Recurrent Urethrocutaneous Fistula Research Articles

Result of simple versus layered repair of urethro-cutaneous fistula developing after hypospadias surgery

Background: Urethro-cutaneous fistula (UCF) after hypospadias surgery occurs regardless of the location of the meatus, procedure performed or experience of the surgeon. Hypospadias repair continues to be a singularly demanding form of surgical expression with considerable artistic latitude. The commonest complication of hypospadias surgery is fistula formation, which almost always requires repeat and similarly demanding surgery. Aims and Objectives: The aim of our study was to compare the result between simple and layered repair of UCF developing after hypospadias surgery. Materials and Methods: This comparative type of study was carried out in the Department of Paediatric Surgery, BSMMU, Dhaka from June 2015 to August 2016 for a period of 15 (fifteen) months. Forty (40) diagnosed cases of UCF were included in the study. All the participants were randomized into two groups named Group A & Group B. Group A was assigned to the simple repair technique & Group B was assigned to the layered repair technique. Relevant data were collected in a predesigned questionnaire. Results: The recurrent fistula formation rate was much higher in Group A (30%) than in Group B (05%), which was statistically significant in between the two groups. The majority of the fistulae recurred within a few days of the removal of the stent (from 7th to 10th POD). 6, out of 7 recurrent UCF were observed in this period. No recurrent fistula was observed beyond 4 weeks after operation. Conclusions: This study revealed that, the layered repair technique, with the addition of vascularized dorsal dartos fascia reduces the recurrent fistula formation rate in a significant number. Though more time consuming and technically difficult, we recommend wide application of layered repair technique in the management of post hypospadias UCF. Journal of Paediatric Surgeons of Bangladesh (2019) Vol. 10 (1 & 2): 37-42

Individual treatment strategy for single urethrocutaneous fistula after hypospadias repair: a retrospective cohort study.

BackgroundUrethrocutaneous fistula (UCF) remains the most common complication after hypospadias repair, and the recurrence rate of UCF is still high if the surgical techniques is not chosen properly, which called for better approaches to this problem. UCF presents different clinical characteristics due to their different locations and sizes, therefore we retrospectively analyzed the effects of different surgical techniques on single UCF after hypospadias repair in order to reduce the recurrence rates of UCF.MethodsA total of 602 patients diagnosed with UCF after hypospadias repair from January 2014 to December 2021 were enrolled. Baseline clinical characteristics such as age of patients, UCF location, size, surgical techniques were recorded. Patients were followed up in the outpatient clinic. The recurrence of UCF was defined as outcomes. Patients were divided according to the location of the UCF into a coronal UCF group and a non-coronal UCF group, which was then further classified according to the diameter of the UCF. The surgical technique and the recurrence rate of different types of UCF were analyzed and summarized.ResultsA total of 425 patients satisfied the inclusion criteria and 71 patients (16.7%) had recurrent UCF. Five surgical techniques were used to repair the UCF, namely tubularized incised plate (TIP) urethroplasty, Mathieu urethroplasty, double ligation, simple classical closure and trap-door procedure. The recurrence rate was 24.1%, 14.3%, 15.1%, 16.7%, and 22.2%, respectively. TIP or Mathieu urethroplasty is recommended for patients with coronal UCF with glans dehiscence or patients with coronal UCF diameter ≥4 mm without glans dehiscence. In patients with coronal UCF without glans dehiscence, double ligation is recommended for small UCF with diameter <2 mm, and simple classical closure is recommended for UCF with diameter 2–<4 mm. In patients with non-coronal UCF, double ligation is recommended for UCF with diameter <3 mm, and simple classical closure is recommended for UCF with diameter ≥3 mm.ConclusionsSingle UCF can be classified according to the location and size of the UCF. Different types of UCF should be treated with more appropriate individualized strategies, which can effectively reduce the recurrence rate of UCF.

