Urology. 2003 Feb ;61 (2):448-51
12597967
Cit:6
Section of Urology, University of Medicine and Dentistry-New Jersey Medical School, Newark, New Jersey, USA.
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.
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Afr J Paediatr Surg. ;7 (2):124-8
20431229
Department of Plastic and Paediatric Surgery, Zagazig University Hospitals, Zagazig, Egypt.
OBJECTIVES The treatment of urethral fistulas is quite challenging. We try to evaluate the results of a simple procedure in post-hypospadias urethral fistula repair. MATERIALS AND METHODS In the period from 2003 to 2007, 35 patients with 35 fistulas, with an average age 3.5 years [range: 2-8], were classified into coronal 12, mid-penile 13 and proximal 10. Based on the size they were grouped into two--either less than 5 mm (20) or more than 5 mm (15). Midline relaxing incision was used for large fistulas and then covered with a vascularised flap dartos-based flap [flip flap] in 19 and tunica vaginalis in 16. If a patient had more than one small fistula adjacent to each other, they were joined into a large single fistula and then repaired. RESULTS We have successfully repaired all urethrocutaneous fistulas using our protocol, with success rate [97.3] 1/35. CONCLUSIONS Dorsal midline urethral incision (DUMI), with dartos flip flap or tunica vaginalis coverage is an appropriate procedure to repair midline and proximal urethral fistulas.
J Pediatr Urol. 2010 Feb ;6 (1):60-5
19539535
Paediatric Surgery Unit, Department of Surgery, University of Benin Teaching Hospital, Benin City, Nigeria. Leadekso@yahoo.com
OBJECTIVE To report the challenges and outcomes of hypospadias repair in a developing country such as Nigeria. PATIENTS AND METHODS This was a prospective study of children who underwent hypospadias repair at the University of Benin Teaching Hospital in 2003-2007. The challenges and outcome of repair were documented with photographs to assess cosmetic results. RESULT A total of 149 operations were performed on 127 children with hypospadias, aged between 9 days and 12 years (mean 2.3 years+/-2.1) with 33 (26.0%) presenting after circumcision; 118 (92.9%) were single and 9 (7.1%) multistage, while 13 had closure of post-hypospadias repair fistulae and redo surgery. Non-availability of suitable pediatric urethral catheters, special dressing materials and microsurgical instruments/sutures, presentation after circumcision, and lack of parents/caregivers' motivation were major challenges. Transurethral urinary diversion, dressing with petroleum jelly impregnated with antibiotic/chloramphenicol ointment, mosquito forceps, scrotal skin flaps, size 6/0 polyglactin sutures, and organized counseling/home visits were employed. Repair was successful in all the children: excellent cosmetic results in 121 (95.3%), fair in 5 (3.9%) and poor in 1 (0.9%). Urethrocutaneous fistula was the main complication with no mortality recorded. CONCLUSION Despite the challenges, improvising with available materials, counseling of parents/caregivers, adequate patient recruitment and appropriately timed repairs gave encouraging results.
Division of Urology and University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada.
The tubularized incised plate (TIP) urethroplasty or Snodgrass procedure has gained worldwide acceptance for distal hypospadias repair due to its low complication rate, good cosmetic result, and technical simplicity. As a result, several articles have been published concerning various aspects and subtle variations of this procedure. The aim of this review is to critically and systematically analyze the published complication rates of TIP repair for distal hypospadias in children. We also reviewed the surgical modifications that have been introduced to the original technique and discussed the potential impact on the final outcome of the Snodgrass procedure.
BJU Int. 2009 Aug ;104 (4):550-4
19254282
Cit:1
Harold Hopkins Department of Urology, Royal Berkshire NHS Foundation Trust, Reading, Berks, UK. peter.malone@royalberkshire.nhs.uk
OBJECTIVE To describe a novel technique for repairing penile urethrocutaneous (UC) fistula, by dissecting out the fistula tract, but instead of excising it, to preserve it and turn it inside out (PATIO); this creates a flap valve inside the urethral lumen that prevents the ingress of urine allowing the fistula to heal. PATIENTS AND METHODS Five UC fistulae in four patients (two adults and two children) were repaired using the PATIO technique over a 4-year period. The two adults had developed the UC fistula after complex salvage hypospadias repair for failed surgery as children. In addition, three UC fistulae were recurrent after failed attempts to close them using conventional techniques, including the interposition of locally sourced 'waterproofing' subcutaneous tissue and, in one child, a rotational skin flap. One child had a difficult coronal UC fistula with little more than a skin bridge distally. RESULTS Four operations were performed as day-cases with no catheter; one child was catheterized and kept in hospital overnight to prevent retention after a caudal anaesthetic. The catheter was removed, before discharge, the following morning. All five repairs were successful with no complications or recurrence, with a mean (range) follow-up of 18 (2-50) months. CONCLUSION The PATIO technique is easy to perform and can be done as a day-case with no need for urethral catheterization. It does not preclude the use of other techniques to minimize the risk of recurrence, but so far these have not been necessary. As with all new operations, reported after only a few cases, caution must be used when interpreting the results and more studies are needed. Nevertheless, the concept makes sense and the early results are encouraging, particularly as it has been used on UC fistulae most liable to recur.
