Prevent Fistula Formation Research Articles

Comparative Study Between Autologous Platelet-rich Fibrin Membrane and Local Flaps as Intervening Layer in Management of Distal Hypospadias

Background/PurposeThe most frequent complication following hypospadias correction is fistula formation. Recently, fibrin glue has been employed as a 2nd layer covering the urethroplasty resulting in a reduction in the incidence of fistulas. Platelet-rich fibrin (PRF) is an autologous growth factor-rich source. Although the authors recommend the use of additional layers in hypospadias correction, there remains a controversy. In a trial to address this issue, our research was conducted to compare the accessibility of urethroplasty coverage using PRF to traditional local flaps, aiming to prevent fistula formation in hypospadias repair. Patients and methodsThis is a prospective single-blinded randomized controlled study that involved 60 hypospadias cases admitted to Mansoura University Children Hospital's Pediatric Surgery department between March 2021 and March 2023. These 60 cases were randomly divided into 2 equal groups: (group A platelet-rich fibrin coverage membrane & group B local dartos flap as an additional layer). Both groups were compared regarding the rate of complications. All cases were evaluated regarding age at repair, type of hypospadias, urethral plate width, length of urethroplasty, and size of the 2nd layer. The blood loss and operative time were documented and post-operatively; the cases were assessed for the repair intactness, shape, and size of the neo-meatus, existence of any post-operative problems such as urethral fistula, urethral stricture, meatal stenosis, failure of the repair, or diverticulum. Statistical analysis was carried out following data collection. ResultsThe median length of the 2nd layer in group A was 20 mm (range 15–23 mm) and in group B was 22.5 mm (range 19.5–25 mm) and the difference between the two groups was statistically significant (p = 0.012∗), while its median width in group A was 10 mm (range 10–11 mm) and in group B was 15 mm (range 10–18 mm) and also there was statistically significant difference (p = 0.001∗). The mean operative time in group A was 95.73 ± 11.9 min and in group B was 102.33 ± 10.32 min and there was a statistically significant difference (P < 0.001). The length of hospital stay in group A was 5.47 ± 1.11 days and in group B was 5.47 ± 0.89 days. The urethral fistula was detected in 4 cases of group A (13.3%) and 3 cases of group B (10%). The failure of repair was similar, one case of each group (3.3%). The meatal stenosis was reported in only one case of group A (3.4%) and 7 cases of group B (24.1%) (P = 0.02∗) and the difference was statistically significant. There were no reports of urethral strictures among the cases in either group over the follow-up period (mean 9 months, range 5–17 months). ConclusionPRF patch may be employed as a coverage layer over the urethroplasty in repair of the distal hypospadias, especially in cases without accessible vascular flap with comparable outcome to traditional local flaps. Type of studyA prospective single blinded randomized controlled trial (computer-generated numbers method). Level of evidenceLevel 2.

Comparison of outcome of TIP urethroplasty with or without Buck’s Fascia repair

ObjectiveTIP is the most common preformed type of Urethroplasty. The intermediate barrier is used as a waterproofing layer to prevent fistula formation. Many tissues have been utilized as a barrier layer, with varying success rates. The search for a better intermediate layer will continue. In this study, we aim to evaluate the role of Buck’s Fascia as a covering for the neo-urethra to prevent fistula formation in patients who underwent Snodgrass Urethroplasty.MethodsThis prospective study was conducted between 2018 and 2022. Patients were randomly assigned to either Group ‘A’ or Group ‘B’. Group A included patients who underwent the Snodgrass procedure with a Buck’s Fascia cover, while Group B included patients whose neo-urethra was covered with the dartos flap. These patients were closely monitored for the development of short- and long-term complications in both groups, and the results were recorded.ResultsThe study involved 164 patients, who underwent midpenile and distal hypospadias repair using the Snodgrass technique. In Group ‘A’ (84 patients), the neo-urethra was covered with Buck’s Fascia, while in Group ‘B’ (80 patients), the neo-urethra was covered with the dartos flap. The mean age of the children was (23.06 ± 16.12) months in group ‘A’ & (26.06 ± 14.07) months in group ‘B’. mean operating time was (40 ± 11.43) minutes, in Group ‘A’, and (70 ± 17.43) minutes, in Group ‘B’. Meatal stenosis occurred in 3.57% of children in Group ‘A’ and 10% of patients in Group ‘B’. Urethral fistulas were encountered in 2.35% of cases in Group ‘A’and 10% in Group ‘B’. The difference between the groups was statistically significant.

