Use of the TIP Principle for the Repair of Non-glanular Recurrent Post Hypospadias Urethrocutaneous Mega Fistula

Abstract

The most significant complication after hypospadias repair is urethrocutaneous fistula. Repair is even more difficult if the fistula is large. Use of the tubularized incised plate (TIP) procedure for hypospadias repair has greatly increased. However, use of the TIP procedure for the repair of recurrent mega fistula has not been previously described. The aim of this study is to present the results of a modified TIP procedure for the repair of recurrent mega fistula occurring after hypospadias repair. All cases of recurrent penile mega fistula after hypospadias repair presenting to our institution between 2002 and 2008 were included in our study. Cases with coronal or glanular fistulae were excluded. Diameters of these large fistulae were > or =0.5 cm. Repair was done a minimum of 6 months after the last repair. After complete dissection of the fistula, the excision was extended a further 2 mm all around the edge in a circumferential manner. A dorsal slit in the penile urethra was made based on the TIP procedure; the urethroplasty was completed using interrupted sutures. Second layer coverage was done and the skin was closed. A total of 11 boys (median age at surgery: 8 years) who developed mega fistula after hypospadias repair were included in the study. The patients had undergone previous attempts at repair, with the number of previous attempts ranging between 1 and 9 times. The last repair was done 6-48 months before surgery (median: 16 months). Fistulae diameters were between 5 and 13 mm (median: 9 mm). All patients underwent the same procedure, with a follow-up period of between 6 and 72 months (median: 33 months). In 7 cases 2 layers were used to cover the urethroplasty, while in 4 cases used only one layer. There were no intraoperative complications. Two cases suffered superficial infection postoperatively, one of whom developed a small fistula (1/11). The advantages of a procedure based on the TIP principle for the treatment of recurrent penile mega fistula are numerous. The procedure is easy to perform and can be successfully used to treat recurrent urethrocutaneous fistula in carefully selected cases. Our recurrence rate of 9% is acceptable. Use of a modified TIP procedure for the repair of mega fistula or partial penile disruption is feasible. More cases are needed to support our initial findings of this new use of the TIP procedure in hypospadias surgery.