Urol J. 2009 ;6 (1):19-22
19241336
Reconstructive Urology Section, Shohada-e-Tajrish Hospital, Shahid Beheshti University (MC), Tehran, Iran. sjhosseinee@yahoo.com
INTRODUCTION The aim of this study was to evaluate the success rate of urethrocutaneous fistula repair using buccal mucosal graft in patients with a previous hypospadias repair. MATERIALS AND METHODS We reviewed records of our patients with urethrocutaneous fistula developed after hypospadias repair in whom buccal mucosal graft fistula repair had been performed. All of the patients had been followed up for 24 postoperative months. A successful surgical operation was defined as no fistula recurrence or urethral stricture. Retrograde urethrography and urethrocystoscopy would be performed in patients who had any history of decreased force and caliber of urine or any difficulty in urination. RESULTS Fistula repair using buccal mucosa patch graft had been done in 14 children with urethrocutaneous fistula developing after hypospadias reconstruction. The mean age of the children was 8.70 +/- 1.99 years old (range, 4 to 11 years). Seven fistulas were in the midshaft, 4 were in the penoscrotal region, and 3 were in the coronal region. Repair of the fistulas was successful in 11 of 14 patients (78.6%). In the remaining children, the diameter of the fistula was smaller than that before the operation, offering a good opportunity for subsequent closure. CONCLUSION Our findings showed that fistula repair using buccal mucosal graft can be one of the acceptable techniques for repairing fistulas developed after hypospadias repair.
Urology. 2005 Apr ;65 (4):782-5
15833528
Cit:4
Charles L Snyder,
Apostolos Evangelidis,
Gregory Hansen,
Shawn D St Peter,
Daniel J Ostlie,
John M Gatti,
George K Gittes,
Ronald J Sharp,
J Patrick Murphy
Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri 64108, USA. csnyder@cmh.edu
OBJECTIVES To review our experience with hypospadias complications (seen after 10%-15% of repairs) and to identify factors influencing outcome. METHODS We reviewed the available medical records of 113 patients who underwent repeat operation for hypospadias complications. Of the 113 patients, 40% had undergone the initial repair at our institution (internal referral); 60% had undergone the initial repair elsewhere before referral (external referral). The variables potentially affecting outcome were reviewed, including the severity of the defect, concomitant disease, age at the initial operation and revisions, type of complications and treatment, and the number of revisions. Outcomes were compared on the basis of specialty and experience. RESULTS Isolated hypospadias was present in 81% and other genitourinary abnormalities in 10%. External referral patients were older at the first revision (7.3 versus 4.2 years, P = 0.027). Complications included fistula (73%), stricture (12%), breakdown of repair (10%), and diverticulum formation (11%). Successful revision was independent of the initial defect. The first, second, and third revision was successful in 77%, 64%, and 67% of patients, respectively. The cumulative success rate was 77%, 92%, and 97% after each respective repair attempt. The success of the repair was independent of the patient's age at the initial operation/revision and of the interval from the initial repair to reoperation. Internal referral and external referral patients had similar results. Specific experience with the repair of hypospadias complications correlated with a successful outcome (P <0.001). CONCLUSIONS Complications after hypospadias repairs are common, with fistula accounting for approximately 75%. The outcome in our series was independent of hypospadias severity, patient age at repair, number of revisions, stent use, and referral status. Repairs performed by an experienced pediatric urologist were associated with improved outcomes (P <0.001).
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Urology. 2002 Aug ;60 (2):329-34
12137836
Cit:1
Section of Urology, University of Medicine and Dentistry, New Jersey Medical School, Newark, New Jersey, USA.
