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

Srivastava RK, Tandale MS, Panse N, Gupta A, Sahane P - Indian J Plast Surg (2011)

Bottom Line: All the waterproofing procedures in this study had a success rate of 100%.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.

View Article: PubMed Central - PubMed

Affiliation: Consultant Plastic Surgeon, Saraswati Hospital & Research Centre, Lucknow, India.

ABSTRACT

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: X(2) 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.

No MeSH data available.


Related in: MedlinePlus

Showing preop proximal penile fistula
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Figure 7: Showing preop proximal penile fistula

Mentions: In this study the majority of fistulas occurred on the day of cathether removal (83%),followed by fistula appearance within 3 days (11%) and 4-7 days (6%), respectively. The majority of patients had no evident cause 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 (9%), urethral stricture (10%) and suture line dehiscence (7%). On analyzing the effects of different variables on successful outcome of fistula repair it is clear from Table 1 that number, size, status of surrounding skin, suture material used have a significant effect on the favourable outcome. On applying Fischers exact test for association of these variables on the outcome -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[458] [Table 3]. The second attempt success rate of fistula repair with simple closure was 33% which significantly improved to 100% when it was combined with an additional waterproofing interposition layer [Table 3]. At third attempt the two recurrent fistulas of simple closure were managed by 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%) as compared to chromic catgut (success rate 96%) [Table 1][11]. The various waterproofing procedures used in this study are listed in Table 4. The majority of waterproofing procedures performed were distant flaps [Figures 3a–d] owing to the limited 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. Distant 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 study which is comparable to other studies[489]. The majority of complications in our study were skin necrosis, repeat fistula and meatal stenosis Table 5. Apart from managing repeat fistulas, two of the six patients with skin necrosis had superficial necrosis which healed spontaneously while three cases had an additional 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 along with redraping with circumferential penile skin. The two patients of meatal stenosis were managed by serial dilatations and were reassessed at frequent intervals to look for development of meatal stenosis. Thus early regular follow-up following the repair should be done to look for impending distal obstruction and timely intervention to prevent recurrence of the fistula.


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

Srivastava RK, Tandale MS, Panse N, Gupta A, Sahane P - Indian J Plast Surg (2011)

Showing preop proximal penile fistula
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3111134&req=5

Figure 7: Showing preop proximal penile fistula
Mentions: In this study the majority of fistulas occurred on the day of cathether removal (83%),followed by fistula appearance within 3 days (11%) and 4-7 days (6%), respectively. The majority of patients had no evident cause 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 (9%), urethral stricture (10%) and suture line dehiscence (7%). On analyzing the effects of different variables on successful outcome of fistula repair it is clear from Table 1 that number, size, status of surrounding skin, suture material used have a significant effect on the favourable outcome. On applying Fischers exact test for association of these variables on the outcome -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[458] [Table 3]. The second attempt success rate of fistula repair with simple closure was 33% which significantly improved to 100% when it was combined with an additional waterproofing interposition layer [Table 3]. At third attempt the two recurrent fistulas of simple closure were managed by 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%) as compared to chromic catgut (success rate 96%) [Table 1][11]. The various waterproofing procedures used in this study are listed in Table 4. The majority of waterproofing procedures performed were distant flaps [Figures 3a–d] owing to the limited 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. Distant 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 study which is comparable to other studies[489]. The majority of complications in our study were skin necrosis, repeat fistula and meatal stenosis Table 5. Apart from managing repeat fistulas, two of the six patients with skin necrosis had superficial necrosis which healed spontaneously while three cases had an additional 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 along with redraping with circumferential penile skin. The two patients of meatal stenosis were managed by serial dilatations and were reassessed at frequent intervals to look for development of meatal stenosis. Thus early regular follow-up following the repair should be done to look for impending distal obstruction and timely intervention to prevent recurrence of the fistula.

Bottom Line: All the waterproofing procedures in this study had a success rate of 100%.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.

View Article: PubMed Central - PubMed

Affiliation: Consultant Plastic Surgeon, Saraswati Hospital & Research Centre, Lucknow, India.

ABSTRACT

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: X(2) 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.

No MeSH data available.


Related in: MedlinePlus