Development Of Urethrocutaneous Fistula Research Articles

Effect of Haematological Parameters in the Development of Urethrocutaneous Fistula After Hypospadias Surgery.

Investigation of the relationship between urethrocutaneous fistula (UCF) development and haematological parameters after hypospadias surgery was aimed for in this study. Patients who underwent tubularized incised plate urethroplasty between January 2015 and June 2021 with the diagnosis of distal hypospadias were included in the study. We divided the participants into two groups based on UCF development. We compared haematological parameters, including neutrophil, lymphocyte, and platelet counts; neutrophil-lymphocyte ratio (NLR); platelet-lymphocyte ratio (PLR); and systemic immune inflammation index (SII) values between the two groups. A total of 78 patients were included in the study. Of the patients, 11 developed UCF. The mean age of the patients was 74.9 ± 42.8 months. Catheter diameter, operation time, neutrophil counts, NLR, and SII values were similar between those with and without UCF (p > 0.05). However, the UCF group had significantly higher lymphocyte and platelet counts than those without UCF (p < 0.05). Moreover, the PLR value was significantly lower in the UCF group (p < 0.05). Patients who developed UCF post hypospadias surgery had a significant association with altered blood cell counts, including increased lymphocytes and decreased PLR rate. The PLRcan be used as a biological marker for UCF development.

The comparison of interrupted and continuous suturing technique in Snodgrass urethroplasty in patients with primary hypospadias: A systematic review and meta-analysis

Hypospadias is among the common congenital anomalies in boys. Snodgrass urethroplasty is one of the most popular techniques for correcting distal and mid hypospadias. Although there is consensus among pediatric surgeons on using absorbable sutures for urethroplasty, there are no established guidelines about the suturing techniques (interrupted suturing [IS] or continuous suturing [CS]) for neourethra creation in Snodgrass urethroplasty. This analysis aims to compare the reported outcomes of both the urethroplasty suturing techniques. This systematic review and meta-analysis was conducted as per the preferred reporting items for systematic review and meta-analyses guidelines. A systematic, detailed search was carried out by the authors in the electronic databases - MEDLINE, PubMed Central, Scopus, Google Scholar, and Clinical Trial Registry. Studies were selected and compared based on primary outcomes - development of urethrocutaneous fistula (UCF), meatal stenosis, and secondary outcomes - wound infection, urethral stricture, and operative time. Statistical analysis was performed using a fixed-effect model, pooled risk ratio, and I2 heterogeneity. Five randomized studies with a total of 521 patients met our inclusion criteria. Pooled analysis for total complications, UCF, meatal stenosis, and wound infection showed no significant difference between the CS and IS groups. Subgroup analysis of patients with the use of polyglactin sutures showed a decrease in total complications and UCF in the IS group. There is no difference in total complication rates among the CS and the IS group with the use of absorbable sutures in Snodgrass urethroplasty; however, there is a decrease in the incidence of total complications and UCF in the IS group when polyglactin was preferred over polydioxanone suture for urethroplasty.

Double dartos flap layer in tubularized incised plate urethroplasty to prevent urethrocutaneous fistula in uncircumcised patients with distal hypospadias.

Urethrocutaneous fistula may complicate hypospadias repair. We noticed that double-layered preputial dartos flaps added to tubularized incised plate urethroplasty can reduce the risk of urethrocutaneous fistula. The aim of this study was to compare the outcomes of tubularized incised plate urethroplasty with double-layered preputial dartos flaps to with single-layered local fascial flaps in preventing urethrocutaneous fistula. A retrospective cohort study was conducted between January 2017 and December 2020 at Jordan University Hospital (Amman, Jordan). Boys who were aged between 6 months and 5 years, diagnosed with distal hypospadias, and not circumcised were included. The primary outcome was the occurrence of urethrocutaneous fistula in patients who underwent tubularized incised plate urethroplasty with a double-layered fascial flap. The results showed a total of 163 boys with distal hypospadias; among them, 116 patients underwent tubularized incised plate urethroplasty with a single-layered fascial flap, and 47 underwent tubularized incised plate urethroplasty with a double-layered fascial flap. The development of urethrocutaneous fistula was higher in the group receiving tubularized incised plate urethroplasty with a single-layered fascial flap than in the group receiving tubularized incised plate urethroplasty with a double-layered fascial flap after 1 month, 6 months, and 12 months (6.9% vs 0, 10.3% vs 0, and 5.2% vs 0, respectively), and the difference after 6 months was statistically significant (P = 0.02).