OBJECTIVES To review our experience with three methods of continent vesicostomy and to examine the morbidity and long-term outcome of each method. In the absence of an appendix, the surgical options for constructing continent vesicostomies include the use of the ureter, retubularized ileum, or stomach, a Benchekroun valve, or creation of a continent stoma from the reservoir itself. METHODS Between 1984 and 1999, 16 children, 14 with neurogenic bladder, 1 with cloacal malformation, and 1 with valve bladder, required access to their continent reservoir other than the urethra. The appendix was unavailable in all, either because it had been removed surgically at an earlier date or it had been used for an antegrade continent enema procedure. Eighteen continent vesicostomies were performed in 16 children. In 5 children, a Benchekroun valve was constructed. Two were subsequently replaced by tapered small bowel. In 7 children, a segment of small bowel was harvested, retubularized, and reimplanted in the reservoir in a submucosal or seromuscular tunnel. In 6 children, a flap of bowel forming the reservoir was raised, tubularized, and then a Nissen valve was constructed. RESULTS The early results of the Benchekroun valve were satisfactory; however, the results with long-term follow-up were disappointing because 4 of 5 children developed stomal stenoses and one subsequent valve perforation. One of the 5 children continued to do well 6 years postoperatively. The 7 children in whom a segment of small bowel was retubularized (Monti procedure) continued to do well and to catheterize their stomas without difficulty. At last follow-up, 1 child was awaiting collagen implant of her bladder neck for urinary incontinence. Five of the 6 children with a Nissen valve were doing well 1 to 8 years postoperatively. One child did well initially, but was lost to follow-up 1 year later. CONCLUSIONS The appendix is the preferred conduit for a catheterizable stoma. In its absence, our experience with the Benchekroun valve was disappointing. The retubularized ileum provided an excellent and reliable alternative to the appendix and is preferable if the bladder capacity is marginal. The Nissen valve constructed out of the reservoir has the advantage of avoiding intraperitoneal dissection and the use of additional small bowel. The two latter methods appear to be reliable in the long-term and are viable options when the appendix is not available.
Department of Pediatric Urology, Schneider's Children Hospital, New Hyde Park, New York, USA.
BACKGROUND: Genital anomalies in females born with classic bladder exstrophy-epispadias complex (EEC) include a bifid clitoris and anterior displacement of vagina. The aesthetic aspects of the genitals acquire greater significance with age and may affect self-esteem. We review our experience with clitoral reconstruction in an EEC population with an emphasis on aesthetic outcomes. METHODS: The study group had 26 female patients; three patients with isolated epispadias and 23 with bladder exstrophy. The patients were separated into four separate groups based on reconstructive technique. Group 1 (n=3) had tubularisation of skin between clitoral bodies for urethral reconstruction; group 2 (n=12) underwent staged exstrophy reconstruction; group 3 (n=8) had initial surgery elsewhere and were referred for secondary reconstructive surgery with clitoroplasty accompanied by puboplasty to reconstruct the fourchette; and group 4 (n=3) had total urogenital sinus mobilisation. The aesthetic outcome was assessed subjectively by the surgeon, parent and age-appropriate patient during follow-up. RESULTS: A total of 33 clitoroplasties were performed. Primary clitoroplasty was performed in 18 patients, while a secondary clitoroplasty was done in 15. The follow-up ranged from 3 months to 31 years. Three patients had partial clitoral atrophy and in one patient the gap between clitoral bodies was widely separated and incapable of being joined. Twenty-three of the26 patients (88%) had a satisfactory or excellent aesthetic outcome following clitoroplasty. CONCLUSIONS: Excellent aesthetic outcomes can be achieved by clitoroplasty in EEC patients by using a variety of surgical techniques. We recommend a 'second look' reassessment near puberty to identify poor cosmesis and offer secondary clitoroplasty to improve aesthetic outcome.
Department of Pediatric Urology, Schneider's Children Hospital, New Hyde Park, New York, New York, USA.
PURPOSE Male children born with bladder exstrophy-epispadias complex may have poor self-image because the esthetic aspects of the genitalia acquire greater significance with age. We reviewed our long-term outcomes of genitoplasty in males born with exstrophy-epispadias complex with emphasis on the esthetic results. MATERIALS AND METHODS A total of 70 male patients with exstrophy-epispadias complex were the basis of this retrospective review. Primary and secondary genitoplasty was performed in 44 and 26 patients, respectively. Various surgical methods were implemented for genitoplasty, including Cantwell Ransley technique with or without paraexstrophy flaps in 36 cases, partial corporeal mobilization with or without dermal graft in 16, subperiosteal corporeal mobilization from the pubic rami in 7 and complete penile disassembly in 6. The parent and when appropriate the patient determined satisfaction with the cosmetic appearance. The incidence of postoperative complications and need for surgical revision were noted. RESULTS Long-term followup was available in 65 of 70 patients. Esthetic satisfaction was present in 60 of 65 patients (92%). A total of 19 revisions (29%) were required with 4 patients undergoing multiple revisions. These revisions included fistula repair, repair of urethral stricture, glanular contouring and recurrent chordee release. CONCLUSIONS The penile malformations observed in exstrophy-epispadias complex may be due to a short urethral strip, corporeal disproportion and/or iatrogenic scarring. The optimal method to correct corporeal disproportion includes placement of a dermal graft. In select cases careful and partial mobilization of the crura from the pubic rami allows penile lengthening. In secondary reconstructive efforts subperiosteal dissection provides a virgin surgical field, while protecting neurovascular and erectile structures.
