Elsevier

Urology

Volume 61, Issue 2, February 2003, Pages 448-451
Urology

Pediatric urology
Management of recurrent urethral fistulas after hypospadias repair

https://doi.org/10.1016/S0090-4295(02)02146-5Get rights and content

Abstract

Objectives

To report on our experience in the management of recurrent urethrocutaneous fistulas in order to understand the etiology and outcome of secondary repair of the failed fistula closure.

Methods

We reviewed the records of 28 patients between 28 months and 19 years of age, who underwent surgery between January 1990 and December 1998. In all patients, urethrocutaneous fistulas developed postoperatively, and the number of operations for their closure ranged from 2 to 15 attempts. In 17 children, a single large fistula was present, and in 11 children, multiple fistulas were present. The causes of failure were believed to be the awkward fistula site in 12 (coronal fistulas), urethral diverticula in 7, and distal urethral strictures in 4. In 5 children, the cause of fistula formation was unclear.

Results

The 12 coronal fistulas were converted into coronal hypospadias. Thereafter, the urethral plate was tubularized using a wider strip (Thiersch tube) with (n = 3) or without (n = 9) a relaxing midline incision (Reddy-Snodgrass). Of the 12 repairs, 11 were successful; 1 child developed wound separation, resulting in a megameatus that was subsequently corrected. In 7 children, the cause of the fistula was a urethral diverticulum, which was excised and closed in multiple layers. All were successful (voiding well and no stricture or fistula). In 4 children (1 with multiple fistulas), the distal urethra was stenotic, and repair of the fistula included repair of the stricture using an island onlay flap in 2 and a buccal mucosal graft in 2. All 4 patients achieved a successful outcome. Dartos flaps were used to cover the repair in 18 patients, and tunica vaginalis flaps were used in 6 children.

Conclusions

Recurrent urethral fistula after hypospadias repair may be a manifestation of another problem, such as urethral stricture and/or urethral diverticulum. Intraoperative calibration of the distal urethra and distension of the repaired hypospadias to search for a diverticulum are recommended. Coronal fistulas are best repaired by converting them into coronal hypospadias, followed by tubularization of the urethral plate with or without a dorsal midline relaxing incision. In resurfacing the operative site, the traditional transposition flaps (Y-V and advancement) may be unreliable, because their vascularity may be compromised by previous surgery. The hairless scrotal island or rotation scrotal flap is more reliable for these cases.

Section snippets

Material and methods

We reviewed the records of 28 children between 28 months and 19 years of age, who underwent surgery between January 1990 and December 1998. We performed the primary hypospadias repair in 7 children, and 21 children were referred after surgery elsewhere. In all patients, urethrocutaneous fistulas developed postoperatively, and the number of operations for their closure ranged from 2 to 15 attempts (Table I). In 17 children, a single large fistula was present, and in 11 children, multiple

Results

Coronal fistulas were found in 12 children. They were converted to coronal hypospadias by dividing the bridge of tissue between the fistula and the meatus. After dividing the inadequately vascularized glans bridge, a redo of the glansplasty was performed in the same setting. Then, the urethral plate was tubularized using a wider strip (Thiersch tube) with a midline relaxing incision (Reddy-Snodgrass) in 3 and without the incision in 9 children. Of the 12 repairs, 11 (92%) were successful; 1

Comment

Hypospadias surgery is not free of complications, and fistula formation is one of the most frequent. The reported incidence of fistula formation in published reports varies considerably, depending on the severity of the initial deformity (0% to 50%).1, 2, 3 Because fistula formation after hypospadias repair continues to be a frustrating complication, surgeons have evaluated their technique, as well as the possible underlying causes that may put the patient at risk of a postoperative fistula.4

Cited by (0)

View full text