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

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

The forked flap repair for hypospadias

Context:

Despite the abundance of techniques for the repair of Hypospadias, its problems still persist and a satisfactory design to correct the penile curvature with the formation of neourethra from the native urethral tissue or genital or extragenital tissues, with minimal postoperative complications has yet to evolve.

Aim:

Persisting with such an endeavor, a new technique for the repair of distal and midpenile hypospadias is described.

Materials and Methods:

The study has been done in 70 cases over the past 11 years. The “Forked-Flap” repair is a single stage method for the repair of such Hypospadias with chordee. It takes advantage of the rich vascular communication at the corona and capitalizes on the established reliability of the meatal based flip–flap. The repair achieves straightening of the curvature of the penis by complete excision of chordee tissue from the ventral surface of the penis beneath the urethral plate. The urethra is reconstructed using the native plate with forked flap extensions and genital tissue relying on the concept of meatal based flaps. Water proofing by dartos tissue and reinforcement by Nesbit''s prepucial tissue transfer completes the one stage procedure.

Statistical Analysis:

An analysis of 70 cases of this single stage technique of repair of penile hypospadias with chordee, operated at 3 to 5 years of age over the past 11 years is presented.

Results and Conclusion:

The Forked Flap gives comparable and replicable results; except for a urethrocutaneous fistula rate of 4% no other complications were observed.KEY WORDS: Chordee, fistula, forked flap, hypospadias, urethral plate     

SURGICAL REPAIR OF URETHRAL CIRCUMCISION INJURIES

Purpose

The 2 types of urethral injury that can occur during circumcision are urethrocutaneous fistula and urethral distortion secondary to partial glans amputation. We report the surgical repair of these rare injuries.

Materials and Methods

In 8 patients urethrocutaneous fistulas located on the distal penile shaft or at the coronal margin were managed by splitting the glans and using a Mathieu style skin flap in 4 or vascularized penile skin flap in 4 to bridge the urethral defect. Three patients underwent repair of a hypospadiac deviated urethra secondary to partial glans amputation by 1 cm. of urethral mobilization and repositioning the meatus into a terminal position within the remaining glans tissue.

Results

The 8 patients with urethrocutaneous fistulas voided via a terminal meatus without fistula recurrence at a mean followup of 3.2 years (range 1 to 6). The 3 patients with partial glans amputation and urethral deviation repaired by short urethral advancement had functionally acceptable results, defined as a normal urinary stream, although 1 required meatal dilation postoperatively.

Conclusions

The 2 types of urethral injuries that can occur during circumcision are a subcoronal urethrocutaneous fistula and scarred abnormal urethra from partial glans amputation. The urethrocutaneous fistula can be successfully repaired by splitting the glans and forming a neourethra from a vascularized pedicle flap of penile skin. The abnormal urethra after partial glans amputation is more difficult to repair but repositioning the urethra in a more cosmetic location has restored function.     

Tunica vaginalis flap following ‘Tubularised Incised Plate’ urethroplasty to prevent urethrocutaneous fistulaa

Introduction:

Surgery for hypospadias has been continuously evolving, implying thereby that no single technique is perfect and suitable for all types of hypospadias. Snodgrass technique is presently the most common surgical procedure performed for hypospadias.

Materials and Methods:

We analysed the results of tunica vaginalis flap (TVF) as an additional cover to the tubularised incised plate (TIP) repair.

Results:

A total of 35 patients of hypospadias were repaired using TIP urethroplasty and TVF as a second layer. Mean age at the time of presentation was 6.63 ± 3.4 years. Post-operative complications namely wound infection, flap necrosis, scrotal haematoma, scrotal abscess, urethral fistula, meatal stenosis were recorded and analysed during follow-up period. Need for re-do surgery was considered as failure of the operative procedure. Out of 35 patients, 8 (22.85%) patients had proximal penile hypospadias and 27 (77.14%) patients had distal penile hypospadias. Mean post-operative follow-up was 24.53 months. During the follow-up complications noticed included wound infection (n = 2), urethrocutaneous fistula (n = 1) and meatal stenosis (n = 1). Wound infection was managed with appropriate antibiotics as per hospital policy/culture and sensitivity reports. Meatal stenosis responded to bougie dilatation/calibration during follow-up.