Department of Pediatric Urology, Schneider's Children Hospital, New Hyde Park, NY, USA.
PURPOSE At times children born with bladder exstrophy-epispadias complex must undergo several operations and the resultant scar tissue on the abdomen can be quite disfiguring. Long-term followup in these patients reveals that many have a poor self-image, and the aesthetic aspects of the genitalia and lower abdomen acquire greater significance with age. We present our retrospective case series of the experience of 1 surgeon during 27 years. MATERIALS AND METHODS Our database includes 116 patients born with exstrophy-epispadias complex. Primary reconstruction was performed in 62 infants and neonates, while 54 children and young adults underwent initial surgery elsewhere. Secondary puboplasty was performed in 88 of the 116 patients. Various techniques were used, ranging from simple excision and longitudinal closure in 12 cases, Z-plasty and pubic contouring in 23, the use of axial pattern inguinal skin flaps in 50 and tissue expanders in 3, when necessary. Long-term followup data were available on 76 patients. The parent and, when appropriate, the patient determined satisfaction with the cosmetic appearance. RESULTS Patient satisfaction with the cosmetic and functional outcomes of surgery was high. Of the 76 patients 73 (96%) were satisfied following puboplasty. Complications included wound infection and keloid formation in 4% and 10% of cases, respectively. CONCLUSIONS Achievement of excellent aesthetic results is possible with secondary puboplasty. Simple closure is associated with a higher incidence of keloid formation compared to the Z-plasty closure technique. Axial pattern skin flaps and Z-plasty techniques yield superior cosmetic results for contouring the mons pubis in patients with exstrophy-epispadias complex.
Department of Pediatric Urology, Schneider's Children Hospital, West Orange, NJ 07052, USA.
Long-term follow-up of patients born with classical bladder exstrophy-epispadias complex (EEC) reveals that many of them suffer from poor self-image, and the aesthetic aspects of the genitalia and lower abdomen acquire greater significance with age. In this article, we review the aesthetic outcomes in performing puboplasty, umbilicoplasty, and genitoplasty in patients born with EEC. Retrospective review of the cosmetic and functional outcomes in 116 patients born with EEC treated by puboplasty, umbilicoplasty, or genitoplasty was performed. Satisfaction with the cosmetic and functional outcomes of these three reconstructive surgeries was high following initial reconstructive efforts (> 90%). Attention to cosmesis during abdominal wall and genital reconstruction for EEC helps to improve a patient's perception of body image and self-esteem. Our experience with these procedures over the past 25 years demonstrated that the efforts directed toward aesthetics have been well worthwhile.
Department of Urology, Schneider Children's Hospital, Long Island Jewish Medical Center, New Hyde Park, New York, NY 11021, USA.
PURPOSE Repeated attempts at surgical repair of hypospadias may leave the penis scarred, hypovascular and shortened. We report on the clinical outcomes of our repaired complex hypospadias cases, often referred to as hypospadias cripples. MATERIALS AND METHODS We evaluated the records of 137 children and young adults from January 1980 through December 2002 who were referred to us after multiple unsuccessful hypospadias repairs. The records of 11 patients were inadequate. The ages of the remaining 126 patients ranged from 14 months to 35 years. The number of prior surgical procedures ranged from 2 to 23. Of the 126 cases 98 (78%) were repaired in a single stage (group 1) and 28 (22%) underwent multistage repairs (group 2). RESULTS Major complications occurred in 17 cases (17%) in group 1 and in 2 (7%) in group 2. Major complications included repair breakdown, stricture, diverticulum and multiple fistulas. Minor complications occurred in 9 (9%) cases in group 1 and in 4 (14%) in group 2. Minor complications included a single small urethrocutaneous fistula, skin tethering, inclusion cysts and glandular irregularity. Urethral substitution using skin grafts and/or bladder mucosa resulted in a high complication rate of 32% and 37%, respectively, whereas use of buccal mucosa resulted in a 15% complication rate. CONCLUSIONS Preoperative psychological counseling and discussion with other parents or patients were helpful. We no longer use free skin grafts and/or bladder mucosa for urethral substitution. Waterproofing the urethral tube was performed using either a dartos or tunica vaginalis flap. When the quality of the tissues was poor or severely scarred a 2-stage repair was performed. When resurfacing the penis local skin flaps may be insufficient or unreliable, and rotation of scrotal skin flaps or burial of the penis in the scrotum (Cecil-Culp) offers dependable skin coverage.
Department of Urology, Schneider Children's Hospital, Long Island Jewish Medical Center, New Hyde Park, New York, USA.
