What Happens If Fistula Develops After Hypospadia Repair

• Journal Listing
• Indian J Plast Surg
• v.44(1); January-Apr 2022
• PMC3111134

Indian J Plast Surg. 2022 Jan-Apr; 44(one): 98–103.

Management of urethrocutaneous fistula after hypospadias surgery – An feel of thirty-five cases

Rajat Kumar Srivastava

Consultant Plastic Surgeon, Saraswati Hospital & Research Centre, Lucknow, Republic of india

Mangesh Southward Tandale

Consultant Plastic Surgeon, Saraswati Hospital & Research Centre, Lucknow, India

Nikhil Panse

Consultant Plastic Surgeon, Saraswati Hospital & Research Centre, Lucknow, India

Anubhav Gupta

Consultant Plastic Surgeon, Saraswati Hospital & Enquiry Centre, Lucknow, Republic of india

Pawan Sahane

Consultant Plastic Surgeon, Saraswati Hospital & Inquiry Centre, Lucknow, Republic of india

Abstract

Introduction:

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

Aims:

To study the consequence of size, location, number of fistulas and surrounding tissues in selecting the process and its result. To place various factors involved in the recurrence and to codify a management in the cases where recurrence has occurred.

Patients and Methods:

This written report of 35 cases of urethrocutaneous fistula repair was washed from July 2006 to May 2009 to achieve meliorate results in fistula management following hypospadias surgery.

Statistical analysis used:

Xⁱⁱ test and Fisher's verbal examination.

Results:

The overall success charge per unit for fistula repair at first attempt was 89% with success rates for simple closure, layered closure and closure with waterproofing layer beingness 77%,89% and 100%, respectively. The 2nd try success rate at fistula repair for elementary closure and closure with waterproofing layer were 33% and 100%, respectively. At third attempt the two recurrent fistulas were managed by elementary closure with a waterproofing interposition layer with no recurrence. All the waterproofing procedures in this study had a success rate of 100%.

Conclusions:

The handling plan for a fistula must exist individualized based on variables which has an effect on the event of repair and to an extent dictates the type of repair to be performed. The significantly improved success rates with the improver of a waterproofing layer suggests the apply of this interposition layer should be done at the primeval available opportunity to forestall a reccurence rather than to reserve it for future options.

Keywords: Hypospadias, tunicavaginalis, urethrocutaneous fistula, waterproofing layer

INTRODUCTION

Urethrocutaneous fistula formation is the commonest complication of hypospadias repair, with a reported incidence of four-25%[1]. The successful repair of this lesion depends on several basic principles. Various techniques have been described for fistula repair only with disappointing results. Unproblematic closure although, technically like shooting fish in a barrel[2,iii] bears the potential risk of overlying suture lines and recurrence rates. Different procedures[1,7] have been tried for repair of larger/multiple fistulas provided the local surrounding skin is vascularized and pliable. For larger/recurrent fistulas with impaired local vascularity an interposition waterproofing layer significantly reduces the recurrence rate of the fistulas[viii,10].

PATIENTS AND METHODS

We have operated on a full of 35 patients which underwent 41 procedures for repair of 60 urethrocutaneous fistulas post-obit hypospadias surgery. The historic period at fistula repair ranged between 3 and18 years (mean age vii years). Urethral scale was routinely done intraoperatively with a urethral sound to exclude whatsoever distal stenosis, thereafter presence, location, number of fistulas was assessed, probing every pit in the skin with the probe to avoid missing smaller fistulae under loupe magnification. In doubtful cases methylene blueish was injected under force per unit area from the concluding portion of neourethra while a tourniquet was practical at the base of operations of the penis to occlude the proximal urethra. The fistulas were measured with calipers in the antero-posterior length of the penis although they were ovoid in shape [Figure ane]. A catheter of suitable size was inserted into the urethra and the fistulous tract excised past circumferential incision around the fistula. If the fistulas were located adjacent to each other they were joined into a unmarried larger fistula then repaired. The number, size of fistulas, status of surrounding skin [Effigy 2] and suture material used in repair are shown in Table 1. The location of various fistulas is mentioned in Table ii. Smaller fistulas were repaired using uncomplicated closure technique with interrupted inverting suture line with 6-0 chromic catgut or vicryl. The subcutaneous tissue flaps were closed with v-0 chromic catgut, respectively. For a larger fistula with skilful surrounding pare post-obit simple closure of fistula site, the pare was closed by a layered closure (pants over vest repair) whereas the larger multiple/recurrent fistulas with scarred surrounding skin - an additional local/distant waterproofing flap process was incorporated between the fistula and peel layer. Urinary diversion in the form of perurethral catheter was done in cases considering the claim of the fistula; however, information technology was non considered mandatory in all cases.