Conclusion:

To conclude, TVF as an additional cover is associated with an acceptable complication rate and good cosmetic results if performed with meticulous tissue handlingKEY WORDS: Hypospadias, tunica vaginalis flap, urethrocutaneous fistula     

One-Stage Anterior Urethroplasty

Purpose

A deficient urethral segment was replaced with penile skin during a 1-stage procedure in patients with a long, tight urethral stricture, multiple attempts at hypospadias repair or severe hypospadias and circumcision.

Materials and Methods

In 29 patients a pedicled circumferential strip of distal penile skin was used to construct a neourethral floor. The roof was formed by regeneration of the epithelium from the edges of the floor over Buck's fascia. In our series the urethra was reconstructed because of an anterior urethral stricture in 11 patients, multiple failed hypospadias repairs in 6 and severe hypospadias with circumcision in 12.

Results

A neourethra of sufficient caliber and length was constructed with minimal postoperative complications in all patients. There were 2 cases of urethrocutaneous fistula at the subcoronal region, 1 meatal stenosis, 1 persistent chordee and 1 small distal penile skin patch slough that required only prolonged dressings. Mean followup was 19 months.

Conclusion

Our urethroplasty technique can be used to correct various types of anterior urethral stricture or hypospadias associated with insufficient penile or preputial skin.     

Successful hypospadias repair with ventral based vascular dartos pedicle for urethral coverage

PURPOSE: We describe an easy technique to reliably harvest a vascularized dartos pedicle for urethral coverage at the time of urethroplasty in hypospadias surgery. The complication of urethrocutaneous fistula in hypospadias surgery as a result of using this technique is also evaluated. MATERIALS AND METHODS: A retrospective review (July 1999 to September 2002) identified 180 pediatric patients who had undergone primary hypospadias surgery by a single surgeon. A modified technique of harvesting a vascularized dartos pedicle was incorporated in 111 hypospadias repairs. A ventral based vascularized dartos pedicle of tissue was used to cover a modified urethroplasty as described by Snodgrass. RESULTS: The intraoperative meatal position before urethroplasty was subcoronal in 95 cases, penile/midshaft in 11 and penoscrotal in 5. The majority of patients (90 of 111) were younger than 12 months at surgery. Ages ranged from 5 months to 16 years (mean 21.1 months). Of the 111 patients reconstruction using the ventral based vascularized dartos pedicle to cover the urethroplasty was successful in 109 (98.2%), and at followup they have an acceptable cosmetic result with no evidence of urethrocutaneous fistula. In 1 patient with distal hypospadias a urethrocutaneous fistula developed, which was recognized 20 months postoperatively. Another patient with penoscrotal hypospadias had a proximal fistula at 6 months. There were no recognized intraoperative urethral injuries or complications. Followup ranged from 3 to 38 months (mean 19.1). CONCLUSIONS: The ventral based vascularized dartos pedicle urethral coverage procedure is an easy and reliable technique to harvest adequate vascularized tissue to cover a hypospadias urethroplasty. In this small single surgeon series, this technique appears to have contributed to a low rate of urethrocutaneous fistulas after hypospadias repair.     

Transverse preputial onlay island flap urethroplasty for single-stage correction of proximal hypospadias

Aims and objectives

Transverse preputial onlay island flap urethroplasty (TPOIF) was described initially for distal hypospadias, but has seen extended application for proximal hypospadias. We describe a set of modifications in the technique and results in a large series of proximal hypospadias.

Materials and methods

All children who underwent TPOIF repair for proximal hypospadias (proximal penile, penoscrotal and scrotal) from June 2006 to June 2013 by a single surgeon were prospectively followed till June, 2014. A standard technique and postoperative protocol were followed. Salient points to be emphasized in the technique: (1) dissection of the dartos pedicle till penopubic junction to prevent penile torsion, (2) incorporation of the spongiosum in the urethroplasty, (3) midline urethral plate incision in glans (hinging the plate), (4) Dartos blanket cover on whole urethroplasty.