Comparative study between snodgrass urethroplasty and modified snodgrass urethroplasty for distal penile hypospadias in terms of post-operative urethrocutaneous fistula formation

Background: Hypospadias is a congenital defect involving the male urethra characterized by the absence of urethral meatus at its normal position. This anomaly is usually associated with the ventrally deficient but dorsally hooded skin. In some cases, the penis is ventrally curved. Surgery is the option for this defect. So many procedures have been developed but none is free from the development of urethrocutaneous fistula. Now-a-days, the popular Snodgrass procedure is widely practiced but still fistula occurs. Many factors are thought to be responsible for it. The most important one is defective ventral penile skin which is deficient of vascular and collagen tissues. To minimize these deficient factors, a dorsal vascular preputial flap is transferred ventrally (modified) to reduce fistula formation further. A comparative study was disigned to determine the role of dorsal vascular flap.Methods: The prospective observational study was conducted in the department of pediatric surgery, Bangabandhu Sheikh Mujib medical university, Dhaka, Bangladesh since February 2017 to May 2021.Results: A total of 40 patients with distal penile hypospadias were included in this study. They were divided into Group A and group B, 20 for each. Snodgrass procedure was for Group A and the modified Snodgrass procedure was done for group B. The outcome of both the groups was determined in terms of fistula formation. Seven patients in group-A and one patient in group B developed fistula. The results were analyzed and were found statistically significant.Conclusions: Modified Snodgrass urethroplasty has a better outcome.

LIMITED URETHERAL MOBILIZATION PROCEDURE (LUMP) FOR DISTAL PENILE HYPOSPADIAS REPAIR, A SINGLE CENTRE RETROSPECTIVE ANALYSIS

Background: Distal penile hypospadias is one of the commonest varieties of hypospadias. Different techniques have been mentioned in literature. The success rate is usually assessed by rate of fistula formation and over all cosmetic appearance and functional outcome. Limited Uretheral Mobilization Procedure (LUMP) for distal penile hypospadias is considered a good technique with almost zero fistula rate in some series. As no new urethral tube is constructed there is no risk of fistula. Objective: To evaluate the results of the Limited Urethral Mobilization Procedure (LUMP) for distal hypospadias repair. Methods.It is retrospective analysis of 32 patients aged up to 12 years who were treated with Limited urethral mobilization procedure for distal penile hypospadias in the Department of Paediatric Surgery Jinnah Hospital Lahore from December 2018 to November 2019. All patients were operated under general anesthesia. The urethra proximal to the meatus was mobilized adequately in such a way that it should reach the tip of glans easily without any ventral bending of penis.Then the urethra was placed in the glandular wings and reconstruction of glans was carried out. Dartos flap was also placed to cover the urethra as a safety measure to avoid urethrocutaneous fistula formation. Follow up was done for a period of 3 months with respect to fistula formation, meatal stenosis, retraction , chordee and over all cosmetic appearance. Results: Age range of children was 9 months to 12 years. Operation time ranged from 60-80 minutes. Seven of 32 cases were previously operated for distal penile hypospadias but after disruption of repair meatus was lying at coronal or subcoronal level. They also underwent LUMP. Five cases had minor chordee, it was corrected at the time of uretheral mobilization by simple excision of fiberous tisse in 4 patients while modified Nesbit dorsal placation was done in one. Cosmetically normal looking circumcised penis with slit like meatus was achieved in all.Two cases got superficial wound infection, two had meatal stenosis, one meatal retraction, one ventral chordee and one urethrocutaneous fistula. Conclusion: LUMP for distal penile hypospadias is a simple and effective procedure with minimum complications.There is no chance for development of urethrocutaneous fistula, a major postoperative complication of other surgical techniques for uretheroplasty. Postoperative management is simple and hospital stay is short.