PURPOSE We review the evolution of the concept of tubularization of the urethral plate and our results in the repair of proximal hypospadias. MATERIALS AND METHODS A total of 281 children born with proximal hypospadias underwent Thiersch-Duplay urethroplasty with or without a midline incision of the urethral plate between 1989 and 1998. Followup data were available in 265 children. RESULTS Excellent functional and cosmetic results were achieved in 88.7% of the patients. The use of either a dartos or tunica vaginalis flap to waterproof the urethral suture line resulted in a decrease in the fistula rate from 17% to 1.8%. CONCLUSIONS The principles of Thiersch-Duplay urethroplasty represent the basic foundation for surgical techniques that use the urethral plate to construct a urethral tube. The use of this principle in the repair of proximal hypospadias compares favorably with other methods.
J Urol. 2003 Nov ;170 (5):1975-7
14532837
Cit:5
Division of Urology, University of Medicine and Dentistry of New Jersey, Newark, NJ, USA.
PURPOSE We examined postoperative outcome, with emphasis on bladder function, in pediatric patients who underwent bilateral ectopic ureterocele repair. MATERIAL AND METHODS We reviewed the records of 117 patients with orthotopic and ectopic ureteroceles treated between 1977 and 2000. Twelve of these patients had bilateral ectopic ureteroceles. All patients with bilateral ureteroceles were females 1 day to 2 years old at referral. Initial treatment was transureteral puncture in 6 cases, transurethral unroofing in 2 and extravesical bilateral reimplantation in 1. Of the remaining 3 patients the initial treatment was unilateral heminephroureterectomy in 1 and bilateral heminephroureterectomy in 2. Definitive treatment included bilateral upper to lower ureteroureterostomy, ureterocelectomy with trigonal and bladder neck reconstruction, and bilateral ureteroneocystotomy with or without tapering of the recipient ureter. In patients who underwent upper pole partial nephrectomy the distal upper pole ureter was removed in conjunction with trigonal surgery and ureteroneocystotomy. RESULTS There was significant morbidity in this group of patients, including voiding dysfunction and poor bladder emptying with residual urine greater than 20% of bladder capacity in 7 of 10 patients studied by serial bladder ultrasonography. Urodynamic evaluation in 3 patients revealed increased bladder compliance and large volume residual urine. Of these 3 patients 2 perform clean intermittent catheterization. Recurrent symptomatic bacteruria was noted in 7 of the 12 patients. CONCLUSIONS Patients undergoing bilateral ectopic ureterocele repair are at increased risk for postoperative voiding dysfunction. Whether this risk is present preoperatively or is a result of trigonal surgery is unclear.
Department of Urology, Schneider Children's Hospital, Long Island Jewish Medical Center, New Hyde Park, New York, USA.
PURPOSE We review our experience with the management of iatrogenic penile injuries. Apart from circumcision, serious damage to the penis can occur following hypospadias repair, surgery for priapism or total loss of the penis following surgical repair of bladder exstrophy. MATERIALS AND METHODS A retrospective analysis of patients with iatrogenic penile amputation referred to us between 1980 and 2000 was undertaken. Causes of injury and choice of management were reviewed. RESULTS Of the 13 cases treated during the 20-year period mechanism of primary injury was circumcision in 4, hypospadias repair in 6, priapism in 1, bladder exstrophy repair in 1 and penile carcinoma in 1. A variety of techniques were used for phallic reconstruction. Penile degloving, division of suspensory ligament and rotational skin flaps achieved penile augmentation and enhancement. Reasonable cosmesis and penile length were achieved in all cases. In indicated cases microsurgical phalloplasty was technically feasible. However long-term followup showed various complications including erosions from the use of a penile stiffener. CONCLUSIONS The ultimate goal of reconstructive surgery is to have a penis with normal function and appearance. The management of penile injury requires a wide variety of surgical techniques that are tailored to the individual patient. Expedient penile reconstruction is successful and therapeutic delay is associated with complications.
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Asian J Androl. 2012 Oct 15;:
23064690
Chao Qin,
Wei Wang,
Shang-Qian Wang,
Qiang Cao,
Zeng-Jun Wang,
Peng-Chao Li,
Jie Li,
Ning-Han Feng,
Li-Xin Hua,
Chang-Jun Yin,
Wei Zhang
Urethrocutaneous fistula (UCF) is a common complication of hypospadias surgery for severe hypospadias. We report our experience in the management of UCF following hypospadias surgery with a prepuce-degloving method (PDM). Our study included 87 patients who developed UCF after hypospadias repair from May 2001 to December 2011. Either simple closure or PDM was performed to repair the fistula. In total, 61 patients underwent a simple closure or Y-V plasty of the fistula, and 26 underwent a PDM repair. The success rate was 78.7% for simple closure or Y-V plasty and 96.2% for PDM repair (P<0.05). PDM repair represents a good choice for UCF repair after hypospadias, and our high 96.2% success rate demonstrates its applicability.Asian Journal of Andrology advance online publication, 15 October 2012; doi:10.1038/aja.2012.85.