PRIMARY REPAIR OF PROXIMAL (GRADE IV) HYPOSPADIAS UTILIZING TUNICA VAGINALIS VASCULARISED FLAP

Background: Proximal (grade IV) hypospadias like scrotal and perineal are considered as severe challenging types for surgeons, problematic for the patients and their families, More than three hundreds surgical techniques were used to manage different type of hypospadias . Most of them associated with high incidence of complications. These complications are much more common in the proximal types as in our study. Post-operative fistula formation is expected complications. Utilising the tunica vaginalis as an additional layer during repair may prevent such complications. In this study we evaluated the benefits of using the tunica vaginalis flap as a supportive layer in the primary repair. Most related literatures about this subject used this technique after surgery to manage cases with post-operative fistulas. In the contrary we used this technique during the formal surgery to cover the new urethra to prevent fistula formation not after surgery. Aims of the study: A retrospective study, on fourteen patients with severe hypospadias (Proximal types), to evaluate the role of tunica vaginalis flap in the primary repair of the hypospadias. Patients and Methods: Between January 2016 and January 2024, fourteen children with Grade IV hypospadias were operated on. Only severe cases were treated with this method other simpler and more common cases were treated by different surgeries like Snodgrass technique. The age range was 2 to 16 years. All of them had 2 staged repair the first stage was correcting the chordae by incising the urethral plate excising the fibrous chordae tissues then covering the bare shaft with dorsal flaps. The tunica flap was used in the second stage which was done 6 to 12 months later. Folly's catheter was used for ten to fourteen days after surgery. And the patients were followed for a variable time 3months to 2 years period for the development of complications like fistula formation or stricture. Cosmetic considerations were also noted. Results: All the fourteen patients had proximal types (Grade IV) hypospadias. After surgery all patients had a good cosmetic outcome no fistula formation two had mild distal urethral stricture cured after few urethral dilatation. No post-operative penile torsion was noted. Two patients developed local infection treated conservatively. One patient had partial glanular dehiscence at the distal end which had no clinical significance. One patient complained from on and off penile cutaneous swelling lasted 3 weeks. Conclusions: Using tunica vaginalis vascularised flap to cover the new urethra in severe proximal hypospadias during the second stage seems to be a successful way in preventing fistula formation without increasing the patient's morbidity.

Reconstruction of oral cavity defects using myogenous-only scapular tip free-flaps.

BackgroundOral cavity reconstruction is very challenging anatomical subsite to reconstruct. Large defects often require free tissue reconstruction to provide the best chance of form and function. Additionally, free tissue reconstruction aids to prevent fistula formation. We aimed to determine outcomes of oral cavity defect reconstruction using scapular tip free flaps with a myogenous intraoral component.MethodsAll patients with a mandibular or maxillary bony defect that included a disruption of the intraoral mucosa component between 07/1/14 and 07/31/17. Patients were reconstructed with a scapular tip free flap, which included a muscular component that was used to recreate the oral mucosa. The primary study outcomes were flap success rates, development of orocutaneous or oronasal fistula, rate of resuming oral diet as well as the occurrence of medical and surgical complications in the first month following surgery. The tested hypothesis was formulated before data collection began.ResultsTwenty‐five patients were identified by the study criteria. There was one (4%) flap that failed, while orocutaneous fistula occurred in two patients (8%). Prior history of osteoradionecrosis was a statistically significant predictor of overall complication (p < .05).ConclusionsIntraoral myogenous reconstruction allows for re‐mucosalization of the oral cavity defect and is associated with high viability and low‐complication rates. In patients with amenable oral mucosal defects, a myogenous scapular tip free flap is a suitable reconstructive option.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula.

