Urethrocutaneous Fistula Research Articles

Congenital Anterior Urethral Obstruction: A Case Series

Congenital Anterior Urethral Diverticulum (CAUD) and Anterior Urethral Valve (AUV) are rare but well-described causes of urinary obstruction in male children. The clinical presentation can range from isolated poor urinary stream with normal bladder and upper tracts to severe obstructive uropathy with renal failure. In the present case series, six children with anterior urethral obstruction managed between June 2014 and June 2024 were retrospectively identified. Age at presentation, clinical features, investigations, management and long-term follow-up were studied. The age at presentation ranged from newborn to seven years. Severe disease, as evidenced by progressive renal failure, was present in 1 of the 6 children (16.6%). One child had undergone foetal intervention by valve ablation but had progressive renal failure on follow-up. Three children (50%) underwent diverticulum excision with urethroplasty, of which one child developed a postoperative urethrocutaneous fistula. One child with AUV had a dorsal urethral fold causing obstruction, unlike the ventral pathology observed in the other children. CAUD and AUV are rare yet important causes of obstructive uropathy. Careful assessment is crucial for making the correct diagnosis. Temporary diversion may be essential when cystoscopy or primary repair is not feasible or in cases of urosepsis.

Voiding Dysfunction inTransgender Patients: What We Know and What We Do Not Know.

Transgender and non-binary patients (TGNB) undergoing gender affirming genital surgery may experience perioperative voiding dysfunction. This review aims to outline and analyze literature about gender affirming pelvic surgery urinary complications, evaluation, and treatment. If a patient is seeking bottom surgery, then urinary goals and pre-operative symptoms should be discussed with respect to variable post-operative outcomes. Urologists should also be aware of the effect that gender affirming hormone therapy has on urinary symptoms. Urethral strictures and urethrocutaneous fistulae occur after feminizing and masculinizing procedures and may manifest as LUTS. Although there is no standardized approach for managing post-operative voiding issues, we present available options. The evaluation of TGNB patients is ideally affirming and tailored to the patient. Long-term urinary and voiding outcomes measurements after vaginoplasty and phalloplasty are also needed, as current validated questionnaires do not capture these symptoms well in TGNB patients.

Urethral strictures post-hypospadias repair in adults

BackgroundUrethral strictures post-hypospadias repair in adults is one of the most complex subjects in urethral reconstruction. Our goal is to provide an overview of the challenges encountered and the current treatment options. MethodsA comprehensive literature review was conducted using PubMed for the period from 2020 to 2023. This was supplemented with a synthesis of guidelines from the AUA, EAU, AFU, and references from textbooks. ResultsUrethral strictures post-hypospadias repair in adults are most often extensive, involving the entire neo-urethra, with a high prevalence of lichen sclerosus. Other pathologies often associated with these strictures include urethrocutaneous fistulas, penile curvature, and a ventral skin deficit with poor cosmetic outcome. It is crucial to address the issue comprehensively — urinary, sexual, and aesthetic — to plan a personalized treatment approach. There is no role for endoscopic treatments in managing these strictures; urethroplasty remains the standard of treatment, and multiple interventions may be necessary. ConclusionUrethral strictures post-hypospadias repair in adults are complex, and urethroplasty remains the standard of treatment.

Outcomes of a 3-day transparent film dressing protocol after hypospadias repair

This study aimed to evaluate a 3-day transparent film dressing protocol after hypospadias repair. A retrospective observational study was conducted in boys with hypospadias who were operated in our institution between 2022 and 2023. Postoperatively, the penis was wrapped with a transparent film dressing, which was removed after 3 days. Postoperative complications were observed until postoperative day 14. The associations of age, meatal location, and type of procedure were analyzed using Chi square, Fisher exact, Mann Whitney, and Kruskall Wallis test (p < 0.05 = significant). Sixty-five patients were studied. Median age was five years, the majority had proximal meatus (58.5%), and underwent urethroplasty (76.9%). After dressing removal, positive bacterial culture was found in 43.1%, mild penile edema in 33.8%, bleeding in 10.8%, and SSI in 49.2% of cases, with pus formation (10.8%), dehiscence (9.2%), and urethrocutaneous fistula (10% after urethroplasty procedure). Surgical site infection and positive culture were significantly higher in patients with proximal meatus compared to distal (p = 0.031, p = 0.019; respectively). A 3-day transparent film dressing prevented penile edema and bleeding in most cases. However, the rate of SSI and positive wound culture was high, and was associated with proximal meatal location.

