistulae using our protocol with a success rate of 100%. There were no other minor and major complications including stricture, diverticulum formation, infection, or flap necrosis in our study. The urinary stream was good postoperatively. We carried out the follow-up for 1-year postoperatively [Figure 1] and [Figure 2].
Table 1: Age of the patients

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Table 2: Location of the fistula

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Figure 1: (a) NG in situ with the visible proximal fistula. (b) Marking for the flaps. (c) Flaps were created – one side is larger than the other side. (d) Larger size folded toward the other side like the Hat of a Box and sutured in a continuous layer.

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Figure 2: (a) Second layer with interrupted sutures over the first layer. (b) Skin closure without opposing suture lines. (c) Dressing removal after the 10th day. (d) Follow-up image.

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We did not use any optical magnification or any vascular tissue in our technique. Yet we had a wonderful success rate. The following are the secrets of the success:

  1. Meticulous suturing technique
  2. Adequate size meatus
  3. Fistula and skin closure in two layers by superimposing them
  4. Hat of box method leads to the wide anastomosis at the fistula site leading to no stricture
  5. Adequate mobilization of the perifistula flap and penile skin.



  Discussion Top


Urethrocutaneous fistulae are the most common complications after hypospadias surgery. Different procedures [1],[4] have been tried for repair. For large/recurrent fistulas with impaired local vascularity, an interposition waterproofing layer significantly reduces the recurrence rate of the fistula [5],[6].

Opposing suture lines are well recognized risk factors in fistula formation [5]. In our study, we also created flaps for skin closure; hence, suture lines did not oppose each other. Several surgical procedures have been described, each claiming good results with refined surgical techniques, fine suture materials and special dressings. The results of surgery after hypospadias repair have improved significantly [7]. In our study, we did not use any special dressings. We used simple penile dressing with tulle grass, gauze piece and adhesive tape.

Distal narrowing and infection are important factors to determine the surgical outcome [8]. In our study, we concluded that the success rate of fistula repair is dependent on meatal stenosis, adequate availability of healthy tissue and tensionless repair. Several procedures have been used for closure of fistula, including simple closure and complex operations, according to the site and size of fistula. A simple closure is technically easy, but the results are less than promising [6],[9]. In our study, we included only midpenile and proximal penile fistula with any size. We did not apply our technique to repair distal penile fistulas. As with hypospadias surgery, there are no perfect techniques for repairing urethrocutaneous fistulae. Many variables could influence the surgical management and outcome, the time of occurrence after urethroplasty, the location (glanular, coronal, midshaft, etc.), size (pin point, large), the number and the condition of local tissue [10]. Factors that affect results of their repair may be the condition of local tissue, duration of time after hypospadias repair, the number, location and size of the fistula, use of magnification, patient age, previous fistula repair and also the types of suture material used, skill of the operating surgeon and proper inversion of the edges, etc.

Cimador et al. [11] suggest that suture materials do not affect the complication rate in flap urethroplasty procedure. Jan et al. [12] published that incidence of the fistula formation after hypospadias repair was low if monofilament subcuticular suture was used. We used polyglactin 6-0 suture material in our study. During the last decade, many principles of an ideal repairing technique have been clarified. Delicate tissue handling, inversion of the urethral mucosa after excising the epithelialized tract of the fistula, a multilayer repair with vascularized tissues, avoiding overlapping sutures and nonabsorbable or thick suture materials, a tension-free closure, use of optical magnification [10],[13] and needlepoint cautery for coagulation are currently considered mandatory. In our study, we used absorbable fine suture material and performed tension-free closure without overlapping the sutures' line. We did not use optical magnification and cautery in our study.

With regard to the time of fistula closure, we prefer to close a fistula after 6 months to allow induration and scarring to subside [13]. Tension suture is the cause of failure after any repair; we avoid this tension through perifistula-based flap technique. The success rate in our study was 100%. Zhao et al. [14] used double skin flaps or pedicled skin flap from the scrotum for the repair. In the latter case, transverse Y or V-shaped skin flaps were used to close fistulae, both small and large, with a success rate of 87.57% in small fistulae and 86.84% for large fistulae. Kiss et al. [15] stated that, in cases with recurrent large fistula after hypospadias reconstruction, the use of buccal mucosa patch graft for closure is a good treatment choice with success rate of 85.7%.

Both simple closure and layered closure of a fistula at first attempt have a comparatively lower success rate [1],[4],[5],[13]. The larger the size of these fistulae, the more difficult is their closure and correction [16]. Numerous techniques have been advised to counteract this problem, and pursuit for an ideal one is still going on. Among these techniques, the most common maneuver is to place some intervening layers of tissue between the neourethra and the skin [17]. We closed the fistula in two layers, which created watertight closure of the fistulas. We did not carry out any test to ensure watertight closure.

With regard to the use of stent or microsurgery, the data from a study carried out by Waterman et al. [16] suggested that there are no clear differences in stent v/s no stent and microscope v/s loupes; age at fistula closure does not affect success; however, the type of original hypospadias procedure may influence success, and success rate is not negatively impacted in recurrent fistula cases. Sahin et al. [18] reported that the success rate of fistula repair was 93.3% and 94.1% in the catheterized and uncatheterized group, respectively. We did not used any magnification and stented all patients.

Awad [19] reported the success of repair was 92.3% in large fistulas and 94.4% in small fistulas with PUIT technique. Our results were comparable with the study of Mohamed et al. [20]. Hosseini et al. [21] had 78.6% success rate by using mucosal graft for fistula repair.

Srivastava et al. [22] reported 100% success rate with the waterproofing layer in the fistula closure. Karakus et al. [23] had similar results for their technique for the smaller fistula. We had a 100% success rate, which is similar to the results of the double deepithelized dartos flap technique [24].