Dorsal Versus Ventral Dartos Flap to Prevent Fistula Formation in Tubularized Incised Plate Urethroplasty for Hypospadias.

The purpose of this study is to evaluate the results of two different flap procedures for prevention of urethrocutaneous fistula in hypospadias patients undergoing tubularized incised plate urethroplasty . We retrospectively reviewed 89 patients who underwent hypospadias repair. The standard technique of tubularized incised plate urethroplasty was used. There were 45 patients in Group 1 and 44 patients in Group 2, in which ventral and dorsal dartos flaps were used to cover the neourethra respectively. Surgical complications were assessed as the main outcomes. The results were analyzed with Chi-square and Mann-whitney u tests. There was no significiant difference between the groups in terms of age and meatus location. We observed postoperative surgical complications in 15 (33.3 %) patients in Group 1 and in 4 (9.1 %) patients in Group 2. The complications noted in the Group 1 were urethrocutaneous fistula in 10 patients ( 22.2 %) and meatal stenosis in 5 patients ( 11.1 %). In Group 2, fistula was observed in 2 patients (4.6 %) and stenosis in again 2 patients (4.6 %). Urethrocutaneous fistulas occurred statistically more frequently when ventral based dartos flaps were used (P < .05). Several flap procedures and their modifications have been suggested to avoid fistula formation. Within these procedures, dartos flaps are reported to be very useful for primary distal or proximal hypospadias repair and reoperations. In this study, we concluded that ; vascularized dorsal preputial dartos flap procedure is safe and more effective than ventral based flap in prevention of fistula formation.

Prevence vzniku pankreatické píštěle u laparoskopických levostranných pankreatektomií

ntroduction: Postoperative pancreatic fistula (POPF) is one of the most serious complications in pancreatobiliary surgery. The management of clinically relevant grade B and C fistulas requires interventional management or reoperation. POPF is accompanied with high mortality rate. Prevention of fistula formation is a possible solution of the problem. Methods: A retrospective observational study of patients with pathology of pancreatic body or tail, who underwent laparoscopic distal pancreatectomy or splenopancreatectomy (LDP) a tour instution between 2016 and 2021. From 2020, a set of perioperative precautions to reduce POPF has been standardised. Primary objective was to determine the total number of POPFs, the number of POPF-associated bleeds, and POPF-associated mortality in the 2016–2021 cohort. Secondary objective was to compare the outcomes of the group of patients with standardised preventive measures operated on in 2020–2021 with the group of patients without standardised measures operated on in 2016–2019. Results: In 2016–2021, we performed a total of 67 laparoscopic distal pancreatectomies. Of these, 10 patients (14.9%) had clinically relevant POPF (CR-POPF) grade B or C and we observed biochemical leakage in 22 cases (32.8%). There was no POPF associated bleeding or POPF associated mortality. In the 2020–2021 group of 20 patients treated with the standardised precautions, we observed no CR-POPF, and biochemical leakage occurred in 7 patients (35%). In contrast, in the group of patients without any standardisation of treatment (47 patients), operated on in 2016–2019, CR-POPF occurred in 10 patients (21.3%) and biochemical leakage in 15 patients (31.9%). Conclusion: The results of our entire cohort of patients confirm high numbers of POPFs after LDP. The results of the subgroup of patients with standardised perioperative procedures aimed at reducing POPFs showed a significant reduction in CR-POPFs, suggesting good rates of efficacy of the preventive measures introduced. Keywords: surgery – Pancreas – postoperative complications – pancreatic fistula – distal pancreatectomy

Subsequent left distal tubal pregnancy following laparoscopic tubal sterilization: a case report