Epidemiological profile of patients undergoing hypospadias correction surgery at a hospital in Recife, Brazil, between 2022 and 2023

Problem: Hypospadias is the second most common genital anomaly after undescended testicles, occurring in approximately 1 in every 250 male newborns. Objectives: The present paper aims to evaluate the surgeries performed to hypospadias repair in a hospital in Recife city from March 2022 to March 2023. Methodology: A retrospective, descriptive study with a quantitative approach with secondary data from medical records. The study population consisted of 97 childrens and 99 surgeries. Results: The results showed that 49.5% of the patients presented with distal hypospadias. The most commonly used technique was Bracka, representing 31.3% of the cases. The mean age of the patients at the time of the first surgery was 5 to 9 years. Of the sample, 24.2% of the patients had complications, 41.7% of which were due to urethrocutaneous fistula. Conclusion: It was concluded that the age at the time of the first surgery was higher than that indicated in the literature. There was a slight prevalence of distal hypospadias to proximal hypospadias, evidencing a demand for complex hypospadias in this hospital.

Editorial Comment on "The effectiveness of double dorsal dartos flap for urethroplasty coverage in distal hypospadias repair: A single surgeon approach to preventing urethrocutaneous fistula".

Editorial Comment on "The effectiveness of double dorsal dartos flap for urethroplasty coverage in distal hypospadias repair: A single surgeon approach to preventing urethrocutaneous fistula".

Efficacy and safety of laparoscopic urethral anastomosis in the repair of congenital urethral stricture in children: a systematic review

Introduction: Congenital urethral strictures are rare but significant defects in pediatric urology, causing urinary system abnormalities. These defects are difficult to manage in children due to differences in anatomy and physiology. Laparoscopic urethral anastomosis, a minimally invasive surgery, has become a popular option in pediatric urology.Objective: The research paper was aimed to assess the outcomes of laparoscopic urethral anastomosis in the pediatric patients with congenital urethral strictureMethods: This review article focuses on the effectiveness and safety of laparoscopic urethral anastomosis in pediatric patients. It includes studies focusing on pediatric patients, surgical outcomes, and published in peer-reviewed journals. Exclusions include adult populations, non-academic studies, non-academic methods, lack of adequate outcome data, and non-academic studies. Data integration and statistical evaluation are performed using a systematic review approach.Result: The studies were selected for the analysis, and the results showed that laparoscopic urethral repair is a secure method with positive postoperative results. The subcuticular uninterrupted suturing method exhibited a reduced complication rate compared to full-thickness interrupted stitches in distal hypospadias treatment. Various suturing methods such as close and open reported various complications. Interrupted suturing in the urological surgical procedure showed a tendency for reduced incidence of urethrocutaneous fistula development. The review indicated that urethral surgical intervention showed significant positive consequences.Conclusion: It was concluded that both interrupted and continuous suturing techniques were effective in treating pediatric patients with congenital urethral strictures. However interrupted suturing showed a potential benefit. The study highlighted the need for more large-scale, randomized controlled trials to validate these findings and improve surgical methodologies and postoperative outcomes

Comparative Study between Grafts and Flaps in Staged Repair of Primary Proximal Hypospadias