J Urol. 2012 Jun 12;:
22698621
Department of Urology, University of California-San Francisco, San Francisco, California.
PURPOSE: Adults with complications from previous hypospadias surgery experience various problems, including urethral stricture, persistent hypospadias and urethrocutaneous fistula. Innate deficiencies of the corpus spongiosum and multiple failed operations makes further management challenging. MATERIALS AND METHODS: We reviewed our prospective urethroplasty database of men who presented with complications of previous hypospadias surgery. Patients were included in study if they had greater than 6 months of followup. Our surgical management was defined as an initial success if there were no urethral complications. The overall success rate included men with the same result after additional treatment. RESULTS: A total of 50 men had followup greater than 6 months (median 89) and were included in study. These 50 patients presented with urethral stricture (36), urethrocutaneous fistula (12), persistent hypospadias (7), hair in the urethra (6) and severe penile chordee (7). Patients underwent a total of 74 urethroplasties, including stage 1 urethroplasty in 19, a penile skin flap in 11, stage 2 urethroplasty in 11, urethrocutaneous fistula closure in 9, permanent perineal urethrostomy in 6, excision and primary anastomosis in 6, a 1-stage buccal mucosa onlay in 4, tubularized plate urethroplasty in 3, combined techniques in 3 and chordee correction in 1. In 25 men (50%) treatment was initially successfully. Of the 25 men in whom surgery failed 18 underwent additional procedures, including 13 who were ultimately treated successfully for an overall 76% success rate (38 of 50). CONCLUSIONS: Managing problems from previous hypospadias surgery is difficult with a high initial failure rate. Additional procedures are commonly needed.
Yogender Singh Kadian,
Kamal Nain Rattan,
Jagjit Singh,
Mahavir Singh,
Pradeep Kajal,
Dheeraj Parihar
Department of Paediatric Surgery, Pt. B.D.Sharma PGIMS, Rohtak, Haryana, India.
Background: Urethrocutaneous fistula is the most common complication of hypospadias surgery. The correction of such fistula is associated with a failure rate of 10 to 40%. The step in successful repair of a fistula is separation of the suture lines in the urethra and skin using well vascularized elastic tissue. We report our experience of using the tunica vaginalis flap as a layer between the neourethra and skin suture line in repair of recurrent urethrocutaneous fistula. Patients and Methods: We have used the tunica vaginalis flap for the repair of recurrent urethrocutaneous fistula in 14 children with a mean age of 6.5 years (range 3-14 years). All patients had undergone previous hypospadias repair and at least one previous attempt to close the fistula had failed. Surgery was initiated by injecting a povidone solution via urethral meatus to identify all fistulae. The fistulae were closed primarily and urethral suture line was covered with a flap of tunica vaginalis which was harvested either through a small scrotal incision and mobilized via a subcutaneous tunnel into the penile shaft (8/14) or by the same incision as for fistula closure (6/14). The testis was fixed to the scrotum. A urethral catheter was kept for urinary diversion for 10 days. Results: The repair was successful in all but one patient in whom there was leak from the fistula site. One patient in whom tunica vaginalis fascia was tunnelled into neourethra developed scrotal haematoma which needed drainage. Penile cosmesis was acceptable without any significant postoperative testicular complication in 13/14 patients. Conclusion: Repair of recurrent urethrocutaneous fistula with a tunica vaginalis flap is highly effective regardless of fistula location. This flap is easy to mobilize and provide effective coverage of urethral suture line. Putting a glove drain should be considered into scrotal wound if perfect haemostasis is doubtful.
Urol Int. 2011 ;87 (4):380-4
21849763
Institute of Pediatrics, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary. jozsa_tamas @ freemail.hu
BACKGROUND The management of recurrent urethrocutaneous fistula (RUCF) is a challenging problem that poses a serious difficulty for the hypospadias surgeon. We report here a novel technique in which a double unfurled dartos subcutaneous flap is utilized in the treatment of patients with RUCF. METHODS We retrospectively reviewed the records of all our patients who underwent surgical treatment of urethrocutaneous fistula with this new operative method after previously failed fistula repair. The main novelty of this technique is the use of two opposite medium thickness flaps, unfurled from the inner surface of the dartos fascia and spread over the fistula and each other so as to cover the urethral suture line completely, and fixed to the surrounding corporal tissue. RESULTS Eight patients with 11 RUCFs (with localizations varying from subcoronal to penoscrotal fistula opening) underwent surgical correction with the new method. There had previously been at least 3 recurrences in 6 of these patients, and different closure techniques had been used. RUCF diameter was <4 mm in all patients. Surgery was performed at the earliest following a 6-month healing period since the last fistula repair attempt. All of the RUCFs were repaired successfully with the technique. After a follow-up of at least 6 months, none of the 8 patients had developed recurrence of the fistula, and there were no postoperative complications. CONCLUSION The double unfurled dartos subcutaneous flap method appears to be a simple and appropriate procedure with which to repair recurrent mid-shaft and proximal urethral fistulas after failed hypospadias repair.