Side-to-side penoscrotal anastomosis: a reliable technique for repair of recurrent urethrocutaneous fistula in male children

Background: Surgical repair of urethrocutaneous fistulae (UCF) is relatively simple and results are often satisfactory. However, in some cases of UCF, recurrence results despite several attempts at repair. Reports are scanty on the management of such recalcitrant UCF. The aim of the study was to present our experience with recurrent UCF, and describes our technique of side-to-side penoscrotal anastomosis for repair of such fistulae.Methods: This was a 10 years analytical comparative study of the outcome of repair of recurrent UCF in paediatric patients using the simple double layer repair technique, and our technique of anastomosing the penis to the scrotum between 2008 and 2019 in our centre. Data obtained and analysed with SPSS 21 version included the number of previous attempts at repair, number, site and size of UCF, technique of repair, and the incidence of recurrence of UCF.Results: Nineteen patients were studied. Nine had conventional double layer repair of UCF with recurrence in 5 (55.6%). Two of the recurrent cases were added to the remaining 10 patients to make a total of 12 cases who had the staged repair by penoscrotal anastomosis (PSA) and there was no recurrence during the average follow up period of 1 year. P value was &lt;0.05.Conclusions: Findings in this study suggest a superior outcome when the penoscrotal anastomosis is used for repair of recurrent UCF. We think it is better to apply this technique in cases of UCF which the surgeon considers potentially difficult than to wait to have a failed attempt before deploying it.

Tunica vaginalis graft for recurrent urethrocutaneous fistula repair after hypospadias surgery.

To evaluate the outcomes of recurrent urethrocutaneous fistula repair using tunica vaginalis graft as an intermediate protective layer. We retrospectively reviewed the data of 45 children with recurrent urethrocutaneous fistula who underwent tunica vaginalis graft repair between February 2011 and January 2019. The repair was carried out at least 6months after a previous fistula repair. Follow up at an outpatient clinic was scheduled on a weekly basis for 1month, then monthly for 6months and then annually. During follow up, every patient was evaluated by history taking. The site of repair and the act of micturition were inspected. Urine analyses together with culture and sensitivity tests were carried out if required. Successful repair was defined as the absence of recurrence, with good force and caliber of the urinary stream. This study included 45 patients with recurrent urethrocutaneous fistula who were managed with a tunica vaginalis graft as a second layer. The mean age of patients was 6.7±2.8years. The mean postoperative hospital stay was 5.5±0.7days. The repair was successful for 43 (95.6%) patients, and urethrocutaneous fistula recurrence was reported for two (4.4%) patients, which were repaired after 6months. In all patients, the cosmetic appearance of the penis was satisfactory without torsion or ventral chordee. Tunica vaginalis graft is a simple and fast procedure that is highly effective as a protective second layer for recurrent urethrocutaneous fistula repair.

Dermal regeneration sheet Integra® in management of recurrent Urethrocutaneous fistula after hypospadias surgery

Urethrocutaneous fistula UCF is the most common complication following surgical repair of hypospadias. Currently, the surgical technique mostly used to prevent recurrence employs preputial dartos or testicular tunica vaginalis flaps as a urethral covering. However, autologous tissues are limited in patients with multiple surgeries, and the use of biomaterials as a urethral coverage may represent a good alternative. The goal of the present study is to assess the results and complications of recurrent UCF correction using a dermal bovine regeneration sheet as a urethral covering. From May 2016 to January 2019, all patients with recurrent UCF of the authors center were repaired using this technique. The inclusion criteria were patients who had undergone one or more unsuccessful UCF repair surgeries and the absence of preputial tissue. The informed consent has been signed by all the patients. Patients were examined in outpatient consultations where their urinary stream was evaluated and a physical examination of the penis was conducted. A total of 12 patients and 13 UCFs were included in the study. The median follow-up was 18 months, (range: 4-26), and only two patients (15%) developed a recurrence of UCF. No complications were observed in the remaining patients (85%) during their evolution. No patient developed a fibrosis increase or loss of elasticity of the tissues in contact with the dermal matrix. The use of an Integra® sheet as a urethral covering during urethral fistula surgery appears to be a safe, effective, and easily reproducible option. However, prospective studies with larger numbers of patients should be performed to corroborate these results.

Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: A 12-year experience

Fistulas are a common complication of hypospadias surgery; they are more frequent after mid-shaft and posterior hypospadias repair. Surgical treatment of fistula still remains challenging with a significant failure rate. The basic principle is to add layers between skin and neourethra in order to decrease the incidence of recurrent urethrocutaneous fistula (UCF). We report our experience of UCF repair using a vascularized tunica vaginalis flap (TVF) after posterior and mid-shaft hypospadias surgery. A retrospective review of all patients operated on using TVF for UCF in our institution between December 2005 and July 2017 was performed. Among 36 cases, TVF was used at a first attempt in 22 patients; 14 children had a prior attempt to close the fistula, and four of them had two surgeries before TVF repair. UCF was respectively penoscrotal (n=3, 8%), posterior (n=19, 53%), midshaft (n=9, 25%) and anterior (n=5, 14%). The size of the fistula was more than 5mm in 26 patients. The UCF was treated successfully in every case after one single procedure. In the three children with two fistulas, both fistulas were successfully treated by the same TVF. After an average follow-up time of 45 months there was no recurrence of the initial UCF. In four cases of undescended testis, it was possible to dissect the flap through an inguinal incision and perform an orchydopexy in the same time. One patient presented a testicular atrophy after undescended testis surgery. Area review of published series shows excellent results in UCF repair including recurrent fistula (Table). TVF can aspire to some advantages with regard to a dartos flap (DF). First of all, a nearly 2.5-fold lower incidence of fistula after fistula repair with TVF than with DF (5.1% vs. 12.2%) has been shown. Secondly, TVF allows treating multiple fistulas, and can also be brought to the anterior part of the penis until the balano preputial furrow, allowing curing anterior fistula. Furthermore, it doesn't lead to aesthetic complications such as penile rotation or distal skin necrosis, which can occur during DF procedures. TVF is a simple and reproductive technique for UCF repair, with a high success rate. The risk of testicular atrophy has to be considered in case of associated undescended testis surgery, and careful attention must be given to the TVF dissection. This technique should be considered as first choice treatment for any UCF.

A simple technique for small-diameter urethrocutaneous fistula repair: Ligation

To describe a simple and effective technique for repairing a small-diameter urethrocutaneous fistula. A total of 13 patients with a solitary and small-diameter (≤2mm) urethrocutaneous fistula underwent repair with a ligation technique. None of the patients had voiding difficulties. One recurrent urethrocutaneous fistula occurred and it was successfully repaired with the same technique. This is a simple, quick and useful technique, particularly for small-diameter (≤2mm) urethrocutaneous fistulas.

Application of vascularized tunica vaginalis flap technique in repairing recurrent urethrocutaneous fistula following hypospadias surgery

0bjective To investigate the feasibility and efficacy of tunica vaginalis flap cover in treatment of recurrent urethrocutaneous fistula (UCF). Methods We reviewed the clinical datas of 25 cases of UCF after urethroplasty of hypospadias from January 2011 to January 2015. The mean age of the patients was 6.2 years(range 1.6 -14.0 years). All patients had undergone previous hypospadias repair and at least one previous failed attempt to close the urethrocutaneous fistulae. There were 5 cases of fistula in the coronary sulcus, 6 cases of fistula in the penile body and 14 cases of fistula at the junction of penis and scrotum.The diameter of urethrocutaneous fistulae were 3-10 mm. Single fistula was present in all patients. 16 cases had undergone UCF repair for two times, 9 cases had undergone UCF repair for more than two times. After closing the fistula with inverting running stitch, a tunica vaginalis flap was mobilized to cover the repair site through a subcutaneous tunnel and the skin closed. Results The mean follow-up time was 2.1 years(range 0.5- 4 years). The overall success rate was 96%(24/25). Penile cosmesis was excellent. There was no evidence of recurrent fistulas or urethral strictures. All parents reported a straight penis when erected, and one patient in whom there was leak from the fistula site because of local wound infection. No postoperative complication was encountered in the testis. The testis was of normal size and position, and the ultrasound findings were normal. Conclusions Repairment of recurrent urethrocutaneous fistulas with a tunica vaginalis flap could be effective regardless of fistula location. The technique is simple to improve the success rate of the repair of UCF effectively and reduce the occurrence of postoperative complications. Key words: Vascularized tunica vaginalis flap; Hypospadias; Urethrocutaneous fistula