Results

Out of 136 children with proximal hypospadias, 92 children who underwent TPOIF formed the study group. Out of 92 children, 48 (52 %) children required a tunica albuginea plication for chordee correction. In total, 16 (17 %) patients developed 24 complications and 11 children (12 %) required second surgeries: fistula closure in 7 (with meatoplasty in 5), glansplasty for glans dehiscence in 2 and excision of diverticulum in 2. Two children required a third surgery. Only 5 children had a noticeable penile torsion (less than 30 degree), and 7 had a patulous meatus.

Conclusions

Transverse preputial onlay island flap urethroplasty can deliver reliable cosmetic and functional outcomes in proximal hypospadias.

     

组织瓣覆盖技术在尿道下裂手术及术后尿瘘修复中的应用

目的探讨组织瓣覆盖技术在尿道下裂手术及尿瘘修复手术的效果。方法1998年3月至2003年5月，73例尿道下裂手术及术后尿瘘修复手术中，采用5种组织瓣覆盖技术覆盖新尿道及尿瘘内口。尿道下裂组45例中采用带蒂背侧皮下组织瓣转移法27例，带蒂鞘膜瓣转移法3例，局部阴囊推进肉膜瓣法15例；尿瘘组28例中采用带蒂背侧皮下组织瓣转移法4例，局部X—V皮瓣法14例，局部U形组织瓣法10例。结果随访3～36个月，尿道下裂组45例术后3例出现尿瘘，尿瘘组28例均未再发尿瘘，成功率95．9％。结论尿道下裂手术及尿瘘修复手术中采用组织瓣多层覆盖技术，可提高手术成功率，降低术后尿瘘发生率。     

INLAY-ONLAY FLAP URETHROPLASTY FOR HYPOSPADIAS AND URETHRAL STRICTURE REPAIR

Purpose

The absence of a segment of the urethral plate renders the onlay urethroplasty procedure impossible. The plate may be too short (in hypospadias), or sacred after previous repair or due to a dense urethral stricture. A modified approach with restoration of urethral plate continuity is proposed instead of the tubularized island flap associated with higher complication rates.

Material and Methods

In 12 of 20 patients with a partially deficient urethral plate the inlay-onlay preputial island flap was used. The wider part of the flap is inlaid in place of the missing plate and anastomosed to the residual plate. Formation of the urethra is then completed with standard onlay overlapping of the flap. In another 8 patients the combined (partially tubularized in advance) tube-onlay flap was used.

Results

The inlay-onlay flap technique was used in 3 new hypospadias patients, in 4 with a scarred, hair-bearing plate after previous operations and in 5 with virtually no urethral plate because of a dense urethral stricture. No urethral complications were encountered. Of the 8 patients undergoing the combined tube-onlay repair 3 had complications, including meatal stenosis (2) and partial dehiscence (1).

Conclusions

Inlay-onlay flap urethroplasty allows correction of complex cases of hypospadias or urethral stricture with a partially deficient urethral plate in 1 stage with a low complication rate.     

Nueva técnica de fijación de dartos en la reparación de hipospadias

ObjectiveThis study investigates the impact of the use of dartos covering to augment the neourethra on functional and cosmetic results. To evaluate a novel technique demonstrating how to fix dartos flap to cover the neourethra as a barrier in hypospadias repair.Patients and methodsThis study comprised 204 male patients with different degree of hypospadias (DPH: 132, coronal hypospadias: 46, MPH: 26). Their ages ranged from 1-23 ys (mean age: 2ys). Penile chordee was in (DPH: 45, coronal hypospadias: 33, MPH: 26). All patients had abnormal downward directed urinary stream. Hypospadias repair was performed by the classic TIP technique in addition to our novel modification of dartos covering. Patients were submitted to 5 years of follow-up including clinical examination of the functional and cosmetic parameters.ResultsSuccess rates were reported in 200 patients, 3 patients had complications with subcoronal urethrocutaneous fistula and one patient with complete repair disruption.ConclusionTriple dartos fixation is a simple technique for all hypospadiologists to minimize urethrocutaneous fistula as common complication of hypospadias repair with good functional and cosmetic results.     