Antonio Macedo Jr,
Riberto Liguori,
Sergio L Ottoni,
Gilmar Garrone,
Eulalio Damazio,
Ricardo M Mattos,
Valdemar Ortiz
Department of Urology, Federal University of São Paulo, Rua Maestro Cardim, 560/215, 01323-000 São Paulo SP, Brazil. macedo.dcir@epm.br
PURPOSE Complex primary hypospadias repair that warrants urethral plate division is treated mostly in two steps, not necessarily in two surgeries. Our aim was to review long-term results with a one-stage strategy based on reconstruction of the urethral plate with buccal mucosa graft and onlay transverse preputial flap anastomosis protected by a tunica vaginalis flap (the three-in-one concept). MATERIAL AND METHODS We were able to report on 35 patients operated for primary scrotal, penoscrotal and perineal hypospadias between March 2002 and June 2008. We reviewed all charts and had phone interviews with patients not seen for the last 24 months. We investigated parameters such as UTI occurrence, fistula, residual curvature, meatal stenosis, urethral diverticula, dehiscence, orchitis and parental perception. RESULTS Surgical complications occurred in 13 patients (37%): 4 meatal stenosis, 4 diverticula, 5 fistulae and 2 residual penile curvatures (total 42%). Meatal dilatation was successful in 2 cases, reflected in fistula resolution. The reoperation rate was 31.5% consisting mostly of simple procedures like fistula closure, meatotomy and penile curvature release, and complex diverticula repair in 4 cases. Parental perception was excellent for 57%(20 patients) and good or acceptable for the remaining. Mean follow-up was 4.6 years. CONCLUSIONS The one-step strategy is associated with 68.5% success in a single operation, whereas 31.5% will need a second repair. We recognize that meatal problems are mostly associated with fistulae and diverticula; therefore, we recommend a final acceptable proximal glandar opening that will not compromise the neourethra.
Miroslav L Djordjevic,
Vladimir Kojovic,
Marta Bizic,
Marko Majstorovic,
Vojkan Vukadinovic,
Gradimir Korac
School of Medicine, Department of Urology, University of Belgrade, Tirsova 10, Belgrade, Serbia. djordjevic@uromiros.com
PURPOSE Urethral stricture is the second most common complication of hypospadias repair after urethrocutaneous fistula. Usually more than 1 procedure is needed for correction due to a lack of available tissue after previous repairs. We evaluated 1-stage urethral stricture management after hypospadias repair using a ventral buccal mucosal graft. We describe the importance of graft hanging and coverage. MATERIALS AND METHODS From August 2004 to April 2009, 15 patients 9 to 17 years old underwent urethral stricture repair after failed hypospadias surgery. Mean time after primary surgery was 7.2 years (range 4 to 13). Vascularized periurethral tissue around the stenotic part of the neourethra was dissected. The urethra was opened ventrally and a buccal mucosal graft of appropriate size was inserted to allow urethral augmentation. Using several U stitches the graft was anchored to the surrounding periurethral tissue to prevent its folding and retraction. Recurrent chordee in 12 patients and secondary vesicoureteral reflux in 3 were also corrected at this time. RESULTS Mean followup was 37 months (range 17 to 73). Successful results were confirmed in all patients by urethrography and uroflowmetry. One urethral fistula was corrected 3 months later by minor surgery. Recurvature did not develop in this group. There was no recurrent reflux in endoscopically treated patients. CONCLUSIONS Ventral buccal mucosal grafting is a simple, safe option for urethral stricture repair. Hanging the graft to periurethral tissue is important for its survival and to prevent postoperative folding and retraction.
Urology department, Qena University Hospital, 83523 Qena, Egypt. abolyosr66@yahoo.com
OBJECTIVE To evaluate the neourethra covering created by a vascularized overlapping double-layered dorsal dartos flap for preventing urethrocutaneous fistula in the Snodgrass hypospadias repair (tubularized incised plate). PATIENTS AND METHODS Between March 2003 and January 2008, 156 boys (mean age, 4.5 years) were enrolled for hypospadias repair. Preoperative position of the urethral meatus was subcoronal in 37, at the distal shaft in 61 and mid-shaft in 58 boys. All patients underwent the Snodgrass hypospadias repair. The neourethra was then covered with an overlapping double-layered dorsal dartos flap before glans and skin closure. RESULTS All 156 patients underwent successful reconstruction. With a mean follow up of 23 months (range 6-42), all boys had a satisfactory subjective cosmetic and functional result with a vertically oriented, slit-like meatus at the tip of the glans. No urethrocutaneous fistula or urethral stenosis occurred. CONCLUSION As the neouretha covering is an integral part of the Snodgrass hypospadias repair, a dorsal well vascularized double-layered dartos flap is a good choice for preventing urethrocutaneous fistula formation.