Background: Post-sterilization pregnancies are rare and many postulations were made for its mechanism. Abdominal pain in women with retained uterus mandates a pregnancy test, regardless of previous tubal surgery or sterilization surgery to exclude the possibility of ectopic pregnancy. Prevention via surgical approach not only prevents future occurrence but also confer prophylaxis measure against ovarian cancer. Case: A 39-year-old woman who had undergone open right salpingectomy due to tubal pregnancy presented with abdominal pain, a positive pregnancy test, and elevated beta-human chorionic gonadotropin (β-hCG) level. Furthermore, an ultrasound exam revealed the absence of a gestational sac in the uterine cavity but the presence of a left adnexal mass; hence ectopic pregnancy was suspected. Laparoscopy revealed a 3 × 4 cm bulging ectopic pregnancy at the left distal end of the remnant stump in the ampulla. The histopathological assessment confirmed ectopic pregnancy in the left distal tubal stump. Post-operation, β-hCG levels decreased. The patient fully recovered postoperatively. Discussion: Ectopic pregnancies after tubal sterilization are caused by fistula formation and intraperitoneal sperm transmigration. To avoid this possibility, surgical techniques should be used to obliterate the residual canal, including the precise location and depth of electrocautery to prevent fistula formation. Total salpingectomy is the recommended treatment approach for effective permanent sterilization and a prophylaxis measure against ovarian cancer.

MP20-14 URETHRAL COMPLICATIONS AFTER MUSCULOCUTANEOUS LATISSIMUS DORSI PHALLOPLASTY IN TRANSGENDER MEN

You have accessJournal of UrologyCME1 May 2022MP20-14 URETHRAL COMPLICATIONS AFTER MUSCULOCUTANEOUS LATISSIMUS DORSI PHALLOPLASTY IN TRANSGENDER MEN Borko Stojanovic, Marko Bencic, Marta Bizic, and Miroslav L. Djordjevic Borko StojanovicBorko Stojanovic More articles by this author , Marko BencicMarko Bencic More articles by this author , Marta BizicMarta Bizic More articles by this author , and Miroslav L. DjordjevicMiroslav L. Djordjevic More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002553.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: An ideal solution for phalloplasty in transgender men still does not exist, and urethroplasty results in high rate of complications. We have evaluated outcomes of staged urethral reconstruction in musculocutaneous latissimus dorsi (MLD) free flap phalloplasty. METHODS: Between January 2007 and January 2020, 147 transgender men, aged 18 – 53 years (mean 27 years) underwent total MLD phalloplasty. In 111 patients phalloplasty was performed as a primary procedure, while in 36 patients it was done after previously performed metoidioplasty. Urethral reconstruction was performed as a staged procedure. In the first stage, simultaneously with total phalloplasty, urethra was lengthened to the maximum extent using all available vascularized hairless tissue (vaginal flap, labia minora flaps and clitoral skin flap) and incorporated into the neophallus. Additional urethral lengthening was achieved in the following stages using buccal mucosa grafts. RESULTS: Follow-up period in our series ranged from 18 to 175 months (mean 96 months). Total length of the neourethra reconstructed during the first stage was measured during the surgery, and ranged from 11.1 to 20.7 cm (mean 14.8 cm). Neophallic urethral lengthening by either one or two-stage buccal mucosa graft tubularization was performed in 92 patients (62.6%). Satisfactory voiding in standing position was achieved in totally 95 patients (64.6%). Urethral fistula occurred in 28 patients (19%) and healed spontaneously in 8 patients, while the remaining patients required revision surgery. Urethral stricture developed in 33 patients (22.4%), and there were 13 strictures in the neophallic segment and 20 cases of bulbar strictures. All strictures required surgical repair, in 22 patients urethroplasty with buccal mucosa graft was performed. Fistula between remnant vaginal cavity and neourethral lumen was noted in 21 patients (14.3%). Vaginal remnant was excised through perineal approach and urethral opening was closed and covered with local vascularized tissue to prevent fistula formation. CONCLUSIONS: The musculocutaneous latissimus dorsi (MLD) phalloplasty combined with urethral lengthening can provide satisfactory esthetic and functional outcomes. Although urethral complication rate is still high, use of vascularized flaps for neourethra has satisfactory outcomes. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e322 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Borko Stojanovic More articles by this author Marko Bencic More articles by this author Marta Bizic More articles by this author Miroslav L. Djordjevic More articles by this author Expand All Advertisement PDF DownloadLoading ...

The tunica-vaginalis flap to prevent postoperative fistula following severe hypospadias repair: Has the search for Holy Grail ended?

