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Management of recurrent urethral fistulas after hypospadias repair
PEDIATRIC UROLOGY
MANAGEMENT OF RECURRENT URETHRAL FISTULAS AFTER HYPOSPADIAS REPAIR FRANK RICHTER, PETER A. PINTO, JEFFREY A. STOCK,
AND
MONEER K. HANNA
ABSTRACT 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. UROLOGY 61: 448–451, 2003. © 2003, Elsevier Science Inc.
U
rethrocutaneous fistulas may complicate any form of hypospadias repair, but in most cases can be closed successfully. However, a recurrent fistula is a frustrating complication for the child, From the Section of Urology, University of Medicine and Dentistry-New Jersey Medical School, Newark, New Jersey; Department of Urology, Long Island Jewish Medical Center, Brooklyn, New York; Childrens Hospital of New Jersey, St. Barnabas Medical Center, Livingston, New Jersey; and New York Hospital Cornell Medical Center, New York, New York Reprint requests: Frank Richter, M.D., Department of Urology, Humboldt University (Charite) Berlin, Schumannstrasse 20-22, Berlin 10117, Germany Submitted: March 13, 2002, accepted (with revisions): September 9, 2002
448
© 2003, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
parents, and surgeon. Their reported incidence varies from 5% to as much as 55%, depending on the severity of the initial deformity.1,2 Kass and Bolong3 reported on about 206 primary hypospadias repairs, with only one fistula in a case of perineal hypospadias. The investigators stressed the importance of single-stage reconstruction and a two-layer closure of the neourethra. However, urethrocutaneous fistulas after hypospadias repair remain a problem, even with meticulous surgical technique, and may be the reflection of another underlying cause, such as a urethral diverticulum or a distal urethral stricture.4 We report on our experience in the management of recurrent urethrocutaneous fistulas to understand the etiology 0090-4295/03/$30.00 doi:10.1016/S0090-4295(02)02146-5
TABLE I. Age distribution and number of repairs for urethrocutaneous fistulas Patients (n ⴝ 28)
Age (yr)
Procedures (n ⴝ 50)
4 5 5 9 3 1 1
3 3 4 4 8 15 18
1 3 4 6 9 12 15
and the outcome of secondary repair of the failed fistula closure. MATERIAL AND METHODS We reviewed the records of 28 children between 28 months and 19 years of age, who underwent surgery between January 1990 and December 1998. We performed the primary hypospadias repair in 7 children, and 21 children were referred after surgery elsewhere. In all patients, urethrocutaneous fistulas developed postoperatively, and the number of operations for their closure ranged from 2 to 15 attempts (Table I). In 17 children, a single large fistula was present, and in 11 children, multiple fistulas were present. The causes of failure based on the chart review were believed to be the fistula site in 12 (coronal fistulas), urethral diverticula in 7, and distal urethral strictures in 4 cases. In 5 children, the cause of fistula formation was unclear (Table II). Fistula repair was performed 6 months after hypospadias surgery, when the tissue was supple and not indurated or inflamed on examination. Treatment success was defined as the absence of a urethrocutaneous stricture or recurrent fistula and a cosmetically favorable reconstruction. Functionally, a uniform and straight urinary stream of adequate caliber for the patient’s age was required to categorize a repair as successful. Follow-up ranged from 1.5 to 10.5 years (median 6).
RESULTS Coronal fistulas were found in 12 children. They were converted to coronal hypospadias by dividing the bridge of tissue between the fistula and the meatus. After dividing the inadequately vascularized glans bridge, a redo of the glansplasty was performed in the same setting. Then, the urethral plate was tubularized using a wider strip (Thiersch tube) with a midline relaxing incision (ReddySnodgrass) in 3 and without the incision in 9 children. Of the 12 repairs, 11 (92%) 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. The diverticulum was excised, and a multilayer closure was performed. Overlapping suture lines were avoided to prevent an epithelial connection between the reconstructed urethra and the skin. All these repairs were successful (voiding well and no stricture or fistula). UROLOGY 61 (2), 2003
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 children achieved a successful outcome. In all fistula repairs, 6-0 or 7-0 Vicryl suture was used for the repair of the urethra, as well as the covering skin flaps. 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. Therefore, we used Dartos flaps to cover the repair in 18 patients and tunica vaginalis flaps in 6 children. The hairless scrotal island or rotational scrotal flap is more reliable for these cases. When repairing recurrent urethral fistulas, the principles of unopposed suture lines and the interposition of Dartos or tunica vaginalis flaps between suture lines are important aspects of a successful repair. The use of catheters for urinary diversion varied dependent on the nature of the case. In simple cases (eg, tubularization), a urethral catheter was left in place for 2 to 5 days. In more complex cases (eg, onlay flaps or buccal mucosal grafts), a urethral stent was left in place for 7 to 9 days. COMMENT Hypospadias surgery is not free of complications, and fistula formation is one of the most frequent. The reported incidence of fistula formation in published reports varies considerably, depending on the severity of the initial deformity (0% to 50%).1–3 Because fistula formation after hypospadias repair continues to be a frustrating complication, surgeons have evaluated their technique, as well as the possible underlying causes that may put the patient at risk of a postoperative fistula.4 Secrest et al.1 reported on the successful urethrocutaneous fistula repair in 53 (91.4%) of 58 patients after hypospadias repair. The investigators emphasized the use of magnification. From a technical standpoint, we do not believe that the use of a microscopic repair will give an advantage over Loupe magnification and routinely use 3.5-fold Loupe magnification. Concerning the use of stents, our approach has been to stent only in complex repairs, as suggested by Waterman et al.4 A recurrent urethral fistula after hypospadias repair may be the manifestation of another underlying problem, such as a urethral stricture and/or a urethral diverticulum. Distal urethral obstruction can lead to increased pressure in the proximal urethra, with subsequent leakage of urine through the suture line.5 Urethral dilation/diverticulum causes a turbulent flow of urine and increases the incidence of fistula formation.5 Intraoperative calibra449
