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Year:2010|Volume:7|Issue:2|Page:124128

Asimpleprocedureformanagementofurethrocutaneousfistulasposthypospadiasrepair
SMohamed,NMohamed,TEsmael,ShKhaled
DepartmentofPlasticandPaediatricSurgery,ZagazigUniversityHospitals,Zagazig,Egypt
CorrespondenceAddress:
SMohamed
PlasticSurgeryDepartment,ZagazigUniversityHospital,Zagazig
Egypt

Abstract
Objectives:Thetreatmentofurethralfistulasisquitechallenging.Wetrytoevaluatetheresultsofasimpleprocedureinposthypospadiasurethralfistularepair.MaterialsandMethods:
Intheperiodfrom2003to2007,35patientswith35fistulas,withanaverageage3.5years[range:28],wereclassifiedintocoronal12,midpenile13andproximal10.Basedonthesize
theyweregroupedintotwoeitherlessthan5mm(20)ormorethan5mm(15).Midlinerelaxingincisionwasusedforlargefistulasandthencoveredwithavascularisedflapdartos
basedflap[flipflap]in19andtunicavaginalisin16.Ifapatienthadmorethanonesmallfistulaadjacenttoeachother,theywerejoinedintoalargesinglefistulaandthenrepaired.
Results:Wehavesuccessfullyrepairedallurethrocutaneousfistulasusingourprotocol,withsuccessrate[97.3]1/35.Conclusions:Dorsalmidlineurethralincision(DUMI),withdartos
flipflaportunicavaginaliscoverageisanappropriateproceduretorepairmidlineandproximalurethralfistulas.

Howtocitethisarticle:
MohamedS,MohamedN,EsmaelT,KhaledS.Asimpleprocedureformanagementofurethrocutaneousfistulasposthypospadiasrepair.AfrJPaediatrSurg20107:124128

HowtocitethisURL:
MohamedS,MohamedN,EsmaelT,KhaledS.Asimpleprocedureformanagementofurethrocutaneousfistulasposthypospadiasrepair.AfrJPaediatrSurg[serialonline]2010
[cited2016Oct26]7:124128
Availablefrom:http://www.afrjpaedsurg.org/text.asp?2010/7/2/124/62844

FullText
Introduction

Urethrocutaneousfistulaafterhypospadiasrepairremainsafrustratingproblemforsurgeons.Furthermore,withtheimprovementinsuturematerialandsurgicaltechniques,such
complicationsareincreasinglyunacceptable.Theoccurrenceofurethrocutaneousfistulaeprecludesagoalofhypospadiassurgery.[1],[2]
Unfortunatelythereisnoonesingleperfecttechniquetorepairanurethrocutaneousfistula.Factorsthatmayaffectresultsoftheirrepairmaybetheconditionsoflocaltissue,durationof
timeafterhypospadiasrepair,thenumber,locationandsizeofthefistula,useofmagnification,patientsage,previousfistularepairsandalsothetypeofsuturematerialused,skillofthe
operatingsurgeonandproperinversionoftheedgesetc.Somefailurerateisexpectedineverytypeofrepair.Byprovidingawatertightcoveringlayer,theincidenceofrecurrencein
urethrocutaneousfistularepaircanbegreatlyreduced,especiallyinlargeurethrocutaneousfistulas.[3],[4]
Thepurposeofthisstudyistoprovideatrialforsimplemanagementoftheurethrocutaneousfistulaeregardingtoitssize,number,andsite.