IntroductionFistula following hypospadias repair remains a bane of the hypospadiologist resulting in the evolution of various techniques. Despite all these, the incidence of postoperative fistula varies from 10 to 30% and it increases with the severity of the hypospadias. Hence, a study was conducted to evaluate the efficacy of tunica vaginalis flap in preventing fistula formation following severe hypospadias repair. Materials and methodsAn observational study was carried out in a tertiary center between 2008 and 2017. The study included children with severe hypospadias (Proximal penile, Penoscrotal, scrotal, and Perineal). In all the patients, a Tunica-Vaginalis flap was used to buttress the urethroplasty. All the patients were followed up for at least a year after the completion of treatment. ResultsA total of 210 patients were included in the study. Bracka’s two-stage repair was performed in 180 patients who had either Penoscrotal hypospadias or a meatus even more proximal. The rest 30 patients with proximal penile hypospadias underwent a single-stage Snodgrass repair. Four (2%) patients developed a fistula, all following two-stage repairs, and half of them required surgical repair. Two (1%) patients had a partial breakdown of repair and underwent a residual repair after six months. ConclusionThe Tunica-Vaginalis flap is an excellent buttress in severe hypospadias repair. It is readily available, easy to harvest, with its good vascularity helps to significantly reduce the incidence of postoperative fistula.

Colgajo de túnica vaginal en la prevención de fístulas postoperatorias tras reparación de hipospadias severos: ¿ha terminado la búsqueda del Santo Grial?

IntroductionFistula following hypospadias repair remains a bane for the hypospadiologist resulting in the evolution of various techniques. Despite all these, the incidence of postoperative fistula varies between 10 to 30% and it increases with the severity of the hypospadias. Hence, a study was conducted to evaluate the efficacy of tunica vaginalis flap in preventing fistula formation following severe hypospadias repair. Materials and methodsAn observational study was carried out in a tertiary center between 2008 and 2017. The study included children with severe hypospadias (proximal penile, penoscrotal, scrotal, and perineal). In all the patients, a tunica-vaginalis flap was used to buttress the urethroplasty. All the patients were followed up for at least a year after the completion of treatment. ResultsA total of 210 patients were included in the study. Bracka's 2-stage repair was performed in 180 patients who had either penoscrotal hypospadias or a meatus even more proximal. The rest 30 patients with proximal penile hypospadias underwent a single-stage Snodgrass repair. Four (2%) patients developed a fistula, all following 2-stage repairs, and half of them required surgical repair. Two (1%) patients had a partial breakdown of repair and underwent a residual repair after 6 months. ConclusionThe tunica-vaginalis flap is an excellent buttress in severe hypospadias repair. It is readily available, easy to harvest, with its good vascularity helps to significantly reduce the incidence of postoperative fistula.

Can the risk of anal fistula development after perianal abscess drainage be reduced?

Perianal abscesses are frequently seen in clinical practice, and perianal fistulas develop in 30%-50% of cases after treatment. This study investigated whether the type of dressing applied after abscess drainage is correlated with fistula development. Prevention of fistula formation would reduce both the loss of work and healthcare costs. The records of patients who underwent drainage of perianal abscesses between January 2015 and January 2018 were retrospectively reviewed. Patients with postoperative dressings changed with washing of the area in the hospital were included as Group 1. Patients with dressings changed at home and the area bathed in 10% povidone-iodine sitz bath were included as Group 2. The frequency and time of fistula formation, age, sex, cost, and workdays lost in the two groups were compared. Between-group differences in age, sex, body mass index, and type of fistula that developed after months and 1 year of the abscess drainage were not statistically significant (p > 0.05). During follow-up, fistula development was significantly lower in Group 1 than in Group 2 (p < 0.001). The risk of perianal fistula development was significantly increased in those with a body mass index (BMI) > 30 (p = 0.004). After perianal abscess drainage, in-hospital washing and dressing of the abscess area until abscess closure reduced the risk of perianal fistula, lost work time, and cost. The risk of perianal fistula development appeared to increase with BMI. A large, prospective study is needed for confirmation.