Showing measurement of fistula

Showing scarred surrounding skin

Table i

Showing association of various variables with repeat fistula rates

Table 2

Showing the frequency of location of fistulas

RESULTS

In this study the majority of fistulas occurred on the day of cathether removal (83%),followed by fistula appearance within 3 days (11%) and four-7 days (six%), respectively. The majority of patients had no evident crusade of fistulation (74%) probably indicating an error in technique of repair with inadequate inversion of mucosa, inadequate layers of closure, ischaemic tissue or overlapping suture line leading to a suture line leak. The other identifiable causes were meatal stenosis (ix%), urethral stricture (x%) and suture line dehiscence (seven%). On analyzing the effects of different variables on successful result of fistula repair it is clear from Tabular array 1 that number, size, status of surrounding skin, suture material used have a significant outcome on the favourable outcome. On applying Fischers exact test for association of these variables on the consequence -P<.05 which was significant. The overall success rate of 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 – which is comparable with other studies[4,5,8] [Tabular array 3]. The 2d endeavor success rate of fistula repair with simple closure was 33% which significantly improved to 100% when it was combined with an boosted waterproofing interposition layer [Table 3]. At 3rd try the 2 recurrent fistulas of simple closure were managed past simple closure along with waterproofing with tunica vaginalis interposition layer with no recurrences [Table 3]. Most of the recurrences occurred where vicryl was used (success rate 62%) every bit compared to chromic catgut (success rate 96%) [Table i][11]. The diverse waterproofing procedures used in this written report are listed in Tabular array 4. The bulk of waterproofing procedures performed were distant flaps [Figures ​ 3a–d] owing to the express availability of unscarred local tissues. Tunica vaginalis as local flap was used in two cases of penoscrotal fistula while penile dartos and scrotal dartos [Figures ​ 4a–d] were used in distal and proximal level fistulas, respectively. Afar flaps (Tunica vaginalis) were used for all varieties of fistula ranging from coronal to penoscrotal levels [Figure 5]. All these waterproofing procedures had a success rate of 100% in our written report which is comparable to other studies[iv,8,9]. The majority of complications in our study were pare necrosis, repeat fistula and meatal stenosis Table 5. Autonomously from managing repeat fistulas, two of the half-dozen patients with skin necrosis had superficial necrosis which healed spontaneously while three cases had an boosted waterproofing layer providing a barrier layer thus preventing a repeat fistula and so were managed conservatively while one with an additional waterproofing layer required refreshening and resuturing of tunica vaginalis flap forth with redraping with circumferential penile peel. The ii patients of meatal stenosis were managed by series dilatations and were reassessed at frequent intervals to look for development of meatal stenosis. Thus early on regular follow-upwards following the repair should be washed to wait for impending distal obstruction and timely intervention to prevent recurrence of the fistula.

Table iii

Showing success rates at various attempts

Table 4

Various h2o proofing procedures used in our study

Showing preoperative micturition

Showing postop micturition

Showing preop proximal penile fistula

Showing mail service-op micturition

Showing distal reach of tunica vaginalis

Table 5

Showing postoperative complications

Showing intraop tunica vaginalis flap top

Showing tunica vaginalis flap suturing

Showing scrotal dartos height

Showing scrotal dartos elevation

DISCUSSION

The incidence of fistula can be used to judge the success of hypospadias surgery ranging from 0 to 23%[5,8,10,12] which in our study is 21% being comparable to other studies.

The cause of fistula remains less known although it is probable that local infection, local ischaemia, inadequate procedure, poor tissue treatment, distal obstruction due to distal stenosis or encrustration with severity of hypospadias has significant impact on the outcome of the master hypospadias repair. On studying the effects and association of variables similar size, location, number of fistulas, amount and condition of bachelor local penile skin, suture textile used on the outcome of the repair-the P-value was <0.05 which was significant (Applying Fischer's verbal test). However, recurrence did not relate to other variables.

The results underline that both elementary closure and layered closure of a fistula at first attempt have a comparatively lower success rates[ane,4,5,12].

Why some fistulas recur is uncertain. Beyond whatsoever deficiencies of surgical technique or postoperative management there is no clear answer, other than that impaired local vascularity-scarred surrounding skin [Figure ii] might be the plausible explaination.

The success rates at 2nd and third attempts were appreciably lower in which simple closure[iv,5,10] was attempted alone ranging from 50% to 80% whereas no recurrence was seen in which unproblematic closure with additional waterproofing layer was incorporated. This further proves our point that repair with the same procedure in a locally scarred fistula leads to increased chances of recurrence and any of the waterproofing procedures should be combined to foreclose farther recurrence.

Shankar et al.[10] in his written report of 10 cases of refistulas at second attempt found l% success rates at tertiary, fourth and fifth attempts only without any waterproofing layer. He express the use of Tunica vaginalis as a waterproofing layer to third or subsequent repairs. Thus it is clear that with subsequent attempts at fistula repair, the chances of recurrence increases with decrease in success rates owing to the further scarring of the already deficient compromised surrounding pare. In our experience the use of Tunica vaginalis or scrotal dartos tissue in a scarred expanse equally a waterproofing cover at the earliest opportunity decreases the recurrence rate coupled with the fact that the fistulas are small, easily manageable and more importantly reduce the psychological trauma of undergoing repeated surgeries by the patient.

The apply of magnification, absorbable suture material and delicate tissue treatment are as well a must for a favourable result.

CONCLUSIONS

The treatment plan for a fistula must be individualized according to the size, location and number of fistulas with due attention to the local surrounding peel which all have an effect on the outcome of repair and to an extent dictates the type of repair to be performed. The minimum time interval of 6 months between any 2 procedures should exist considered for a favourable outcome. The significantly improved success rates in the repair at the beginning, second and 3rd attempts with the add-on of a waterproofing layer suggests the use of this interposition layer should exist done at the primeval available opportunity to prevent a reccurence rather than to reserve it for future occasions.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared.

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Articles from Indian Journal of Plastic Surgery : Official Publication of the Clan of Plastic Surgeons of India are provided here courtesy of Thieme Medical Publishers

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What Happens If Fistula Develops After Hypospadia Repair,

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111134/

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