Risk Factors of Urethro-cutaneous Fistula Development in Hypospadias Surgery

Urethrocutaneous fistula development is the most common complication found hypospadias surgery. Several factors associated with the incidence of fistulas are the age at the time the surgery. The type of hypospadias, the degree of chordae, the operative technique applied and catheter type. This study aimed to determine the risk factors associated with the urethro-cutaneous fistula development in hypospadias surgery. The results showed that from 310 hypospadias patients undergoing urethroplasty, urethra cutaneous fistula development occurred among 105 patients (30.6%) with a mean age of surgery 10.89+6.27 years. Hypospadias type has a significant difference with the incidence of urethro-cutaneous fistula development (p = 0.027). Age (p = 0.615), degree of chordae (P=0.805), operative technique (P=0.901) and catheter type (P=691) do not have a significant impact to urethro-cutaneous fistula development. It can be concluded that operative urethroplasty has a risk of urethra-cutaneous fistula that associated with hypospadias type.

MANAGEMENT OF ANTERIOR HYPOSPADIAS, OUR EXPERIENCE WITH SNODGRASS REPAIR TECHNIQUE MARDAN MEDICAL COMPLEX MARDAN TEACHING HOSPITAL

OBJECTIVE: To report on the short-term outcomes of anterior hypospadias tabularized incised plate urethroplasty,as reported by Snodgrass.MATERIAL AND METHODS: From January 2014 to December 2016, patients with anterior hypopadiaswithout chordae were the subjects of this research, which took place at the Mardan Medical Complex surgical department in Mardan. The research had 56 patients ages 3 to 13 years, with a mean age of 5.1. Anterior distal shafthypospadias with a healthy urethral plate was an inclusion criterion, while chordae and a history of prior surgery wereexclusion criteria. A new urethra was created around a size 6 to 8 Fr stent after the full length of the urethral platewas cut along the midline. Subdartos fascia covered the newly formed urethra. In every instance, sufratullae were usedfor pressure dressing.RESULTS: During the investigation, there were three complications: six cases (10.7%) of urethrocutaneous fistuladevelopment, four cases (7.1%) of meatal stenosis, and two cases (3.5%) of glandular dehiscence. In our research, theoverall rate of problems was 21.42%.CONCLUSIONS: For anterior hypospadias, the Snodgrass treatment has outstanding functional and estheticoutcomes. Comparing this operation to others, the incidence of complications is modest.KEYWORDS: Distal Hypospadias, Snodgrass repair.

Association between intra-operative meatal mismatch and urethrocutaneous fistula development in hypospadias repair

The Glans-Meatus-Shaft (GMS) Score is a pre-operative phenotypic scoring system used to assess hypospadias severity and risk for post-operative complications. The 'M' component is based on pre-operative meatal location, but meatal location sometimes changes after penile degloving, resulting in 'meatal mismatch.' To identify: 1) the incidence and clinical predictors of meatal mismatch, and 2) the association of meatal mismatch with post-operative urethrocutaneous fistula development. We performed a retrospective cohort study on patients who underwent primary hypospadias repair at a single center from 2011 to 2018. Meatal mismatch was defined as: upstaging (meatus moving more proximally after degloving), downstaging (moving more distally after degloving), or none. Covariates included: pre-degloving meatal location, chordee severity, penoscrotal anatomy, pre-operative testosterone, and number of stages for repair. To test the association between meatal mismatch and fistula development, we constructed two, nested, multivariable Cox proportional hazards regression models with and without meatal mismatch and compared them with the likelihood ratio test. A sensitivity analysis excluded patients with <6 months of follow-up. Of 485 patients, 99 (20%) exhibited meatal mismatch, including 75 (15%) with upstaging and 24 (5%) patients with downstaging (Figure). Meatal mismatch was significantly associated with penoscrotal webbing, number of stages for repair, and pre-degloving meatal location, with downstaging being associated with more proximal meatal location. Over a median follow-up of 7.3 months (interquartile range 2.0-20.9), fistulae developed in 56 (12%) patients. On multivariable analysis, meatal upstaging was associated with a 3-fold increased risk of fistula development (Hazards Ratio [HR]: 3.04, 95% Confidence Interval [CI]: 1.44-6.45) compared to no mismatch. Meatal downstaging had similar risk of fistula development compared to no mismatch (HR: 0.99, 95% CI: 0.29-3.35). Multi-stage compared to single-stage repair was associated with reduced risk of fistula development (HR: 0.24, 95% CI: 0.09-0.66). The likelihood ratio test favored the model that included meatal mismatch. The sensitivity analysis showed similar findings. Our short-term results suggest that meatal mismatch may be an important additional consideration to the GMS score as a tool to assess hypospadias severity, counsel families, and predict outcomes. Longer-term studies are needed to enhance the precision of risk stratification in hypospadias. Meatal mismatch occurred in 20% of patients undergoing hypospadias repair. Among this cohort, meatal upstaging was associated with a 3-fold increased risk of post-operative urethrocutaneous fistula development.