Isolated recto-vaginal septum injury during parturition: Single-center experience.

Traumatic rectal injuries are uncommon and can originate due to various causes. Rectal injuries have a high mor-bidity, regardless of cause, and detection at the time of occurrence is important to prevent fistula formation and/or stoma. In this article, treatment approaches in patients with isolated rectovaginal septum injury without perineal and sphincter injury during sponta-neous vaginal delivery are presented and the current literature is reviewed. The records of spontaneous vaginal deliveries that resulted in live births between January 2015 and January 2020 were analyzed retrospectively at our center. The records of patients with isolated rectovaginal septum injury were evaluated in terms of demographic and obstetric data, trauma, classification of injury, and early and late results. Isolated septum injuries were detected 12 women (0.06%). Of the isolated rectovaginal septum injuries, 9 (75%) were clas-sified as Type III, 2 (16.6%) as Type IV, and 1 (8.3%) as a Type V injury according to the Rosenshein classification. Transvaginal repair was performed because all of the injuries underwent early surgical intervention, were limited, and exploration through the vagina was possible. Rectal examination should be performed simultaneously with a detailed perineal examination after vaginal delivery. For birth-related rectal injuries detected early in appropriate patients, a primary repair without diversion stoma may be the best option.

3012 Lessons Learned from Ten Litigated Cases of Genitourinary and Gastrointestinal Fistulas Post Benign Gynecological Surgeries: A Multi-Center Case Series

Study Objective We aim to summarize all litigated cases of vesicovaginal, colovaginal and ureteric-vaginal fistulas from benign gynecological surgeries in Canada between 1997 to 2017. We outline the initial post-operative presentation, course of treatment and recovery, clinical and legal outcomes associated with each case. Design Retrospective case series of 10 genitourinary, gastrointestinal and enterocutaneous fistulas occurring post gynecological surgeries for benign indications. Setting Eight secondary and tertiary hospitals across Canada. Patients or Participants Ten women aged 18 years or older receiving laparoscopic, vaginal or open surgeries to treat benign gynecological conditions. Interventions Benign gynecological procedures including laparoscopic-assisted vaginal (1 case), vaginal (1 case) and open abdominal hysterectomies (3 cases), laparoscopic ovarian cystectomy (2 cases), laparoscopic cautery of endometriosis (2 cases) and operative hysteroscopy (1 case). Measurements and Main Results Median age at time of initial operation was 43 (range 39-55). The most common post-op presentation was fever, abdominal pain and tachycardia between post-op days (POD) 4-10. A bladder, small bowel or rectal injury was found on imaging at the time of presentation for 9 out of 10 cases, with one case diagnosed five weeks post op on outpatient serial CT scans. All patients required a laparotomy with involvement from a general surgeon or urologist, and five patients received second and third look laparotomies and bowel resections. 7 patients required ICU observation post-op. In all cases, the fistulas manifested as delayed presentations for unrecognized intra-operative bladder, bowel or ureteric injuries. One patient had ongoing fistulous drainage per vaginal at the time of case settlement. Most litigated cases were dismissed. Conclusion GU and GI fistulas are rare but morbid entities, which most often manifest after missed bladder or bowel injuries, post benign gynecological surgeries. Early detection and recognition of GI and GU injuries may be key for secondary prevention of fistula formation.

Dorsal double layer dartos flap in the Snodgrass technique of hypospadias repair: An experience in Dhaka Medical College Hospital

Introduction: Hypospadias is one of the most common congenital anomalies and more than 300 operation techniques have been described for primary hypospadias. The Snodgrass technique and its modification have become a preferred for all varieties of hypospadias in the past decade. However fistula is the most common of this technique. The aim of the study is to investigate the importance of double layer dartos flap to prevent fistula formation in the Snodgrass technique. Materials and Methods: It’s a retrospective study, among 52 patients aged 11 months to 144 months who underwent mid penile and distal hypospadias repair in the Snodgrass technique using dorsal dartos flap for neo-urethral coverage. This study was done in the Department of Pediatric Surgery in Dhaka Medical College &amp; Hospital from November 2014 to December 2016. Results: Urethrocutaneous (UC) fistula were encountered in 10 patients (19.23%), meatal stenosis in 3 patients (5.76%), partial glanular dehiscence in 1 patient and residual chordee in 1 patient. Conclusions: For preventing fistula formation, urethral covering by a well vascularized dorsal double layer dartos flap should be the important part of the Snodgrass technique. Journal of Paediatric Surgeons of Bangladesh (2017) Vol. 8 (2): 47-51