Comparative outcomes of the tubularized incised plate and transverse island flap onlay techniques for the repair of proximal hypospadias

Purpose

The optimal management of proximal hypospadias remains uncertain. In this study, the surgical outcomes of tubularized incised plate repair (TIP) and transverse island flap (TVIF) onlay urethroplasty in boys with hypospadias were compared.

Methods

A total of 176 patients with proximal hypospadias underwent TIP (n = 83) or TVIF onlay repairs (n = 93) by a single surgeon and were evaluated retrospectively. No patient received a testosterone injection prior to surgery. A retrospective review of their medical records collected data regarding age at surgery, chordee, dorsal plication, hypospadias site, penoscrotal transposition, bifid scrotum, congenital hernia, undescended testis and any postoperative complications, including fistula, recurrent curvature, dehiscence, diverticulum, meatal stenosis and urethral stricture. The pediatric penile perception score (PPPS) was completed by parents to evaluate their perception of cosmetic outcomes.

Results

There was no statistical difference in age or any of the anatomical and clinical features of hypospadias. The median follow-up duration was 22 months (range 12–48 months) and 25 months (14–51 months) for the TIP and TVIF onlay groups, respectively. The overall complication rate in the TVIF onlay group was 21.5 % (20/93), which was higher than 18.1 % (15/83) in the TIP group, but the difference was not statistically significant (P = 0.569). The most common complication was urethrocutaneous fistula, occurring in 9.6 % (8/83) of the TIP group and 10.8 % (10/93) of the TVIF onlay group. There were no significant differences in the rate of any complication and the overall PPPS between the two groups.

Conclusion

TIP and TVIF onlay are clinically equivalent for the repair of proximal hypospadias.     

URETHRAL REPLACEMENT WITH VASCULARIZED TUNICA VAGINALIS: DEFINING THE OPTIMAL FORM OF USE

Purpose

Residual urethral defects after failed hypospadias surgery present difficulties in reconstruction. In these situations, repair using vascularized tissue flaps remains ideal, yet challenging. In order to offer more surgical alternatives in these cases, the use of vascularized tunica vaginalis flaps as urethral replacements has recently been established in an animal model. We undertook the following studies to further define the role of tunica vaginalis in urethral reconstruction.

Materials and Methods

A vascularized flap of tunica vaginalis was used to replace an experimentally created 25-30 mm. gap in the anterior urethra of 26 rabbits, either as an onlay or tube flap. A control group consisting of 7 animals underwent only a segmental anterior urethral resection and primary re-anastomosis.

Results

Satisfactory urethral healing occurred in all control animals that survived the procedure. All 8 animals which had tunica vaginalis tube flap reconstruction underwent contracture of the neourethra probably secondary to the presence of striated cremasteric muscle elements brought with the tunica during mobilization. All 16 animals available for long term study in the onlay flap group had excellent flap viability and 100% urethral patency rates. The mesothelial lining of the tunica was seen to be replaced by a stratified epithelial lining similar to the urothelial lining of the native urethra.

Conclusion

The tunica vaginalis is a viable alternative to other tissues presently used for urethral replacement and can be used successfully as a vascularized onlay flap.     

The use of octyl cyanoacrylate (superglue) in hypospadias repair including its use as a fixator for urethral stents

Background

Octyl cyanoacrylate has been used for many years for simple skin closure, but its use in hypospadias repair and as a urethral stent fixator has not been previously reported. We report our experience.

Method

A retrospective study was performed of all children undergoing hypospadias surgery from July 2007 to July 2011. Octyl cyanoacrylate was used for skin closure after placing a few sutures to align the skin edges. No other dressing was used. A urethral stent, if used, was glued to the penis and removed after one week.

Results

Seventy two procedures were performed on 37 patients. Eight distal hypospadias (22%) underwent single stage repair. Seventeen (46%) underwent staged repair for severe hypospadias, and twelve (32%) “hypospadiac cripples” underwent various salvage procedures.One patient (1/72) had partial dehiscence, and one stent dislodged. There were no wound infections. Four (4/25) tabularized urethroplasties developed a fistula (16%).

Conclusion

Octyl cyanoacrylate is easy to apply on difficult hypospadias contours. It forms a strong, waterproof adhesive bond which separates from epithelial surfaces in 7 to 10 days and makes it an effective urethral stent fixator and an ideal dressing for hypospadias surgery.     