MaterialsandMethods

Wehaveoperatedonatotalof35caseswithn=35urethrocutaneousfistulasduringaperiodfromJune2003toApril2007,ageofthepatientsrangedfrom2to14yearswithanaverage
5.32years.Allthepatientsunderwentroutinepreoperativeinvestigations.Outofthe35fistulacases,fivewererecurrentafteritsrepaironcebyroutinemethodsusingadjacentlocalflaps
and30caseswereprimary.Theywereclassifiedintocoronal12,midpenileinn=13andproximalinn=10,andaccordingtothesizeintotwogroupseitherlessthan5mminn=20and
morethan5mminn=15.Allthepatientswerecoveredwithavascularisedflapdartosbasedflap[flipflap]inn=19andtunicavaginalisinn=16.Ifapatienthadmorethanonesmall
fistulaadjacenttoeachother,theywerefusedtoalargesinglefistulaandthenrepaired[Table1].
Inthisstudy,managementforcoronalfistulasaimedtoconvertitintohypospadiasandrepairedasSnodgrassoperation.Theseconditem,themidpenilefistula,wastreatedwithdorsal
midlineurethraincisionbiggerthanthesizeofthefistulawith2mmoneachsideasarelaxingincisionforlargefistulasfollowedbycoveringthesuturelinewithdartosflipflapafterwater
tightclosureandfinallytheproximalhypospadiastreatedasthemidpenile,exceptthatwecovereditwithtunicavaginalis.Inallpatientsacatheterofsize68Frenchwaskeptasastent
for10to12daysdurationpostoperatively.
Surgicaltechnique
Thefirststepaftergeneralanaesthesiaandpaintingofthepatientsistodeterminetheactualsizeandnumberofthefistulas.Wehadtwopatientseachwithtwofistulasincloseproximity
oradjacenttoeachother.ThentheywereconvertedintoasinglelargefistulatoinfiltratesubcutaneouslywithXylocaineandAdrenalineusinganeedleof27gaugesaroundthefistula
edgesthisforaneasyunderminingofthefistulaedge.
Thesecondstepistoincisethedorsalmidlineurethrawithasmallknifeoppositetothefistulasiteandinlargersize2mmonbothsidesthenthepatientwascatheterizedwithacatheter
ofsize68Frenchsize[Figure1]and[Figure2].
Thethirdstepisthefistulaclosuredoneusing50Vicrylsutureonacuttingneedleinacontinuousmannerandunderloupemagnification.Coveredwithdartosflipflap[Figure3],[Figure

4],[Figure5],itwasthenharvestedincasesofthemidpenilefistulainlengthtobreadthratio1/3afterskindeglovingandweselectedthetunicavaginalisfortheproximaltypes[Figure6]
and[Figure7]thoseweresuturedovertheurethrocutaneousfistulaeinawatertiedclosureallaroundthefistulawithinterruptedVicryl50.
Finallythepenileskinwasclosedovertheflapandsteriledressingwasapplied.Theurethralcatheterwasremovedafter10days.

Results

Wehavesuccessfullyrepairedallurethrocutaneousfistulasusingourprotocol,intheperiodfromJune2003toApril2007,withgoodcosmeticresultsIntheearlypostoperativeperiod,we
hadfour[11.4%]caseswithurinaryretention,threecaseswithhaematomaandfive[14.4%]withwoundinfection.Allweretreatedconservativelywithoutsurgicalinterventionandfour
[11.4%]caseswithimmediatefistulaorurinaryleakage,three[8.7%]wereclosedaftertwicedilatationweeklyforthreeweeks,themeanhospitalstay,1.71.1(24)allthepatientswere
dischargedonedayafterexceptcaseswithretentionforassuranceoftheparentsandthemeanoperativetimewasintherangeof25.511(3045)minutes[Table2],[Table3].Inthelate
postoperativetimeonecaseofrecurrencewasnoticed[Figure8].