Urol Int. 2009 ;83 (3):354-8
19829040
Cit:1
Department of Urology, Duzce University School of Medicine, Duzce, Turkey.
INTRODUCTION This prospective study was designed to compare symmetrical overlapping double flaps with a single dartos flap in regard to fistula formation as an adjunct to tubularized incised plate urethroplasty (TIPU). PATIENTS AND METHODS 77 consecutive children with primary coronal or subcoronal hypospadias were randomized into 2 groups. A single layer dartos flap was used to cover the anastomotic site in the first group (37 patients). A wider dorsal dartos flap bisectioned in the midline was utilized in the second group of 40 patients. The complication rates were compared. RESULTS There was no difference between the 2 groups in terms of age, and meatal location. Postoperative median follow-up was 34 months. Urethrocutaneous fistula occurred in 3 patients (8.1%) of the monolayer group. No fistula developed in the second group with double flaps. CONCLUSIONS The current study proposes that the use of double dorsal flaps, although statistically not significant, better prevents fistula formation compared to monolayer dartos flaps following TIPU operation.
Kaliyaperumal Muruganandham,
M S Ansari,
Deepak Dubey,
Anil Mandhani,
Aneesh Srivastava,
Rakesh Kapoor,
Anant Kumar
Department of Urology , SGPGIMS, Lucknow, UP, India.
OBJECTIVE To evaluate the outcomes of three surgical techniques for the closure of urethrocutaneous fistula (UCF) after hypospadias repair. MATERIALS AND METHODS Fifty-one patients (mean age 6.5 years) who underwent UCF closure between June 1998 and February 2008 were divided in to three groups depending on fistula size; group I had <2 mm and (n = 17, 33.4%), group II had 2-4 mm (n = 21, 41.2%) and group III had >4 mm or multiple fistulas (n = 13, 25.4%). Group I patients were treated by excision and simple closure. Patients in group II and III were treated with flip flap technique along with the wrapping of repaired area with scrotal dartos flap and tunneled tunica vaginalis flap (TVF), respectively. RESULTS Mean surgical time was 45 min (range 30-55), 60 min (range 50-75) and 80 min (range 60-100) in three techniques, respectively. The mean follow-up was 3.5 years (range 6 months-10 years). No patient had recurrence of fistula in group III, while 2 (9.5%) and 4 (25.4%) patients in groups II and I, respectively, had recurrent UCF. No postoperative complications were encountered in the testis or the scrotum. No patient had torsion or deviation of penis. CONCLUSION Simple fistula closure carries a higher risk of recurrence even in small sized fistulas. The application of scrotal dartos or TVF for wrapping the repaired area gives excellent results and they are easy to harvest with no harmful effects on the scrotum or testis.
Urol J. 2009 ;6 (1):19-22
19241336
Reconstructive Urology Section, Shohada-e-Tajrish Hospital, Shahid Beheshti University (MC), Tehran, Iran. sjhosseinee@yahoo.com
INTRODUCTION The aim of this study was to evaluate the success rate of urethrocutaneous fistula repair using buccal mucosal graft in patients with a previous hypospadias repair. MATERIALS AND METHODS We reviewed records of our patients with urethrocutaneous fistula developed after hypospadias repair in whom buccal mucosal graft fistula repair had been performed. All of the patients had been followed up for 24 postoperative months. A successful surgical operation was defined as no fistula recurrence or urethral stricture. Retrograde urethrography and urethrocystoscopy would be performed in patients who had any history of decreased force and caliber of urine or any difficulty in urination. RESULTS Fistula repair using buccal mucosa patch graft had been done in 14 children with urethrocutaneous fistula developing after hypospadias reconstruction. The mean age of the children was 8.70 +/- 1.99 years old (range, 4 to 11 years). Seven fistulas were in the midshaft, 4 were in the penoscrotal region, and 3 were in the coronal region. Repair of the fistulas was successful in 11 of 14 patients (78.6%). In the remaining children, the diameter of the fistula was smaller than that before the operation, offering a good opportunity for subsequent closure. CONCLUSION Our findings showed that fistula repair using buccal mucosal graft can be one of the acceptable techniques for repairing fistulas developed after hypospadias repair.
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