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap

Introduction and hypothesis

Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial.

Methods

This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap.

Results

The patient’s postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula.

Conclusions

Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

     

Nonstented tubularized incised plate urethroplasty with Y-to-I spongioplasty in non–toilet trained children

Introduction

This study was designed to evaluate the supportive role of spongioplasty during tubularized incised plate (TIP) urethroplasty repair of hypospadias.

Methods

All non–toilet trained children who underwent TIP repair for primary hypospadias by 1 surgeon over a 30-month period were included in our study. The divergent spongiosa was mobilized off the corpora cavernosa and was rotated toward the midline to wrap the neourethra. A dartos flap was used to cover the neourethra. The neourethra was calibrated immediately after surgery in all patients. A urethral stent was left in place only when difficult calibration was encountered. Complications and cosmetic appearance were documented at last follow-up.

Results

Thirty-two consecutive patients with a mean age of 18 (standard deviation [SD] 6) months were included in the study. The defects were distal and mid-shaft in 26 patients (81.3%) and proximal-shaft in 6 (18.8%). No intraoperative catheterization difficulties were encountered and all repairs were nonstented. Antibiotics and anticholinergics were not required. Mean follow-up was 9 (SD 6) months. Urinary extravasation developed in 1 patient (3.1%) on the second postoperative day. A urethral catheter was easily inserted and left indwelling for 5 days. One patient presented 6 days postoperatively with suspected voiding difficulty. Urethral calibration was easily performed excluding any mechanical obstruction. There were no urinary fistulae and reoperation was not required. An excellent cosmetic appearance was achieved in all patients.

Conclusion

TIP urethroplasty is a versatile operation that can be performed in almost all cases of penile hypospadias. A nonstented technique for hypospadias repair simplifies postoperative care and obviates the need for antibiotics and anticholinergics. We believe that spongioplasty provides good support to the neourethra and the hypoplastic distal urethra that may facilitate catheterization in the immediate and early postoperative periods, if required. Future controlled study is warranted to further evaluate the role of spongioplasty.Several authors have reported excellent results with a stent-free tubularized incised plate (TIP) urethroplasty repair without an increase in the complication rate.^1,2,2,4 However, early postoperative urinary retention occurs in 2%–24% of patients.^3,5,6 In such cases, urethral catheterization is discouraged, as it is believed to increase the risk of fistula formation. Suprapubic catheter placement has been recommended as the preferred treatment.³ This may necessitate another anesthetic and may add the risk of hematuria secondary to inadvertent bladder mucosal injury. The risk of urinary retention has led some surgeons to continue using stents during TIP repairs.Y-to-I wrap spongioplasty has been shown to recreate a nearly normal urethra in most cases.⁷ We hypothesized that spongioplasty can provide sufficient urethral support to withstand early urethral catheterization without compromising the repair. This study was designed to evaluate the supportive role of spongioplasty during TIP repair for various degrees of penile hypospadias.     

Split onlay skin flap for the salvage hypospadias repair

PURPOSE: Following failed hypospadias repair absence of the penile foreskin, a shortage of ventral skin and residual chordee may all contribute to poor long-term results. We describe a technique called the split onlay skin (SOS) flap that has improved our surgical outcomes in boys requiring salvage hypospadias repair. MATERIALS AND METHODS: The SOS flap uses a transverse island of penile shaft skin that is mobilized on its vascular pedicle and rotated into position to the ventrum of the penis at the site of the urethral defect. The flap is transected transversely, and half of the flap is used as an onlay to repair the urethra and the other half is used for additional skin coverage where needed on the penile shaft. We treated 11 boys 30 to 124 months old (mean age 60.3 months) who had a mean of 2 previous failed hypospadias repairs. All 11 boys presented with complex combinations of urethrocutaneous fistulas, stricture or urethral diverticula. RESULTS: Of the 11 patients 6 (54.5%) had development of postoperative fistulas. Five of these fistulas were surgically closed with no further complications. One penoscrotal fistula closed spontaneously after 7 months. Mild chordee from contraction of the flap and a urethral diverticulum developed in 1 boy. At a mean followup of 24.5 months all patients, including those who underwent closure of the secondary fistula, were voiding well with excellent appearance. CONCLUSIONS: In cases where little local tissue is present the SOS flap procedure is an excellent way to transfer healthy dorsal tissue to the ventrum for an onlay salvage urethroplasty while providing additional coverage of the urethral defect and a tension-free skin closure. Despite the high fistula rate we encountered following the initial SOS procedure, we endorse this technique because the transferred dartos provides additional tissue, which facilitates subsequent fistula repair. These boys can achieve a successful cosmetic result without incorporation of scrotal tissue or a free graft, which we believe leads to more predictable results.     

