Coronal fistula repair under the glans without reoperative hypospadias glansplasty or urinary diversion

Abstract

Coronal fistulas present a potential dilemma in management. Successful closure requires reoperative glansplasty when there is only a thin band of tissue separating the urethral meatus from the fistula, indicating glans dehiscence. However, we avoided reoperative glansplasty during coronal fistula repair when the glans wings remained well-fused, given the increased risk for complications, including recurrent fistula, following reoperative glansplasty. We report coronal fistula closure without reoperative glansplasty in patients with preserved fusion of the glans wings. We also compare this closure done with versus without postoperative urinary diversion. The primary outcome was recurrent fistula. Consecutive patients with coronal fistula and no glans dehiscence (Figure) underwent repair by dissecting the fistula tract under the glans rather than re-opening the glans wings. A midline incision facilitated creation of a ventral dartos barrier flap, used in all cases, as well as selective skin revision when needed. Initial patients had postoperative urinary diversion, whereas later consecutive patients did not. Data was recorded prospectively at the time of service into a database. WS performed 122 fistula repairs from 2001 to 2013, of which 78 were coronal. Of these, 33 had glans dehiscence with only a thin band of skin separating the fistula from the distal meatus and underwent reoperative hypospadias repair. The other 45 met inclusion criteria with maintained glans wings fusion and had only fistula closure. These 45 patients all had fistulas </= 3 mm, and none had evidence of meatal stenosis, defined as calibration <8 Fr in prepubertal and <12 Fr in pubertal males. Median age at fistula closure was 3 y (1-51), and mean follow up in 37 of the 45 patients was 18 m (1.6-84). Recurrent fistulas occurred in 2 (5%), with no difference in those with versus without urinary diversion. There was a 5% fistula recurrence rate after dissecting under the glans and closing the urethral defect without reopening the glans in patients with well-fused glans wings. All patients had a ventral dartos barrier flap which covered the urethral defect. There was no difference in outcomes based on use of urinary diversion or not, and so we no longer use postoperative catheter drainage. Ours is the first report on fistula repair using a standardized protocol in consecutive patients, and it is difficult to compare our results to other published series which included fistulas in various locations, heterogeneity in decision-making based on "simple vs "complex" designations, and varied use of urinary diversion. Other reported recurrence rates vary from 4% to 30%. All our patients had primary fistulas <3 mm in size, and so we cannot comment on use of this technique for recurrent fistulas and/or larger defects. We report outcomes during a mean of 18 months follow up, and it is possible there will be additional recurrences with longer follow up. This study is the first on fistula repair using a standardized procedure in consecutivepatients with prospectively recorded data. We found coronal fistulas ≤3 mm under well-fused glans wings can be repaired with low risk for recurrence by elevating the glans rather than re-opening the wings for reoperative glansplasty. Postoperative urinary diversion did not impact the recurrence rate and so is no longer used.