Risk factors for urethrocutaneous fistula following hypospadias repair surgery in Indonesia

Hypospadias is one of the most common congenital malformations with a worldwide increasing trend over the years. Despite advancements in hypospadias repair, complications still occur. One of the most common complications of hypospadias repair surgery is Urethrocutaneous fistula. Studies attempting to analyze the association between the complication and risk factors are always beneficial, especially for studies performed in different areas of the world. We hypothesize that several evaluated risk factors among Indonesian hypospadias patients could be associated with the occurrence of urethrocutaneous fistula after the repair procedure. To determine the risk factors associated with urethrocutaneous fistula after hypospadias repair surgery by collecting and analyzing data obtained from multiple centers in Indonesia. A nationwide, retrospective study with 12 hospitals in Indonesia of children with a diagnosis of hypospadias was conducted. The collected data, taken from patients admitted in 2018, from each center's medical records consisted of patient identity, repair technique used, neourethra length, percutaneous cystostomy, and splint size as independent variables speculated to be possible risk factors correlated to the presence of urethrocutaneous fistulae. Binomial logistic regression analysis was performed using SPSS 21.0 to determine the relationship between urethrocutaneous fistulae as a post-repair complication and possible risk factors. We collected 591 hypospadias cases from 12 centers in 9 cities in Indonesia. Most patients came when they were already at the age of more than four years old (60.4%). The chordee-only and failed urethroplasty groups are excluded from the analysis as they are not classified as true hypospadias. Most repairs were performed by using the Tubular Incised Plate (TIP) with Thiersch-Duplay technique (44.16%). Most of the reconstructed neourethra are 2-3cm in length (32.13%). The 8 Fr urethral splint (46.41%) was mostly used during the operation. Most surgeons decided not to perform cystostomy throughout the procedure (61.03%) based on personal preferences. Urethrocutaneous fistula was found in 80 patients (15.27%) out of the total patients who underwent the surgery. The binomial logistic regression analysis shows that age (OR=1.398, p=0.015), the decision to not perform cystostomy (OR=2.963, p=0.014), and splint size (OR=1.243, p=0.023) are significantly associated (p<0.05) with the development of urethrocutaneous fistula. Age and splint size are significant risk factors for urethrocutaneous fistula after hypospadias repair in Indonesia, whereas performing percutaneous cystostomy during the repair decreases the risk for urethrocutaneous fistula occurrence.

Urinary flow measurement in hypospadias correlated to surgical procedure and risk of development of urethra-cutaneous fistula