Outcome of buccal mucosal patch graft in the Management of recurrent hypospadias urethrocutaneous fistula

Background: urethrocutaneous fistula after hypospadias surgery repair is the most common complication and remains a frustrating problem for surgeon and the patient. The problem is exacerbated because the urethrocutaneous fistula may recur which adds more demands surgery.Objectives: The purpose of this study is to evaluate of the use of oral mucosal graft for management of recurrent urethrocutaneous fistula after hypospadias repair.Patients and Methods: twelfth patients with age ranging from 4 year to 15 years were presented with history of recurrent fistula. Most of fistula were located in proximal penile and penoscrotal region (58.3%) . those patients were repaired by using oral mucosal graft with mean postoperative follow up period up to 6 months.Results: analysis of results showed 10 out of 12 cases (83.3%) had a final successful outcome with no recurrent fistula during follow up period. The two patients with failed repair were candidate for another attempt for fistula repair later on. No donor site morbidity was observed in all patients.Conclusion: Oral mucosal graft showed very good take and promising results when used for management of recurrent urethrocutaneous fistula after hypospadias repair.

نتائج استخدام الغشاء المخاطي المبطن للفم في معالجة ناسور الاحليل المتكرر بعد عملية اصلاح المبال التحتاني الولادي

الخلفيه:يعتبر ناسور الاحليل بعد عملية اصلاح المبال التحتاني الولادي من اكثر المضاعفات شيوعا واكثرها صعوبةوتكمن صعوبتها بكونها من المضاعفات التي تتكرر حتى بعد اصلاحها جراحيا. الهدف:الهدف من هذه الدراسه هو لتقييم نتائج استخدام الغشاء المخاطي الولادي في اصلاح ناسور الاحليل المتكرر بعد عملية اصلاح المبال التحتاني الولادي. طريقة العمل:اخضع لهذه الدراسه 12 مريض باعمار تتراوح مابين 4-15 سنه في مستشفى الشهيد غازي الحريري.هؤلاء المرضى كانوا يعانون من ناسور متكرر بعد عمليات اصلاح المبال التحتاني الولادي، وكانت معظم النواسير تقع في الجزء القريب من العضو الذكري وفي منطقه اتصال كيس الصفن مع عضو القضيب(58.3%).جميع هؤلاء المرضى تم اصلاح نواسيرهم باستخدام الغشاء المخاطي المبطن للفم وتمت متابعة حالاتهم لفترة 6 اشهر بعد العمليه. النتائج: تحليل النتائج اظهر 10 مرضى من اصل 12 مريض (%83.3) كانوا قد استفادوا من العمليه ولم يلاحظ اي رجوع للناسور طيلة فترة المراقبه بعد العمليه.ولم تكن هناك اية مضاعفات قد شوهدت من مكان اخذ الغشاء المخاطي من الفم. الاستنستاج: استخدام الغشاء المخاطي من الفم في علاج الناسور المتكرر بعد عملية اصلاح المبال التحتاني الولادي اظهر نتائج جيدة وبدون رجوع الناسور مرة اخرى وبدون اي مضاعفات لمكان اخذ الغشاء من الفم.

Traction-assisted dissection with soft tissue coverage is effective for repairing recurrent urethrocutaneous fistula following hypospadias surgery.