We have used our technique for midpenile and proximal penile regions with any size of fistulas, and primary and recurrent types without suprapubic diversion with the same good results. The key points for the success of our study is tensionless two-layer one-side repair and not midline closure, as is the traditional technique of the fistula closure; its relieves the pressure over the repair site.


  Conclusion Top


The present technique can solve the problem of primary or recurre hypospadias fistula of any size midpenile, with a high success rate and promising results. The minimum time interval of 6 months between any two procedures should be considered for a favorable outcome. We strongly recommended its use as an alternate technique for tension-free fistula closure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Belman AB. The de-epithelialized flap and its influence on hypospadias repair. J Urol 1994; 152:2332–2334.  Back to cited text no. 1
    
2.
Walker RD. Outpatient repair of urethral fistula. Urol Clin North Am 1981; 8:573.  Back to cited text no. 2
    
3.
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4.
Moscona AR, Groven Yehudian J, Hirshowtitz B. Closure of urethral fistulae by transverse Y-V advancement flap. Br J Urol 1984; 56:313–313.  Back to cited text no. 4
    
5.
Raj HY. Role of Tunica Vaginalis interposition layer in hypospadias surgery. Indian J Plast Surg 2006; 39:152–156.  Back to cited text no. 5
    
6.
Shankar KR, Losty PD, Hopper M, Wong L, Rickwood AM. Outcome of hypospadias fistula repair. BJU Int 2002; 89:103–105.  Back to cited text no. 6
    
7.
Baskin L. Hypospadias. A critical analysis of cosmetic outcomes using photography. BJU Int 2001; 87:534–539.  Back to cited text no. 7
    
8.
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9.
Demirbilek S, Kanmaz T, Aydin G, Yucesan S. Outcome of one-stage techniques for proximal hypospadias fistula repair. Urology 2001; 58:267–270.  Back to cited text no. 9
    
10.
Retik AB, Keating M, Mandell J. Complications of hypospadias repair. Urol Clin North Am 1988; 15:223–236.  Back to cited text no. 10
    
11.
Cimador M, Castagnetti M, Milazzo M, Sergio M, De Grazia E. Suture materials: do they affect fistula and stricture rates in flap urethroplasties? J Urol 2002; 168:1751–1753.  Back to cited text no. 11
    
12.
Jan IA, Mirza F, Yaqoot M, Ali M, Arian A, Saleem N, et al. Factors influencing the results of surgery for hypospadias: experience at NICH. J Pak Med Assoc 2004; 54:577.  Back to cited text no. 12
    
13.
Latifoglu O, Yavuzer R, Unal S, Cavusoglu T, Atabay K. Surgical treatment of urethral fistulas following hypospadias repair. Ann Plast Surg 2000; 44:381–386.  Back to cited text no. 13
    
14.
Zhao GJ, Liu CX, Wu GD, Zhang YG, Ou. Repair of urethral fistula resulting from correction of hypospadias: experience with 56 cases. Di Yi Jun Yi Da Xue Xue Bao 2004; 24:113.  Back to cited text no. 14
    
15.
Kiss A, Pirót L, Karsza L, Merksz M. Use of buccal mucosa patch graft for recurrent large urethrocutaneous fistula after hypospadias repair. Urol Int 2004; 72:329–331.  Back to cited text no. 15
    
16.
Waterman BJ, Renschler T, Cartwright PC, Snow BW, DeVries R. Variables in successful repair of urethrocutaneous fistula after hypospadias surgery. J Urol 2002; 168:726–730.  Back to cited text no. 16
    
17.
Djordjevic ML, Perovic SV, Vukadinovic VM. Dorsal dartos flap for preventing fistula in the Snodgrass hypospadias repair. BJU Int 2005; 95:1303–1309.  Back to cited text no. 17
    
18.
Sahin C, Aksoy Y, Ozbey I, Polat O. Outpatient urethrocutaneous fistula repair with local anesthesia in adult patients. Ann Plast Surg. 2003; 50:378–381.  Back to cited text no. 18
    
19.
Awad MS. A simple novel technique [PUIT] for closure of urethrocutaneous fistula after hypospadias repair: preliminary results. Indian J Plast Surg 2005; 38:114–118.  Back to cited text no. 19
    
20.
Mohamed S, Mohamed N, Esmael T, Khaled S. A simple procedure for management of urethrocutaneous fistula; post-hypospadias repair. Afr J Paediatr Surg 2010; 7:124–128.  Back to cited text no. 20
    
21.
Hosseini J, Kaviani A, Mohammadhosseini M, Rezaei A, Rezaei I, Javanmard B. Hypospadias fistula repair by mucosal graft. Urol J 2009; 6:19–22.  Back to cited text no. 21
    
22.
Srivastava RK, Tandale MS, Panse N, Gupta A, Sahane P. Management of urethrocutaneous fistula after hypospadias surgery – an experience of thirty-five cases. Indian J Plast Surg 2011; 44:98–103.  Back to cited text no. 22
    
23.
Karakus SC, User IR, Akcaer V, Ozokutan BH, Ceylan H. A simple technique for small-diameter urethrocutaneous fistula repair: ligation. J Pediatr Urol 2017; 13:88–90.  Back to cited text no. 23
    
24.
Yildiz A, Bertozzi M, Akin M, Appignani A, Prestipino M, Dokucu AI. Feasibility of a tubularised incised-plate urethroplasty with double de-epithelised dartos flaps in a failed hypospadias repair: a preliminary report. Afr J Paediatr Surg 2012; 9:8–12.  Back to cited text no. 24
    


    Figures

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    Tables

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