To explore the correlation between fistula development and urinary flow measurements after hypospadias repair with emphasis on patients with urethrocutaneous fistula complications and to identify risk factors for fistula development. Urinary flow was examined in boys operated on for hypospadias. Outcome of maximum urinary flow (ml/s) (Qmax), voided volume for age (ml) (Volume), and pathological flow pattern (n) (Curve) was compared between the Byars, Mathieu, and Tubularized Incised Plate (TIP) surgical repair methods and between the groups of those who had and had not developed a fistula. Logistic regression analysis was performed for age at operation, genetics, comorbidity, or urinary flow measurements regarding the development of urethrocutaneous fistula. Seventy-three boys underwent hypospadias repair. Overall, the urinary flow measurements differed significantly between the three reconstructive methods, being favorable for the Mathieu procedure regarding Qmax (p<0.01), volume (p=0.04), and frequency of pathological voiding curve (p<0.01; Table). The frequency of urethrocutaneous fistula was 18% (13/73) and did not differ significantly between the three different reconstructive surgery methods (Byar 33%, Mathieu 32%, and TIP 12%; p=0.22). Urinary flow measurements did not differ between patients with and without fistula complications regarding Qmax 10ml/s (4-16) vs. 8ml/s (2-18), voided volume 74ml (35-171) vs. 71ml (9-270), or abnormal urinary flow pattern (23% vs. 30%). On logistic regression analysis, age at operation, genetics, comorbidity, and urinary flow measurement parameters did not turn out to be independent risk factors for development of urethrocutaneous fistula after hypospadias repair. The study demonstrated significant differences between the urinary flow measurement results between the three different repair methods, favoring the Mathieu procedure. A low Qmax was a common postoperative finding. Urinary flow measurements did not differ between boys developing fistula and those who did not. No risk factors for fistula development were identified. The study did not support that it would be possible, at an early postoperative stage, to identify those with an upcoming postoperative fistula neither with urinary flow measurements nor through risk factors. No similar reports have studied the possibility of using postoperative urinary flow measurements to determine patients at risk of fistula development after hypospadias repair. Urinary flow measurements were favorable after hypospadias reconstruction with Mathieu compared with Byars and TIP. Furthermore, urinary flow measurements did not differ between reconstructed with and without a fistula complication. No risk factor for fistula development was identified.

Urethro-cutaneous fistula after hypospadia repair: a single institution study

Urethro-cutaneous fistula (UCF) is one of the most frequently seen complications of hypospadias surgery requiring reoperation; it occurs with an incidence of between 4% and 28%. Risk factors associated with the development of UCF can be classified as preoperative, intraoperative or postoperative. The aim of this study was to determine the association of perioperative risk factors and the development of urethrocutaneous fistula after hypospadias repair. A retrospective review of patients who had undergone hypospadias repair at Kenyatta National Hospital between 2013 and 2017 was conducted. 114 patient records were retrieved. The incidence of UCF was 47%. Risk factors that were significantly associated with UCF are hypospadias type (p=0.028), lack of a protective intermediate layer (p=0.002), and presence of postoperative complications (p=0.001). Age at surgery, suture material, type of repair and use of catheter/stents were not significant factors. Multivariate analysis showed wound infection and meatal stenosis as the most significant factors associated with UCF development.Keywords: Hypospadias, Urethro-cutaneous fistula, Risk factors, Wound infection, Meatal stenosis

Postoperative outcomes in distal hypospadias: a meta-analysis of the Mathieu and tubularized incised plate repair methods for development of urethrocutaneous fistula and urethral stricture

PurposeTo compare the two major complications, namely postoperative urethrocutaneous fistula and urethral stricture, between the Mathieu and tubularized incised plate (TIP) repair methods for distal hypospadias.MethodsIn this meta-analysis, electronic databases were searched for comparative studies on the two techniques. The Oxford Centre for Evidence-based Medicine Levels of Evidence was used to evaluate the included studies. The main outcome measure was the frequency of postoperative fistula and urethral stricture. RevMan 5.3 was used for statistical analyses, with P < 0.05 indicating statistical significance.ResultsA total of 17 studies, which included 1572 patients, met the inclusion criteria. The frequency of urethrocutaneous fistula did not differ between the Mathieu [115 (13%)] and TIP [90 (13%)] methods [odds ratio (OR) 1.1, 95% confidence intervals (CI) 0.6–1.9; P = 0.73)]. Urethral stricture was less frequent after the Mathieu [15 (2%)] method than after the TIP [37 (5%)] method (OR 0.5, 95% CI 0.3–0.8; P < 0.01), even after the subgroup analysis of eight randomized controlled trials was included. Overall, the quality of the included studies was determined to be satisfactory. The levels of evidence on which this review was based ranged from 1b to 2b using the CEBM Levels of Evidence.ConclusionCompared with TIP repair, Mathieu repair for hypospadias had a significantly lower risk for urethral stricture; however, the risk for urethrocutaneous fistula was similar.