Urethrocutaneous fistula (UCF) complicating hypospadias surgery is associated with compromised tissue and perfusion at the UCF site, especially if recurrent. We report our technique for UCF repair. Between 1997 and 2014, we treated 35 UCF in 26 postoperative hypospadias patients; 12 UCF were recurrent (mean 2.5; range 1-5). Mean age at UCF repair was 9.3years (range 2-22). Our repair involves making a superficial incision 3-5mm around the fistula orifice, placing multiple stay sutures in the outer edge of this incision and dissecting only the epidermis under traction for 7-10mm. This technique does not compromise underlying connective tissue or tissue perfusion. The skin layer of the inner edge of the circumferential incision is trimmed completely and the fistula closed using 7/0 absorbable interrupted sutures. A pedicled external spermatic fascia, or tunica vaginalis flap is then mobilized to cover the repair site through a subcutaneous tunnel and the skin closed. A urethral catheter is placed and removed the next day. Duration of follow-up was calculated as the period from discharge home until the last outpatient clinic attendance. Repair was successful in all cases. Penile cosmesis was acceptable to good without any testicular complications or scrotal deformity. At mean follow-up of 7.4years (range 0.4-17.3) there have been no recurrences. Our technique allows UCF to be repaired effectively and is also indicated for recurrences.

Evaluation of tunneled tunica vaginalis flap (TVF) used as adjunct in the repair of urethrocutaneous fistula post tubularized incised plate urethroplasty (TIP) technique

Background and purpose: Urethrocutaneous fistula (UCF) remains the most frequent encountered complication of hypospadius surgery even in experienced surgical hands. The key measure to ensure a successful repair is separation of the suture lines in the urethra and skin, using well vascularized elastic tissue. This study aims to use tunneled tunica vaginalis flap(IVF) as adjunct in UCF repair either initial or recurrent following TIP technique and to evaluate outcome of cases regarding recurrence of fistula and other postoperative complications. Material and methods: In period between Jun. 2007 to Jun.2009, 14 cases of urethrocutaneous fistula post TIP technique with a mean age 5.6 year (3-11) were operated on using TVF. For each patient, we reported original preoperative location of urethral meatus, the number and location of fistulas, number of surgery, size of fistula and duration of surgery. Outcome of cases regarding to recurrence of fistula and other complications was reported. Follow up of cases ranged.from 6 months to 24 months (mean 12 months). Result: Of total 14 patients, 5 (35.7%) patients had previous attempt for closure of UCF ranged.from 1-2 times. 4 (28.6%) patients had multiple UCF ranged.from 2-3 fistulae at different location. Site of UCF was maximally located proximal penile followed by midpenile. Size of UCF ranged .from 2 to 10mm .Operative time ranged from 45 to 90 minutes with a mean time (60) minutes.Duringfollow up period no delayed postoperative complications had been observed. Conclusion: The tunneled tunica vaginalis flap is an excellent method for closure of both initial and recurrent urethrocutaneous fistula post TIP technique. The flap is easy to be harvested and mobilized without testicular complication and provide sufficient length to cover repaired UCF regardless of number, location and size of fistula

Double Unfurled Dartos Flap Technique in the Surgical Treatment of Recurrent Urethrocutaneous Fistulas

Background: The management of recurrent urethrocutaneous fistula (RUCF) is a challenging problem that poses a serious difficulty for the hypospadias surgeon. We report here a novel technique in which a double unfurled dartos subcutaneous flap is utilized in the treatment of patients with RUCF. Methods: We retrospectively reviewed the records of all our patients who underwent surgical treatment of urethrocutaneous fistula with this new operative method after previously failed fistula repair. The main novelty of this technique is the use of two opposite medium thickness flaps, unfurled from the inner surface of the dartos fascia and spread over the fistula and each other so as to cover the urethral suture line completely, and fixed to the surrounding corporal tissue. Results: Eight patients with 11 RUCFs (with localizations varying from subcoronal to penoscrotal fistula opening) underwent surgical correction with the new method. There had previously been at least 3 recurrences in 6 of these patients, and different closure techniques had been used. RUCF diameter was <4 mm in all patients. Surgery was performed at the earliest following a 6-month healing period since the last fistula repair attempt. All of the RUCFs were repaired successfully with the technique. After a follow-up of at least 6 months, none of the 8 patients had developed recurrence of the fistula, and there were no postoperative complications. Conclusion: The double unfurled dartos subcutaneous flap method appears to be a simple and appropriate procedure with which to repair recurrent mid-shaft and proximal urethral fistulas after failed hypospadias repair.