Abstract Background Choosing between flaps or grafts to substitute the urethral plate in 2-stage hypospadias repair has been a matter of debate with no consensus in the literature. Flaps have reliable blood supply that maybe theoretically less liable for strictures or contractures. Grafts are more versatile, which can be used in primary and recurrent cases when healthy local skin is deficient. In this report, our aim was to compare outcomes of grafts and flaps when used to substitute the urethral plate in two-stage repair of primary proximal hypospadias with ventral curvature. Methods This retrospective study included primary cases of hypospadias with significant curvature who underwent two-stage repair using either grafts or flaps to substitute the urethral plate in the first stage. Cases included in the study were divided into two groups according to the technique of substituting the urethral plate at the first stage of repair. During first part of the study period (2015 through 2018), we mostly used grafts to substitute the urethral plate (group A); later, we shifted to skin flaps (Group B) during the period 2019 through 2021. Results The study included 37 boys with primary proximal hypospadias who underwent two-stage hypospadias repair. The meatus position was penoscrotal in 18, scrotal in 16, and perineal in three. Inner preputial graft was used to substitute the urethral plate in 18 cases (group A), while dorsal skin flaps were used in 19 (group B). Out of the 37 cases, 27 were available at follow-up after second stage (group A = 14; group B = 13). Follow up period ranged between 6 and 42 months (mean 19.7; median 18.5). Overall, 14 cases required reoperations for different indications: partial disruptions of distal part of the repair in six, closure of urethro-cutaneous fistula in six, and urethral strictures in two. The rate of complications was higher in group A (10 cases: 71%) compared to group B (4 cases: 31%) (Fisher exact test, p-value = 0.057). Conclusion Grafts were associated with higher complication rate than flaps when used to substitute the urethral plate in two-stage repair of proximal hypospadias with chordee. Type of Study and Level of Evidence. This is non-randomized comparative study (level III evidence).

Enhancing Tubularized Incised Plate (TIP) Technique for Hypospadias Repair: The Role of Tunica Vaginalis Flap in Minimizing Urethrocutaneous Fistula

Enhancing Tubularized Incised Plate (TIP) Technique for Hypospadias Repair: The Role of Tunica Vaginalis Flap in Minimizing Urethrocutaneous Fistula

Comparative Study of Circumcision

Background: Male circumcision is a significant practice in Muslim tradition and is widely performed for religious reasons, especially in Muslim-majority countries like Bangladesh. Objective: This study aims to compare different surgical techniques of male circumcision in children and highlight the complications arising from procedures performed by non-qualified practitioners Quack (Hazam) in Bangladesh. Method: A comparative study was conducted at Sher-E-Bangla Medical College Hospital, Barisal, from December 2022 to February 2023. Two hundred male children were included, with 100 circumcised by pediatric surgeons using guillotine and dorsal slit techniques, and 100 presented with complications from circumcision performed by non-qualified quacks. Results: Out of 200 children, 50% underwent circumcision by quacks using the guillotine method, resulting in complications such as infection (10%), bleeding (4%), glans injury (1%), urethrocutaneous fistula (1%), and incomplete circumcision (4%). Among the 100 children circumcised by pediatric surgeons, complications were minimal, with 2% minor infections, 2% minor bleeding, 1% respiratory distress, and 1% vomiting. The guillotine and dorsal slit techniques performed in the hospital setting demonstrated significantly lower complication rates compared to procedures conducted by quacks. Conclusion: Circumcision performed by trained medical professionals under aseptic conditions is safe and associated with fewer complications. Public awareness and discouragement of procedures by quacks are essential to prevent circumcision mishaps.

Topography-guided Anatomical Reassembly for Distal Penile Hypospadias Without Chordee: A Comprehensive Illustration and Midterm Results of a Novel Approach

ObjectivesTo provide a comprehensive illustration of the newly introduced ‘topography-guided anatomical reassembly’ approach, which has shown promising early results, and to report the mid-term outcomes of an extended series. MethodsThis is a prospective cohort study of all patients presenting to the author’s facility with distal penile hypospadias without chordee between June 2018 and January 2023. Redo cases, circumcised cases, and cases with non-preservable plates are excluded. The procedure follows the most recently introduced principle of the topography-guided anatomical reassembly approach for distal penile hypospadias, that is, the exclusive zipping-up of the unfolded spongiosal plate. ResultsA subset of 97 boys met the enrolment criteria. The hypospadias meatus was coronal or sub-coronal in 35 boys, distal penile in 45 boys, and mid-penile in 17 boys. The mean age at the time of surgical correction was 8.11 months. The mean operative time was 66.7 min. After a mean follow-up of 27 months, five urethrocutaneous fistulae were reported: three glanular and two sub-coronal. Meatal disfigurement with downward stream deviation was reported in two more patients. Two more occurrences of meatal recession were identified, yet surgical correction was not necessary. The overall reoperation rate settled at 7%. ConclusionsThe proposed topography-guided anatomical reassembly technique for distal hypospadias is simple, effective, and highly feasible at mid-term follow-up of the given series. Maintaining the integrity of well-developed penile tissues eliminates the possibility of unforgivable tissue damage and avoids the need for challenging revision procedures.