The risk factors of Urethrocutaneous fistula after hypospadias surgery in the youth population

BackgroundThe current research aims to evaluate the risk factors of urethrocutaneous fistula after hypospadias surgery among the youth in China.MethodsOne hundred twenty hypospadias patients were enrolled in our study. All of them were defined as Tanner 4 or 5. The information collected from the participants include age, urethral operation history, urinary comorbidities before operation, urine test before operation, body temperature before and after operation, type of surgical repair, chordee degree, urethral defect length and whether received vesicostomy after surgery or not. Independent t test, chi-square test and multivariate logistic regression were performed to evaluate the risk factor of urethrocutaneous fistula.ResultsAmong the enrolled patients, 39 patients (32.5%) developed urethrocutaneous fistula after hypospadias repair. Our result showed significant association between the group with urethrocutaneous fistula and the group without urethrocutaneous fistula with respect to age, pyuria before operation, urethral defect length and the urethral operation history. The following logistic regression showed that urethral defect length and the urethral operation history were the risk factors of urethrocutaneous fistula.ConclusionsUrethral defect length and urethral operation history should be taken into consideration before undergoing hypospadias surgery since our study discovered that the risk of developing urethrocutaneous fistula after hypospadias repair is associated with urethral defect length and urethral operation history. Age, surgical procedure, type of surgical repair, chordee degree and other factors were not obviously related to the development of urethrocutaneous fistula.

Limited Urethral Mobilization Technique in Distal Hypospadias Repair : An Overview

Background: Fistula formation is the most common complication with various rates among different techniques of hypospadias repair. The urethral advancement as an one stage technique for repair of hypospadias is considered a good technique. As no new urethral tube is constructed there is no risk of fistula. We assess the outcomes of the Limited Urethral Mobilization (LUM) technique in distal hypospadias repair.Methods: Our study included 20 patients aged upto 12 years who were treated with Limited urethral mobilization technique for distal hypospadias in Shaheed Suhrawardy Medical College Hospital from December 2014 to December 2015. The urethra proximal to the meatus was mobilized for a distance sufficient to allow it to reach the glans tip without tension. Then the urethra was placed in the glanular bed and glanular reconstruction was performed.Results: Three-fold urethral mobilization was sufficient for construction of tension-free urethra-glanular anastomosis. Cosmetically normal looking circumcised penis with ventrally slit meatus achieved in all but one subcoronal case where the most distal of the glans approximation sutures disrupted leading to a minor detachment in the glans. The minor complications includes preputial edema in one patient, two patients had wound infection, one had meatal stenosis which was treated with gentle dilatations. Postoperative urethro cutaneous fistula, retraction of the urethral meatus or recurrent chordee were not observed.Conclusion: Distal hypospadias repair with the LUM technique can be effective with satisfactory cosmetic and functional results. There is no chance for development of urethro cutaneous fistula, a major postoperative complication of other surgical techniques of creating a neourethra. Postoperative management is simple and a brief hospital stay is sufficient.Chatt Maa Shi Hosp Med Coll J; Vol.16 (1); Jan 2017; Page 37-41

Does the early removal of urethral stent can reduce postoperative complications of Snodgrass urethroplasty for hypospadias repair? A prospective randomized trial

Background: Hypospadias is a relatively common congenital defect of the male external genitalia. The objective of this study was to evaluate whether the early removal of urethral stent following TIP Snodgrass repair of hypospadias can reduces postoperative complications of this procedure.Methods: In Al-Yarmouk teaching hospital, the surgical procedure included 61 tabularized incised plate (TIP) repairs for penile hypospadias. The patients were prospectively observed over 36 months and randomized into 2 groups, group (A) was 30 patients where the urethral stent was removed after 24 hours of operation, and group (B) was 31 cases where the stent removed in the 6th postoperative day. Suprapubic urinary diversion was done for all patients. All of the operations were performed by the same surgeon. Complications and cosmetic appearance were documented at last follow-up.Results: The average age of the patients was 3.9 years, urethrocutaneous fistula was observed in 2 cases in group A (6.6 %), while 11 patients had fistula in group B (35.4 %) with a statistically significant difference (p &lt; 0.05). meatal stenosis was reported in 4 patients in (group A) (13.3%), while 12 patients had such complication in group B (38.7%) with a statistically Significant difference as (P&lt; 0.05). 6.6 % of group A developed wound infection, while 32.2 % had wound infection postoperatively in group B with a statistically significant difference (P&lt; 0.05). Complete surgical failure when wound dehiscence occurs, it was found that no significant difference between the 2 groups (P value=0.1).Conclusions: TIP repair is a versatile operation that can be performed in almost all cases of penile hypospadias. We believe that early stent removal after 1 day of surgery for hypospadias repair simplifies postoperative care, highly reduces risk of development of urethrocutaneous fistula, meatal stenosis and wound infection, so obviates the need for antibiotics.

