Management Of Urethrocutaneous Fistula Following Hypospadias Repair
Urethrocutaneous fistula complicating the initial repair occurred in 7% (n=123) of our patients. These were anterior in 34% (n=40), middle in 51% (n=60) and posterior in 15% (n=17). Assuming that all procedures were performed with meticulous care, the type of primary repair did not seem to have direct influence or effect on the development of a subsequent fistula.
Successful repair occurred in 73% of 117 cases on the first attempt, but noted undiagnosed distal obstruction in the form of meatal stenosis or anterior urethral stricture in 27 cases and 4 of the 31 cases repaired for the second time. Our study population revealed that recurrent urethrocutaneous fistula was more common in those patients with a posterior fistula, simple repair or with evidence of anterior urethral obstruction.
Of interest, 35 of the initial fistulas were coronal in location, 9 of the second fistulas and just 1 of the third. Simple repair was performed in 23 (66%) of the first and 4 (44%) of the second fistulas. Recurrent coronal fistulas following the first repair occurred in 4 (17%) of 23 simple repairs and 2 of the 12 complex repair. For coronal fistula requiring a second repair, 5 were repaired using simple technique with no recurrence and 4 were using complex technique with 1 recurrence.
A point to note was that among the anterior fistulas, the coronal site occurred in more than 80% of the cases. It seems possible that glans undergoes repeated minor episodes of lateral tension during erection, resulting in gradual thinning and splaying of the proximal glans and distal shaft with subsequent fistula formation. Alternatively this may represent a persistent weak point due to the abnormal development of the glans and corpora cavernosa in boys with hypospadias.
Whilst parents and patients need to be made aware of urethrocutaneous fistulas complicating hypospadias repair, this review suggests that they should also be encouraged that this may be satisfactorily addressed albeit after more than one surgical procedure.
Written by A. J. A. Holland, M. Abubacker, G. H. H. Smith, and D. T. Cass as part of Beyond the Abstract on UroToday.com
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