Comparison of dartos flap and dartos flap plus spongioplasty to prevent fistula in tubularized incised plate urethroplasty

Introduction: Hypospadias is one of the most common congenital anomalies and more than 300 operation techniques have been described for primary hypospadias. The complication rate varies with the complexity of the repair and the surgeon’s experience level. To decrease fistula rate, an additional tissue cover after neourethra reconstruction has been described using various tissues. This technique of spongioplasty with dartos flap interposition allows a better quality of the intermediate layer, with the object of preventing fistula. Aims and Objectives: The aim of our study is to evaluate the role of paraurethral spongial tissue plus dartos flap using an additional tissue cover to prevent fistula formation in patients who underwent urethroplasty with the Snodgrass technique. Materials and Methods: It’s a prospective study, performed on 60 patients aged 15 months to 144 months who underwent mid penile and distal hypospadias repair using the Snodgrass technique. The patients were assigned to one of the two groups. In Group I (30 patients), neourethra was covered with dartos flap, and in Group II (30 patients), the neourethra was covered with dartos flap plus spongioplasty. Results: Urethral fistula were encountered in twelve cases (40%) in Group I, and five cases 16.7%) in Group II (p value 0.045). Conclusions: Considering the results of this study, approximation of the corpus spongiosum along with dartos flap as an intermediate layer in urethral coverage as part of Snodgrass technique reduces the rate of fistula formation. This procedure can be applied easily and effectively to prevent the formation of fistula. Journal of Paediatric Surgeons of Bangladesh (2017) Vol. 8 (1): 5-10

“Flip-over flap” in two-stage cleft palate repair

PurposeThis study served to evaluate a two-stage concept in cleft palate repair, including key use of a triangular hinge (“flip-over”) flap, in order to prevent palatal fistulae. It uses data from a prospective registry established in 1991. Materials and methodsThe concept entails Furlow soft palate repair (at 1 year of age) and hard palate closure (at 4 years) by a three-pronged approach [paring of the edges with or without postero-lateral relaxing incisions, peninsula (Veau) flap(s)], plus a triangular hinge flap. The latter is elevated from the oral layer of the already-repaired soft palate, stays based anteriorly, and is flipped over to close the posterior nasal layer defect. The case series is compared with data from the literature. ResultsThe palatal fistula rate for Veau II to IV types (two-stage surgeries) was 4.3%. The overall fistula rate in the cleft population (Veau I–IV) was 2.9%. Meta-analyses describe 4.9 and 8.6% on average. There was no difference between sample A in which the flip-over flaps were used only when modified Veau flaps were indicated (until 2006) and sample B in which it was used regardless of the technique of hard palate closure applied (2006–2018). The fistula rate decreased to zero after 2010, which may reflect also an influence of other factors such as the interpositioning of a collagen membrane and also of improved surgical judgment. ConclusionsUsing a flip-over flap in two-stage cleft palate repair may contribute to prevent fistula formation at the hard/soft palate junction. Level of evidenceIII.

Effect of One-Stage versus Two-Stage Palatoplasty on Hypernasality and Fistula Formation in Children with Complete Unilateral Cleft Lip and Palate: A Randomized Controlled Trial.

