INTRODUCTION
| H |
ypospadias is one of the most common congenital anomaly of urogenital tract with an incidence of one in 300 to 400 births1. More than 300 procedures are in use and newer one introduced every year2. Hypospadias surgery is unique in this respect having so many procedures for a single disease. It also shows dissatisfaction on the part of surgeons and their patients. In fact, the hypospadias surgery carries very high complication rate even in experienced hands3-5.
The most common complication after hypospadias repair is urethrocutaneous fistula with reported incidence of 12.1 to 91%6. The repair of these fistulae is even more demanding. Fistula repair after hypospadias surgery has been given relatively little attention in urological and plastic surgery literature. Plastic surgery unit Hayyatabad Medical Complex is well reputed for hypospadias surgery since its birth in 1997. A two stage procedure is exclusively performed in all types of hypospadias in this unit.
Our catchment area not only includes N. W. F. P and adjoining
areas of
MATERIALS AND METHODS
This would be a descriptive study.
All those cases that underwent urethrocutaneous fistula repair, after hypospadias surgery in plastic surgery unit during the last seven years (1997 to 2003) were included in this study. Record of all these cases is saved in our database. These patients were followed up post operatively at 2 weeks, 3 months, 6 months and 1 year period. Outcome, progress and complication if any were recorded.
Inclusion criteria:
1. All those patients operated for hypospadias in this unit, subsequently developing fistula and operated for the same were included in this study.
2. All patients with urethrocutaneous fistula after hypospadias surgery performed elsewhere, referred to our unit and having undergone fistula repair were also included in this study.
Exclusion criteria
All patients developing urethrocutaneous fistula secondary to other causes e.g. trauma, infection and malignancy were excluded from this study.
Technique
All fistulae were repaired under general anaesthesia. Under tourniquet control (made from a strip of latex glove) the fistulae were examined carefully for their number, size, site and the state of surrounding tissue. Saline was injected (with 22 G cannula) into the urethra to confirm our findings regarding fistula and to find out any missed fistula. A silicon catheter of appropriate size was then passed to asses the diameter of urethra, to find out any stricture/ stenosis and for postoperative urinary drainage. Meatotomy was performed in case of meatal stenosis, in the same session. Fistula was marked with dye. The margins of the fistula were excised. Small fistulae of less then 4 mm were closed with inverting 6/0 polyglactin suture in a purse string manner. Larger fistulae were closed with inverting running suture like in standard stage II repair7. Adjacent fistulae were joined to close them as one. Distal fistulae at glans were dealt like stage II repair. Local penile/ scrotal flaps of skin were used when the adjacent scarring precluded use of adjacent skin. All repairs were checked for water tight anastomosis by injecting saline in to the urethra with a fine bore cannula. Repairs were done in three layers with intervening Buck's fascial layer. All patients were discharged on first post operative day. Catheter was removed on fifth post operative day. Follow up visits were done on 2 weeks, 3 months and 6 month and one year postoperatively. All record was maintained manually and in our data base.
RESULTS
During the study period of seven years (1997 to 2003) 52 patient of post Hypospadias repair fistulae with 76 fistulas were operated. Distribution of different types of hypospadias is given in Fig 1. Mid penile was noted in 16 (31%) patients. Year wise distribution is given in Fig 2, where the maximum patients had fistula repair in 2001. 10 patients were referred from other unit for fistula repair. 37 patients (71.15%) had single fistula while 15 patients (28.84%) had more than one fistula Fig 3. Simple closure was done in 68 fistulae (89.47%) Fig 4. Success rate at first, second, third and fourth attempt was 65%, 66%, 83% and 100% respectively. Mean age at primary surgery was 7 years and eleven month (range 3.6 -21 years) while mean age at fistula repair was 9 year.75% of our patients were less than 10 years of age. The minimum follow up period was 6 months.23 patients (44.23 %) were Hypospadias cripples. Risk factors identified for fistula formation were post auricular and buccal full thickness graft, previous surgeries and proximal Hypospadias.