Reconstructive surgery of difficult urethrocutaneous fistula following gender-affirming surgery.

In Japan, transgender individuals have historically had limited therapeutic options, prompting many to seek gender-affirming surgeries in private or foreign clinics because of restricted access to public hospitals. This has led to challenges for patients undergoing surgery. A transgender man underwent surgery at a private clinic and experienced recurrent complications. Subsequent examination at another clinic and our hospital revealed limited medical records, complicating our understanding of this case. After a detailed investigation, the urethrocutaneous and urethrovaginal fistulas were identified and addressed by joint urologists and plastic surgeons, resulting in no recurrence after 1 year. This case underscores the importance of thorough preoperative assessment with a flexible mindset, emphasizing the need to avoid being misled by inadequate records or appearances in complication management of gender-affirming surgery. Collaborative efforts among healthcare professionals based on comprehensive evaluations lead to safer complication treatments.

Current trends in the management of hypospadias: the Ibero-American experience

Introduction: Hypospadias management has seen various trends over the years, likely due to the diverse clinical presentations and evolving surgical techniques. However, there is a lack of consensus among pediatric urologists on many aspects of hypospadias management. To address this, our research aims to survey specialists and establish a consensus on hypospadias management. Methodology: In July 2021, a cross-sectional study was conducted using a Survey Monkey questionnaire consisting of 23 questions. The survey aimed to gather information about the generalities and management preferences of distal and proximal hypospadias from specialists belonging to the Ibero-American Society of Pediatric Urology (SIUP). The data collected was categorized into subgroups based on surgical techniques, perioperative preferences, and complications. Results: Most hypospadias surgeries are performed between 13-18 months. Penile curvature is evaluated with artificial erection and visual inspection. The Nesbit technique (36.1%) and ventral corportomies (26.9%) corrections are more common, while grafts corporoplasties are used less frequently (10.2%) for correction. For urethroplasty, the surveyed group prefers using a running suture or a combination of continuous and interrupted stitches (49.1% and 24.3%, respectively). The use of Polydioxanone 6-0 in a double-layer suture group yielded a higher response rate. The use of prophylactic antibiotics and their maintenance when the catheter is in place was also favored by most surgeons. Discussion: When repairing hypospadias, the surgeon must consider factors such as the quality of the urethral plate, the presence of penile curvature, and the location of the urethral opening. This study highlights the different strategies and technical preferences used for hypospadias repair by a group of specialists from different countries. Conclusion: The survey describes current trends in hypospadias management. Two-stage repair is commonly used for proximal hypospadias, while TIP repair is the most used technique for distal hypospadias. The most common complication is the development of an urethrocutaneous fistula.

Surgical Evaluation of Autologous Platelet-rich Fibrin Membrane as a Coverage Layer in Repair of Urethrocutaneous Fistula after Hypospadias Surgeries: A Randomized Controlled Trial.

It has recently been reported that the use of platelet-rich fibrin (PRF) as an extralayer over the urethroplasty has been related to a considerable reduction in fistula rates. Due to the lack of evidence supporting the usage of PRF in urethrocutaneous fistula (UCF) repair, we conducted this study to evaluate the efficacy of PRF in patients with UCF. We conducted a randomized controlled study on patients with distal fistula after hypospadias repair. Patients were randomized into two groups, one with local dartos coverage and the other with PRF coverage layer. In the present study, we included 37 patients; 20 patients underwent local dartos coverage, and 17 patients underwent PRF. The mean age was 22.45 ± 4545 ± 4515 ± ±15.35 (range 11-56) months for the study group and 20.6 ± 66 ± 614 ± ±14.5 (range 6-45) months for the control group. The incidence of recurrent UCF was 11.8% in the treatment group (two patients), whereas the incidence was 30% (six patients) in the control group (P = 0.246). UCF surgery may benefit from the use of PRF as a supportive tissue that promotes wound healing, angiogenesis, and tissue restoration. We believe that the use of PRF as a new approach for UCF repair should be investigated further through clinical studies.

Snodgrass (tubularized incised plate) versus Mathieu repair of distal hypospadias: A systematic review and meta-analysis of randomized controlled trials.