Is one-stage or two-stage palatoplasty more effective for preventing fistula formation and hypernasality in patients with complete unilateral cleft lip and palate? This parallel blocked randomized controlled trial included 100 patients with nonsyndromic complete unilateral cleft lip and palate with a repaired cleft lip, divided into two equal groups. Group A had one-stage palatoplasty patients at age 12 to 13 months while group B had two-stage palatoplasty patients with soft palatoplasty at age 12 to 13 months and hard palatoplasty at age 24 to 25 months. Presence of a fistula was tested clinically at 3 years and speech was tested using nasometry and perceptual analyses at 6 years. Group C consisted of noncleft controls (n = 20, age 6 years) for speech using nasometry. Fistula rates, hypernasality ratings, and nasalance scores were compared between groups A and B. Nasometry recordings of groups A and B were compared with control group C. There was no difference in fistula rates between groups A and B (p = 0.409; 95 percent CI, 0.365 to 11.9). Mean nasalance scores of group A showed higher nasalance than group B (p = 0.006; 95 percent CI, 1.16 to 6.53). Perceptual analysis showed no difference between groups A and B (p = 0.837 and p = 1.000). Group A showed higher mean nasalance than group C (p = 0.837 and p = 1.000), whereas group B showed no difference (p = 0.088; 95 percent CI, -0.14 to 2.02). There was no difference in fistula rates between groups. Nasalance was slightly higher in patients in the one-stage palatoplasty group than two-stage palatoplasty group, but the difference was not clinically significant. Therapeutic, II.

EVALUATION OF THE USE OF DORSAL DARTOS FLAP FOR THE PREVENTION OF FISTULA AFTER SNODGRASS REPAIR OF HYPOSPADIAS

The Snodgrass technique or the tubularized incised plate (TIP) repair is considered as excellent option for treatment of distal and mid-shaft hypospadias. Urethro-cutaneous fistula remains the most frustrating complication of hypospadias repair. After performing a tubularized incised plate (TIP) repair, the incidence of fistulae is reported to be up to 17% of cases. This study aimed to evaluate the use of dorsal dartos flap for the prevention of fistula formation after Snodgrass repair for distal hypospadias. The current study included 35 patients aged 2-6 years during the period between February 2013 to January 2016. All the patients had distal hypospadias and underwent Snodgrass or TIP repair. The neo-urethra was covered by dorsal preputial interpositional flap transposed ventrally via a button hole maneuver as a method to prevent fistula formation. Patients were followed up and their complications were assessed based on the patients’ medical records. The procedure was completed successfully in all patients, with no intraoperative complications. All patients had good functional results with straight penis and vertical slit shaped meatus at the tip of the glans. Thirty four (97.14%) patients had no evidence of fistula development. One patient only (2.8%) developed fistula. Meatal stenosis occurred in 3 patients (8.5%). In conclusion, the neo-urethral covering with well-vascularized dartos flap, harvested dorsally and button holed at its base for ventral transposition, represents a good choice for fistula prevention after Snodgrass repair.

Is the double cross flap technique the panacea for avoiding fistula formation in hypospadias surgery?

Objective The aim of this study was to analyze retrospectively the 9-year experience of a single institution in the use of the double cross flap technique to interpose a double dartos flap to protect the neourethra with the aim of preventing fistula formation. Patients and methods Between October 2005 and September 2014 a total of 127 children with distal and midshaft primary hypospadias underwent tubularized incised plate urethroplasty by means of a double dartos flap obtained with a double cross flap to protect the neourethra. A Foley catheter was left in situ for 7 days. Success was defined as no incidence of complications requiring reintervention, along with good cosmetic result. A questionnaire was administered to estimate parental satisfaction. Parents were asked to evaluate the cosmetic appearance of the penis as good, acceptable, bad, or indifferent. Results The patient age at the time of surgery ranged from 12 months to 10 years (median 39 months). Three patients exhibited fistula at follow-up (2.3%). In two patients a glandular dehiscence of the urethroplasty occurred (1.5%). Mild stenosis of the neomeatus occurred in three patients (2.3%). No penile iatrogenic rotation occurred. A ‘good’ cosmetic result was reported by 68.5% of parents, acceptable by 22.8%, bad by 3.9% and indifferent by 4.7% of parents as per the parental questionnaire. Conclusion The double cross flap technique is not the panacea to prevent fistula formation in hypospadias surgery. Nevertheless, it offers an unquestionable advantage in terms of avoidance of fistula formation. The experience and skills of the surgeon performing urethroplasty remain the mainstay for best results.