Role of tubularization of urethral plate in development of urethrocutaneous fistula post hypospadias repair.

Introduction:This study aimed to demonstrate the outcome of hypospadias repair in the pediatric population using the tubularized urethral plate technique and to compare the incidence of fistula between incised and unincised urethral plate.Methodology:This is a retrospective cohort study of pediatric patients who had hypospadias repair in a tertiary hospital in Jeddah, Saudi Arabia, between January 2000 and December 2012. They were divided into two main groups according to the status of the urethral plate: Group A included patients who had incision of the urethral plate just before tubularization, and Group B included patients who underwent tubularization without incision.Results:After reviewing 310 medical records, 106 patients were included in the final analysis, with a median age of 2 years (interquartile range = 3 years). There was no statistically significant relationship between types of hypospadias and the development of fistula (P = 0.26). In Group A, we identified 87 patients (82%), and in Group B, there were 19 patients (18%). The overall incidence of fistula was 34.9% (n = 37). The incidence of fistula in Groups A and B was 36% (n = 31) and 32% (n = 6), respectively. This difference was not statistically significant. Despite a high fistula rate, only 12 patients (11%) were required to repeat surgery.Conclusion:Incision of the urethral plate did not affect the fistula rate. In comparison to international literature, the incidence of fistula was significantly higher which could be explained by the fact that one-third of those patients had a previous hypospadias repair.

Urethral mobilization and advancement for distal hypospadias

Background/purpose Despite the existence of numerous techniques for the repair of distal penile hypospadias, none of them is completely satisfactory. Advancing the urethra without mobilization for repair of glanular hypospadias has the advantage of avoiding a common problem occurring with other techniques: urethrocutaneous fistula. This study aims at evaluation of our experience with this technique for repair of distal hypospadias. Materials and methods A prospective study was conducted on patients with glanular, coronal and subcoronal hypospadias during the period from December 2012 to December 2014. Recurrent cases were excluded. Feasibility of the technique and postoperative complications were recorded. Results A total of 30 boys between 9 months and 7 yearsof age were included in the study. They underwent repair of glanular (five), coronal (10), and subcoronal (15) hypospadias. The urethra was mobilized to the proximal shaft in almost all cases. Three cases developed postoperative hematoma, which were managed conservatively and resolved spontaneously. Two cases developed wound infection and were managed with antibiotics and daily dressing until infection resolved. None of the patients had major complications such as dehiscence, urethral stricture, or fistula. Three patients developed meatal stenosis; two of them responded to repeated dilatation twice weekly for 2 weeks; and one needed meatoplasty. In one patient, the most distal of the glans approximation sutures disrupted, leading to a minor detachment in the glans. There was no recurrent chordee. Two patients underwent meatal retraction, wherein the urethra migrated proximally but still within the glans; only one of these patients required a second procedure. Conclusion The urethral mobilization technique seems tobe a good method for the repair of distal hypospadias with or without chordee with satisfactory cosmetic and functional results. The procedure has the advantage of avoiding the need for a second layer of tissue covering during repair. Moreover, there is no chance for the development of urethrocutaneous fistula, a major postoperative complication of other surgical techniques creating a neourethra. Postoperative management is simple and a brief hospital stay is sufficient. Keywords : distal hypospadias, hypospadias repair, urethral mobilization

Risk Factors for the Development of Urethrocutaneous Fistula after Hypospadias Repair: A Retrospective Study