Tunica vaginalis: An aid in hypospadias fistula repair: Our experience of 14 cases

Urethrocutaneous fistula is the most common complication of hypospadias surgery. The correction of such fistula is associated with a failure rate of 10 to 40%. The step in successful repair of a fistula is separation of the suture lines in the urethra and skin using well vascularized elastic tissue. We report our experience of using the tunica vaginalis flap as a layer between the neourethra and skin suture line in repair of recurrent urethrocutaneous fistula. We have used the tunica vaginalis flap for the repair of recurrent urethrocutaneous fistula in 14 children with a mean age of 6.5 years (range 3-14 years). All patients had undergone previous hypospadias repair and at least one previous attempt to close the fistula had failed. Surgery was initiated by injecting a povidone solution via urethral meatus to identify all fistulae. The fistulae were closed primarily and urethral suture line was covered with a flap of tunica vaginalis which was harvested either through a small scrotal incision and mobilized via a subcutaneous tunnel into the penile shaft (8/14) or by the same incision as for fistula closure (6/14). The testis was fixed to the scrotum. A urethral catheter was kept for urinary diversion for 10 days. The repair was successful in all but one patient in whom there was leak from the fistula site. One patient in whom tunica vaginalis fascia was tunnelled into neourethra developed scrotal haematoma which needed drainage. Penile cosmesis was acceptable without any significant postoperative testicular complication in 13/14 patients. Repair of recurrent urethrocutaneous fistula with a tunica vaginalis flap is highly effective regardless of fistula location. This flap is easy to mobilize and provide effective coverage of urethral suture line. Putting a glove drain should be considered into scrotal wound if perfect haemostasis is doubtful.

Single-donor fibrin sealant for repair of urethrocutaneous fistulae following multiple hypospadias and epispadias repairs

Purpose To evaluate the efficacy of fibrin sealant for repair of urethrocutaneous fistula after multiple failed hypospadias and epispadias surgeries. Materials and methods The study population comprised 11 boys (mean age 12.18 years) with history of hypospadias or epispadias and at least two failed fistula repair operations leading to recurrent urethrocutaneous fistula. During the operation, single-donor fibrin glue, either from the patient (7) or a parent (4), was applied over the suture lines and beneath the skin. A urethral catheter was kept in place for 7–10 days. Follow up ranged from 6 to 24 months (mean 12.63 months). Results Nine patients had an uneventful postoperative course. In one patient with a large fistula, partial wound dehiscence occurred. In another patient with complete hypospadias, hematoma formation caused skin dehiscence but the urethra remained intact. Both cases recovered after 6 months with no further intervention. No fistula recurrence was reported during follow up. Conclusion Single-donor fibrin glue could be a useful adjunct to surgical management of patients after multiple failed attempts at hypospadias or epispadias fistula repair. Moreover, this product improves the safety margin regarding the risk of disease transmission.

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

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.

Urethrocutaneous fistula after hypospadias repair: outcome of three types of closure techniques