Discussion

Thefistulaformationafterhypospadiasrepaircontinuestobeafrustratingcomplication,thussurgeonshaveevaluatedtheirtechniques,aswellasthepossibleunderlyingcausesthat
mayputthepatientsatriskofapostoperativefistula.[4]Secrestetal,[5]reportedonthesuccessfulurethrocutaneousfistularepairin53(91.4%)ofthetotal58patientsafterhypospadias
repair.Theinvestigatorsemphasizedtheuseofmagnification.Fromatechnicalstandpoint,wedonotbelievethattheuseofamicroscopicrepairwillgiveanadvantageoverLoupe
magnification[3.5foldLoupemagnification].
Richteretal.[6]preferredconvertingcoronalfistulasintocoronalhypospadias,followedbytubularisationoftheurethralplatewithorwithoutadorsalmidlinerelaxingincision.[7]The
Thierschtuberepairwithorwithouttherelaxingurethralplateincision,asdescribedbyReddy,[8]Richetal.[9]andSnodgrass,[10]hadasuccessrateof92%.
Aswithhypospadiassurgery,therearenoperfecttechniquesforrepairingurethrocutaneousfistulae.Manyvariablescouldinfluencethesurgicalmanagementandoutcomethetimeof
occurrenceafterurethroplasty,thelocation(glanular,coronal,midshaft,etc.),size(pinpoint,large),thenumberandtheconditionsoflocaltissue.[11]
Weselectedallourpatientssixmonths,afterurethroplastyorafterthelastoperationafterconsumptionofanyconservativemethods.Weprefertoconvertthecoronalfistulaintocoronal
hypospadiasallcasesweretabularisedwithmidlineurethralplateincisionasarelaxingincisionwithsuccessrate91.6%[11/12].
Acommonerrorobservedistimingoffistularepair.Consensusandlogicinthisregarddictatesawaitandseepolicyforatleastsixmonthsoflastrepairtoenablethescarstomatureand
alsotheoedemaandindurationstosubside.[12]Wehadfourcaseswithimmediatepostoperativeurinaryleakagelikeminorfistulaallwerehealedconservativelybeforeonemonth
exceptonetobearecurrentfistulalateron.Duringthelastdecademanyprinciplesofanidealrepairingtechniquehavebeenclarified.Delicatetissuehandling,inversionoftheurethral
mucosaafterexcisingtheepithelialisedtractofthefistula,amultilayerrepairwithwellvascularisedtissues,avoidingoverlappingsuturesandnonabsorbableorthicksuturematerials,a
tensionfreeclosure,useofopticalmagnificationandneedlepointcauteryforcoagulationarecurrentlyconsideredmandatory.[13]
Weadvisetheuseofbipolardiathermyformeticulousdissectionandnonbloodyfield,byinfiltrationofZylocainwithadrenaline1/2000000alsoweusedtheloopformagnificationand
perfectsubcuticulartissueclosurewith5/0vicryle.
Variousmethodsandtechniqueshavebeenreportedintheliteratureforthemanagementoftheseurethrocutaneousfistulaewithvariableresults.Largerthesizeofthesefistulaemore
difficultistheirclosureandcorrection.[14]Wehadnodifferencebetweenbothpatientsgroupsregardingitssize.Asthelargerthesizethemoredifficultclosurethisduetotheclosure
withtensionsuturesthusweavoidthisproblembymakingthedorsalmidlineincisionforalllargefistulasasarelaxingincisiontoavoidtensionsuturesandischemia.
Someauthorsadvisedtheuseofpursestringsuturesasasimplemethodtoclosefistulathismaybeofvalueinsmallsizedfistulaswherethelargerthefistulathemoretensionwillresult
this,Wedisagreeasthisprinciplecarriestheriskoftensionattheedgeofthefistulaopeningandischemiaalsoitsinterruptedsilksuturesinspiteofitssimplicityitalsohadthepossibility
ofimpededurethralepitheliuminbetweenthesutures.[15]Subcuticularcontinuoussutureshadthebenefitsforpreventingtheleakageoftheurineandpassingtheurethralepithelium
throughthesutures.[16]
Numeroustechniqueshavebeendevisedtocounteractthisproblemandpursuitforanidealoneisstillgoingon.Amongthesetechniques,themostcommonmanoeuvreistoplacesome
interveninglayeroftissuebetweenneourethraandtheskin.[17]
Someauthorsadvisedtheuseof(Tunicavaginalisorscrotaldartoslayer)forrecurrentfistulas,tissuesfromanunscarredarea7,butweperformeditforbothtypeseithertheprimaryor
therecurrenttypes.Weselectedthepeniledartosflapasarandomflapwithalengthtobreadthratio1/2to1/3[flipflap]withgoodresultsforfistularepairwithsuccessratemorethan
96%.Thedartosflapisfibroadiposetissuethisflapmayreachesthedistalpenileshaftwithouttension.Dartosflapshavebeenusedforboththeprimarywaterproofingofhypospadias
repairandfistularepair.[17]WeselectedtheTunicavaginalisfortheproximalfistulatypesthislayerwasconsideredwaterproofinglayerbetweenurethraandskinandwellvascularised
furthermorewereducingitsindicationforalltypesoffistularepairtoavoidtesticularcomplicationsaspossibleasalsoweconsidereditthebestchoiceafterdartosflaps.

Conclusion

Midlineurethralincisionasarelaxingincisionwiththedartosflipflapisthekeyforsuccessfultreatmentofurethralfistula.

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