Distal hypospadias accounts for the majority of hypospadias. Mathieu and Snodgrass techniques are widely used for repair of distal hypospadias but their comparative efficacy and reported outcomes are still debated. We conducted a systematic review and meta-analysis to compare the outcomes of these two techniques. Electronic databases and trial registries were searched for randomized controlled trials (RCTs) comparing Mathieu and Snodgrass techniques for primary distal hypospadias repair. Outcome measures included complication rates and cosmetic outcomes. Risk of bias assessment was performed using the ROB2. Data was analyzed using Review Manager 5.4; Trial Sequential Analysis (TSA) also was conducted for important outcomes. Twelve RCTs were eligible for inclusion. The Snodgrass technique showed a significantly lower incidence of urethrocutaneous fistula (UCF) (RR 0.48, 95% CI [0.30-0.77]). However, there was no significant difference in the incidence of meatal stenosis (MS) between the two (RR 1.64, 95% CI [0.85-3.15]). TSA supports the findings for outcome UCF but not for MS. Operative time was shorter with the Snodgrass technique. This SRMA indicates a lower incidence of UCF with Snodgrass technique compared to the Mathieu technique in distal hypospadias repair. However, there was no significant difference in the risk of MS.

The use of an autologous platelet-rich fibrin membrane in urethroplasty for cases of distal hypospadias

BackgroundAmong pediatric surgical procedures, hypospadias surgery is one of the most difficult. The most prevalent complication following hypospadias repair is urethrocutaneous fistula. Numerous procedures have been developed to prevent and resolve this issue. One such method is platelet-rich fibrin (PRF) membrane preparation, which is a straightforward process requiring only the patient’s serum. It has already been utilized successfully in plastic and reconstructive surgeries, where it significantly enhances the healing capacity and decreases the risk of infections. The purpose of this study is to assess the efficacy of an autologous PRF membrane in promoting healing and reducing fistula occurrence in cases of de novo distal hypospadias.MethodsForty patients with primary distal hypospadias underwent TIP repair, as a part of a prospective controlled randomized study from April 2017 to February 2018. The cases were randomly allocated into two categories. TIP repair done in all cases by the same surgeon. Twenty cases comprised group A, which utilized a preputial or local dartos flap as an additional protective layer over the urethroplasty. In contrast, group B comprised 20 cases in which the urethroplasty was covered with a PRF membrane. The initial follow-up duration was 6 months. Each group’s fistula incidence and other associated complications were documented.ResultsTwo groups were compared during the initial 6-month follow-up period. There were seven cases of urethrocutaneous fistula in group A, representing a 35% incidence rate. In group B, there were two cases that had fistula with an incidence of 10% in the early postoperative period. Two patients (10%) in group A developed meatal stenosis and only one patient in group B (5%) developed meatal stenosis. Glandular dehiscence occurred in one patient (5%) in group B. There was no skin wound infection in both groups.ConclusionThe PRF membrane may be a promising method as a coverage layer over the urethroplasty aiming to reduce the fistula rate after the repair. A larger comparative study is needed to evaluate the efficacy of PRF membranes in promoting wound healing.

The Outcome of a Single Stage Repair for Proximal Hypospadias in Otherwise Healthy Child at Mymensingh Medical College Hospital

Hypospadias is a birth defect that involves the development of a penile urethra that opens on the ventral side of the penis. Proximal hypospadias is one of the most severe forms of hypospadias that is generally associated with chordee. Hypospadias surgery, especially in the proximal location, is challenging, and many operations have been proposed, including one-stage and two-stage operations. Objectives: The aim of the study was to evaluate the success rate and safety of a single-stage surgery in children with proximal hypospadias and to determine the complications. Materials and Methods: This interventional study was conducted on forty patients, aged between one and twelve years, who had proximal hypospadias and were admitted to Mymensingh Medical College Hospital between January 2014 and April 2015. A one-step operation with tabularized incised plate urethroplasty (TIPU) was done. Patients’ demographic data, intraoperative details, and postoperative outcomes were recorded within 3 months after the operation. Results: The common age at surgery was 2-4 years, and they were 40% of the total patients. There was Haematoma in 5% of cases, a devitalized skin flap in 7.5% of cases, and stent blockage in 10% of cases during the immediate postoperative period. In our 3-month follow-up, all the patients had conical glans and cylindrical penises. Meatal stenosis and narrow stream were noted in 5 percent of patients but were relieved with meatal dilatation. Urethrocutaneous fistulas remained patients in 7.5% of cases. Conclusion: TIPU repair of proximal hypospadias is safe, effective, yields good results, and has low risks of complications in otherwise healthy children. It is a less risky and more viable method that helps to exclude extra steps in the process.