Management of urethrocutaneous fistula after hypospadias surgery �C An experience of thirty-five cases

Introduction:

The commonest complication following hypospadias repair is occurrence of urethrocutaneous fistula. The smaller fistulas (<2 mm) are easier to close with a simple closure whereas larger ones (>2 mm) with good vascular surrounding skin require a local skin flap closure for avoiding overlapping suture lines. For the recurrent/larger fistulas with impaired local surrounding skin - incidence of recurrence is significantly reduced by providing a waterproofing interposition layer.

Aims:

To study the effect of size, location, number of fistulas and surrounding tissues in selecting the procedure and its outcome. To identify various factors involved in the recurrence and to formulate a management in the cases where recurrence has occurred.

Patients and Methods:

This study of 35 cases of urethrocutaneous fistula repair was done from July 2006 to May 2009 to achieve better results in fistula management following hypospadias surgery.

Statistical analysis used:

X² test and Fisher''s exact test.

Results:

The overall success rate for fistula repair at first attempt was 89% with success rates for simple closure, layered closure and closure with waterproofing layer being 77%,89% and 100%, respectively. The second attempt success rate at fistula repair for simple closure and closure with waterproofing layer were 33% and 100%, respectively. At third attempt the two recurrent fistulas were managed by simple closure with a waterproofing interposition layer with no recurrence. All the waterproofing procedures in this study had a success rate of 100%.

Conclusions:

The treatment plan for a fistula must be individualized based on variables which has an effect on the outcome of repair and to an extent dictates the type of repair to be performed. The significantly improved success rates with the addition of a waterproofing layer suggests the use of this interposition layer should be done at the earliest available opportunity to prevent a reccurence rather than to reserve it for future options.     

Congenital urethrocutaneous fistula: Case report with review of literature

We are presenting two cases of congenital urethrocutaneous fistula on ventral penile shaft. Congenital urethral fistula is an extremely rare, but easily manageable anomaly that may be confused with hypospadias. Awareness of the entity will avoid complications. This condition may be associated with other anomalies like congenital hernias and anorectal malformations. Treatment of this entity is individualized according to site of fistula, associated anomalies and condition of the distal urethra. All the principles of hypospadias surgery should be strictly followed.KEY WORDS: Congenital, fistula, urethro cutaneous     

Use of fibrin glue in preventing urethrocutaneous fistula after hypospadias repair

Urethrocutaneous fistula is one of the most common complications after hypospadias surgery.The incidence of fistula development has varied from 4% to 20% in larger series. We sought to investigate the role of fibrin glue (Tisseel manufactured by Baxter India Pvt Ltd, Chennai, India) to reduce the chances of fistula formation in cases in proximal penile hypospadias.

Method

A total of 120 patients with proximal penile hypospadias (patients having urethral meatus at posterior third of penile shaft and at penoscrotal junction) were included in the present study. Patients were randomly allocated into 2 groups of 60 each by using Strata 9 software random number table. In group A, fibrin glue was used as a sealant after hypospadias surgery, whereas in group B, no sealant was used. All the operations were performed by single surgeon using transverse preputial tubularized island flap urethroplasty.

Result

Fistula formation occurred in 6 cases in group A (10%) and 19 cases in group B (32%) (P = .027). The fistulae observed in fibrin glue group A were single and small in size (<1 mm). Multiple (≥2 fistulae) and larger fistulae (>2 mm) were observed in group B. Overall complication was significantly higher in group B (P = .006).

Conclusion

Fibrin glue in hypospadias repair does not eliminate fistula formation. However, it seems that it minimizes the incidence of fistula formation.