PurposeThe purpose of this study was to investigate the risk factors for urethrocutaneous fistula development after hypospadias repair.Materials and MethodsBetween January 1990 and May 2010, 348 patients underwent hypospadias repair. This study included 294 patients who were followed up for more than 6 months. Potential risk factors for the development of fistula after operation included age, location of hypospadias, type of hypospadias repair, suture materials and methods, methods and duration of catheterization, combined congenital urologic disorders, timing of presentation and repair of fistula, and location of fistula. Data were analyzed retrospectively. Binary logistic regression analysis was used for univariate and multivariate analysis.ResultsOut of 294 patients, 63 patients (21.4%, 63/294) developed urethrocutaneous fistulas after hypospadias repair. In the univariate analysis, fistula formation was statistically related with type of hypospadias and type of hypospadias repair. In the multivariate analysis with stratification by hypospadias site, however, only the location of hypospadias was a significant independent risk factor in urethrocutaneous fistula development after hypospadias repair (p<0.001).ConclusionsOur results suggest that the risk of developing urethrocutaneous fistula after hypospadias repair is associated with the location of hypospadias (more proximal-type hypospadias). Type of hypospadias repair, suture materials, suture techniques, and number of other combined urologic disorders were not related to the development of urethrocutaneous fistulas.

“Limited” double dorsal dartos flap coverage. An effective alternative to conventional flap coverage of the neourethra following Mathieu repair for subcoronal hypospadias

Double dorsal dartos flap coverage of the neourethra has been reported to be superior to single flap coverage for the prevention of urethrocutaneous fistula following hypospadias surgery. Conventional flap coverage involves covering the entire neourethra with vascularised flap. We describe a "limited" double dorsal dartos flap coverage of the neourethra following Mathieu repair for subcoronal hypospadias. In a prospective study conducted between Feb 2003 and Feb 2007, 31 patients with primary subcoronal hypospadias who had a flat and narrow urethral plate with a healthy urethral meatus and minimal or no chordee underwent Mathieu hypospadias repair. A "limited" double dorsal dartos flap coverage of the neourethra was done in all patients. This involved covering only that portion of the neourethra which remained exposed after glans closure, i.e. the proximal neourethra. Primary surgical outcome assessed was the development of urethrocutaneous fistula following surgery. The mean age at the time of repair was seven years and mean follow up was eight months. There was no flap loss, urethrocutaneous fistula formation, or glanular dehiscence in any of the 31 patients. One patient developed meatal stenosis which was managed by dilatation. One patient developed superficial sloughing of the penile skin. Overall complication rate was 6.45%. "Limited" double dorsal dartos flap coverage of the neourethra seems to be an effective method to reduce the fistulous complication rate following Mathieu repair for subcoronal hypospadias. A larger comparative study needs to be done to evaluate conventional neourethral coverage with "limited" neourethral coverage.

Tunneled Tunica Vaginalis Flap is an Effective Technique for Recurrent Urethrocutaneous Fistulas Following Tubularized Incised Plate Urethroplasty

In the last several years the use of the tubularized incised plate hypospadias repair has greatly increased. The most significant complication after this mode of urethroplasty is urethrocutaneous fistula development. Tunneled tunica vaginalis flap is a well described technique for repair of urethrocutaneous fistula. However, to our knowledge its use after tubularized incised plate repair has not yet been described. We present our results with this technique. We retrospectively reviewed all patients undergoing repair of urethrocutaneous fistula after initial tubularized incised plate repair between January 2001 and December 2005. We analyzed the initial number and location of fistulas, number of previous urethrocutaneous fistula repairs, duration of surgery, and intraoperative and postoperative complications. A total of 16 boys (median age 2.2 years) underwent tunica vaginalis flap repair at our institution for urethrocutaneous fistula following initial failed tubularized incised plate repair. Of these patients 4 had not previously undergone urethrocutaneous fistula repair and 12 had undergone 1 to 4 failed repair attempts. All boys had a subcoronal fistula and 8 had additional fistulas along the penile shaft, 4 each with 3 and 4 fistulas, including 1 penoscrotal fistula. Mean surgical time was 45 minutes, and no intraoperative or postoperative complications occurred. After a mean followup of 18 months (range 4 to 36) no patient had recurrence of urethrocutaneous fistula. Tunneled tunica vaginalis flap repair is a highly successful technique for the treatment of urethrocutaneous fistula after initial failed tubularized incised plate repair. The technique is technically simple to perform, and we encountered no complications. Tunneled tunica vaginalis flap repair should be considered for treating urethrocutaneous fistula following initial failed tubularized incised plate hypospadias surgery, particularly in a repeat surgical setting.