A rare case of isolated congenital anterior urethrocutaneous fistula misinterpreted as urethral duplication

A rare case of isolated congenital anterior urethrocutaneous fistula misinterpreted as urethral duplication

Urethral Mobilisation and Glanuloplasty Technique for Primary and Second-Stage Repair of Hypospadias: A Single Hospital Experience.

Background Over the years, the technique used to correct hypospadias has undergone several modifications to improve outcomes and reduce complication rates. In this study, a modification has been made to the second stage of the two-stage repair of proximal hypospadias. This modification utilises urethral mobilisation and glanuloplasty, traditionally used to repair distal hypospadias, in the second stage of repair of proximal hypospadias. This study aims to assess the implications of this modification on the outcomes in addition to adding to the pre-existing literature on the outcomes of urethral mobilisation and glanuloplasty in the repair of distal hypospadias. Methodology A prospective study was conducted at Salmaniya Medical Complex in Bahrain between January 2016 and December 2021. All patients with either proximal or distal hypospadias who underwent a surgical repair using the urethral mobilisation and glanuloplasty technique were included. The following cases were excluded: patients with proximal hypospadias who did not undergo a first-stage repair, those with a hypoplastic urethra, and those aged 14 years or more. Results The mean operative time for the proximal hypospadias group was 78 minutes, while it was 62 minutes in the distal hypospadias group. Furthermore, the catheter remained in situ for a mean of three days postoperatively in the proximal hypospadias group. Overall, four of 35 patients (11.4%) experienced complications in the proximal hypospadias group. Of these, there were two(5.7%) cases of meatal stenosis, two(5.7%) cases of wound dehiscence, and no cases of diverticula or urethrocutaneous fistulas. Meanwhile, in the distal hypospadias group, one of 117 patients (0.9%) experienced a complication; the complication was meatal stenosis. there was a significant correlation between the age of patients and the complication rate (p = 0.06). The operative time was also found to be a significant factor influencing the occurrence of complications. The follow-up duration ranged between five months and 12 months. All patients had good cosmetic outcomes. Conclusions This study found that urethral mobilisation and glanuloplasty for the second-stage repair of proximal hypospadias resulted in lower complications than the traditional two-stage operation and a short duration of urinary catheterisation. There is a need to conduct studies with longer follow-up durations and objective measures of function to provide a better comparison between the different techniques used.

Human umbilical cord allograft associated with higher pediatric urethrocutaneous fistula repair success rates

Urethrocutaneous fistula (UCF) formation is a known complication following hypospadias repair, affecting between 5 and 70% of cases. Moreover, approximately 30% of patients experience refistulization after UCF repair. The use of extracellular matrices, such as AmnioCord, a dehydrated human umbilical cord allograft manufactured by MiMedx®, may mitigate high rates of refistulization. To determine whether the use of AmnioCord during UCF repair is associated with reduced incidence of subsequent UCFs among pediatric patients. Electronic medical records were retrospectively reviewed among 60 patients who underwent at least one UCF repair at a pediatric hospital in a large urban setting in the U.S. between January 2012-June 2018. Patients were followed through January 2024. Adjusted generalized estimating equation regression models were used to assess the association between AmnioCord use and rates of refistulization, while controlling for confounding variables. The number of fistula presentations per patient ranged from one to four; 53.3% had one fistula, 30.0% had two, and 16.6% had three or more. Overall fistula repair success rate was 56.8% but significantly differed by AmnioCord use in adjusted modelling; 69.4% of cases that received AmnioCord were successfully repaired, compared to 47.2% of cases that did not receive AmnioCord. In adjusted models, patients who received AmnioCord had 2.66 times greater odds of surgical success than patients who did not receive AmnioCord (95% CI:1.13-6.24; p=0.02). This study demonstrates a positive association between AmnioCord use and successful UCF closure among pediatric patients.