Fig 1: Hypospadias type in fistula patients.
Fig 2: Year wise distribution of fistula repair.
Fig 3: Distribution of fistula site.
Fig 4: Techniques used for fistula repair.
DISCUSSION
Urethrocutaneos fistula is the most common and embarrassing complication after Hypospadias surgery. Proximal Hypospadias and reoperated cases are at greater risk of fistula formation11. While only 33% of our patients had proximal hypospadias, 44.23 % were hypospadias cripples. High fistula rate in reoperated cases has also been observed by others3,5,12. Previous surgeries lead to scaring and ischemic fibrotic issue with poor healing and increased risk of fistula formation. Other risk factor includes distal obstruction, poor surgical techniques, urethral diverticulae, overlapping suture lines and erection during early post operative period1,6,13. While 4 of our patients (7.69%) had meatal stenosis needing Meatotomy and five adult patients (9.6 %) had erection episode history in early postoperative period, in rest of the patients no obvious cause was found.
In 37 patients (48.68 %) fistula site was at corona or distal penile. Similar findings were noted by ELBAKRY8 and JOSEPH14. The coronal sulcus is relatively hypo vascular area. Dissection and suturing at this area further compromises the blood supply with increasing risk of fistula formation. While majority of the series reported corona to be the most common site, the findings of EARDLEY7 were in contrast. Penile shaft was the most common site of fistula formation in his series.
A common error observed is timing of fistula repair. Consensus and logic in this regard dictates a wait and see policy for at least six months until the oedema and induration has subsided1. The mean duration between primary surgery and fistula repair in this series was about one year. Break of this basic principal with earlier repair may lead to embarrassing high fistula rate7. 5/6 fistula repaired within three months in his series ended in failure. Interestingly, LAPOTINE used N-bytyl cyanoacrylat application for repair of urethrocutaneous fistula in early post operative period with reasonable success rate of 62.5%15.
Although this small study with preliminary results include only 8 cases and long term results unknown, this newer technique can change the whole course of fistula management in future.
In our series, almost 90% of the fistulae were closed by simple purse string suture. While we achieved good overall results of 77.75% success rate with this technique others have found this technique to be a total failure7.
Recurrence after Hypospadias fistula repair is common16. An important cause of this recurrence is opposing suture lines. Various tissues have been utilized to interpose between the suture line of eourethra and skin as waterproofing layer. These include de-deepithelized skin17, dartos fascia18 and tunica vaginalis19. We have been using Buck's fascia as waterproofing layer in all of our cases. It has been found safe, simple, time saving and effective method of waterproofing with very low complication rate.
Comparing our results with other published data (Table 1) they are intermediate between excellent results ofMascona6 and modest results ofEardly7. A explanation to our low over all success rate (77.75%) may be that 44% of our patients were Hypospadias cripples. This group of patient is universally notorious for high complication rate3.5.12.
Table 1: Success rate: comparison with other studies.
| Author |
Year |
Cases |
1st Attempt |
2nd Attempt |
3rd Attempt |
4th Attempt |
| Moscona6 |
1984 |
24 |
92% |
100% |
-- |
-- |
| Eardly7 |
1992 |
48 |
53% |
45% |
50% |
33% |
| Albakry8 |
2001 |
42 |
70% |
66% |
50% |
-- |
| Waterman9 |
2002 |
123 |
71% |
72% |
77% |
100% |
| Shanker10 |
2002 |
113 |
71% |
70% |
50% |
50% |
| Current study |
2003 |
52 |
65% |
63% |
83% |
100% |
CONCLUSION
Surgery for Hypospadias fistula is quite demanding and characterized by universally high recurrence rate. Failure rate is higher in Hypospadias cripple cases. Optimal results can only be achieved by adhering to the basic principals of plastic surgery including gentle tissue handling, using fine sutures, avoidance of opposing suture lines, absolute Haemostasis and tension free anastomosis.
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