To evaluate the outcomes of three surgical techniques for the closure of urethrocutaneous fistula (UCF) after hypospadias repair. Fifty-one patients (mean age 6.5 years) who underwent UCF closure between June 1998 and February 2008 were divided in to three groups depending on fistula size; group I had <2 mm and (n = 17, 33.4%), group II had 2-4 mm (n = 21, 41.2%) and group III had >4 mm or multiple fistulas (n = 13, 25.4%). Group I patients were treated by excision and simple closure. Patients in group II and III were treated with flip flap technique along with the wrapping of repaired area with scrotal dartos flap and tunneled tunica vaginalis flap (TVF), respectively. Mean surgical time was 45 min (range 30-55), 60 min (range 50-75) and 80 min (range 60-100) in three techniques, respectively. The mean follow-up was 3.5 years (range 6 months-10 years). No patient had recurrence of fistula in group III, while 2 (9.5%) and 4 (25.4%) patients in groups II and I, respectively, had recurrent UCF. No postoperative complications were encountered in the testis or the scrotum. No patient had torsion or deviation of penis. Simple fistula closure carries a higher risk of recurrence even in small sized fistulas. The application of scrotal dartos or TVF for wrapping the repaired area gives excellent results and they are easy to harvest with no harmful effects on the scrotum or testis.

Timing of the Presentation of Urethrocutaneous Fistulas After Hypospadias Repair in Pediatric Patients

We evaluated the timing of the presentation of urethrocutaneous fistulas after hypospadias repair and the development of recurrent urethrocutaneous fistulas after prior fistula repair. We reviewed the charts of all patients with urethrocutaneous fistulas following hypospadias repair who were seen from 1995 to 2005. Age at hypospadias repair, hypospadias level, hypospadias repair type, time when the parent/patient noted the fistula, date/type of fistula repair, time when fistula recurrence was noticed, date/type of secondary repair and date of last followup were documented. A total of 26 patients with urethrocutaneous fistula were seen, of whom 15 had undergone at least 1 prior operation elsewhere. Of the patients 58% and 61% with fistulas following hypospadias repair and recurrent fistulas following the initial fistula, respectively, presented in the immediate postoperative period. Of the patients 23% with initial fistulas presented more than 2 years after hypospadias repair (up to 17 years later), while only 5.5% with recurrent fistulas presented more than 1 year after fistula repair. Age at presentation with initial fistulas after hypospadias repair was 0 to 12 months in 5 patients, 12 to 24 in 6, 24 to 36 in 6, 36 to 48 in 2 and more than 48 in 7. Mean followup was 5.5 months (range 0 to 69). While many urethrocutaneous fistulas develop immediately following hypospadias repair, almost a quarter present well beyond the typical followup of many urologists. These findings suggest that reported rates of urethrocutaneous fistula may be underestimated and longer followup may be warranted. Late recurrence of urethrocutaneous fistula is rare with 5.2% seen at more than 1 year, suggesting that more limited followup may be appropriate in these patients.

Management of urethrocutaneous fistula following hypospadias repair

Urethrocutaneous fistulas complicating hypospadias repair appear a common problem. There appears less data in the literature regarding the risk and management of recurrent fistulas. A retrospective review of urethrocutaneous fistulas complicating hypospadias repair was performed to evaluate their aetiology, management and outcome. Between 1993 and 2003, 1,753 patients had a hypospadias repair at our institution. Overall 123 (7%) boys developed a fistula, although detailed information was available on 117 patients only. Median age was 3.5 years at the time of fistula repair; 13% had anterior, 57% had middle and 30% had posterior hypospadias. The most common primary surgical procedure was a Durham Smith two-stage repair in 29% (n = 34), followed by a Tubularised Incised Plate urethroplasty in 19% (n = 22) and an Onlay in 14% (n = 16). Thirty-one (27%) patients developed a recurrent fistula, 9 (29%) of which recurred following a second repair. None recurred after a third repair. The risk of a recurrent fistula after an initial distal fistula repair was 12.5% and after a posterior fistula was 62% (chi(2) = 15.4, P = 0.001). Use of a stent, suture type, numbers of fistula and closure attempts did not influence the recurrence rate. Undiagnosed distal obstruction was thought to be related to 27 of 117 first fistula repairs (23%) and 4 of 31 second fistula repairs (13%). The risk of recurrent urethrocutaneous fistula was increased in those boys with a posterior fistula, following a simple repair or when there was evidence of distal urethral obstruction.

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.