TABLE II. Etiology of urethrocutaneous fistulas after hypospadias repair, method of repair, and outcome Etiology
Patients (n)
Procedure
Coronal hypospadias
12
Urethral diverticulum
7
Transformation into coronal hypospadias; Thiersch-tube-repair with (n ⫽ 3) and without (n ⫽ 9) relaxing midline incision Excision and multilayer closure (n ⫽ 7)
Distal urethral stricture
4
Island-onlay flap (n ⫽ 2)
Other
5
Buccal mucosal graft (n ⫽ 2) Excision and multilayer closure (n ⫽ 5)
tion of the distal urethra and distension of the repaired hypospadias to search for a diverticulum or stenosis are therefore recommended.6 – 8 Coronal fistulas are notoriously difficult to repair by layered closure, because the distal glandular tissue is fixed.4 This often causes some degree of tension on the suture line, hence the high failure rate of coronal fistula repairs. In our experience, 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. The Thiersch tube repair with or without the relaxing urethral plate incision, as described by Reddy,8 Rich et al.,9 and Snodgrass,10 had a success rate of 92%. In resurfacing the operative site, the traditional transposition flaps (Y-V and advancement), as described by Saad et al.11 and Moscone et al.,12 may be unreliable, because their vascularity may be compromised by previous surgery. The hairless scrotal island or rotation scrotal flaps are more reliable for these cases, because these are random flaps with a good vascular supply, provided a width/length ratio of 1:2 is maintained. If local tissue cannot be used because of extensive scar formation or a compromised vascular supply, buccal mucosal grafts provide a reliable option for repair of urethrocutaneous fistulas.13–16 Researchers from Mainz described the technique of buccal mucosal grafting after experiments on dogs in 6 patients, without evidence of stricture or fistula formation.13 A report from the same group in 1998 demonstrated the successful use of buccal mucosal grafts in 62 children with complex hypospadia repairs followed up for 23 months.16 Two of our patients who developed urethrocutaneous fistulas in conjunction with distal urethral stenoses required buccal mucosa onlay grafts. Both 450
Result 11/12 without recurrence; good functional result; wound separation in 1 case with formation of a megameatus All without recurrence; good functional result All without recurrence; good functional result All without recurrence; good functional result
children experienced cosmetically and functionally favorable results. Finally, when repairing recurrent urethral fistulas, a meticulous suture technique is important. If the suture passes through the urethral epithelium or epidermis, urine leakage under the skin flap may result. We try to avoid long through-and-through suture lines during the primary hypospadias repair. Instead, we prefer a subcuticular suture whenever possible. The principles of unopposed suture lines and interposition of Dartos or tunica vaginalis flaps between suture lines are additional important considerations for a successful outcome.17–19 With strict adherence to plastic surgery principles of avoiding overlapping suture lines and a search for possible underlying factors, such as a urethral diverticulum or distal urethral stricture, a successful repair of a urethrocutaneous fistula can be performed. REFERENCES 1. Secrest CL, Jordan GH, Winslow BH, et al: Repair of the complications of hypospadias surgery. J Urol 150: 1415–1418, 1993. 2. Smith PJB, Townsend PLG, Hiles JRW, et al: Hypospadias—problems of postoperative fistula formation and a modified 2-stage procedure to reduce these. Br J Urol 48: 703–707, 1976. 3. Kass EJ, and Bolong D: Single stage hypospadias reconstruction without fistula. J Urol 144: 520 –522, 1990. 4. Waterman BJ, Renschler T, Cartwright PC, et al: Variables in successful repair of urethrocutaneous fistula after hypospadias surgery. J Urol 168: 726 –730, 2002. 5. Scherz HC, Kaplan GW, Packer MG, et al: Post-hypospadias repair of urethral strictures: a review of 30 cases. J Urol 140: 1253–1255, 1988. 6. Lau JT, and Ong GB: Double-breasted technique for the repair of urethral fistulas after hypospadias repair. Br J Urol 54: 111–113, 1982. 7. Lau JT, Saing H, Tam PK, et al: Interposing fascial pedicle flap for the repair of urethral fistulae after hypospadias surgery. Plast Reconstr Surg 70: 206 –209, 1982. UROLOGY 61 (2), 2003
8. Reddy LN: One-stage repair of hypospadias. Urology 5: 475–478, 1975. 9. Rich MA, Keating MA, Snyder HM, et al: Hinging the urethral plate in hypospadias meatoplasty. J Urol 142: 1551– 1553, 1989. 10. Snodgrass W: Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 151: 464 –465, 1994. 11. Saad MN, Khoo CT, and Lochaitis AS: A simple technique for repair of urethral fistulae by Y-V-advancement. Br J Plast Surg 33: 410 –412, 1984. 12. Moscone AR, Govrin-Yehudain J, and Hirshowitz B: Closure of urethral fistulae by transverse Y-V-advancement flap. Br J Urol 56: 313–315, 1984. 13. Burger RA, Muller S, Damanhoury HE, et al: Buccal mucosal graft for urethral reconstruction: a preliminary report. J Urol 147: 662–664, 1992. 14. Ahmed S, and Gough DC: Buccal mucosal graft for sec-
UROLOGY 61 (2), 2003
ondary hypospadias repair urethral replacement. Br J Urol 80: 328 –330, 1997. 15. Burger RA, Muller SC, El-Damanhonny H, et al: The buccal mucosal graft for urethral reconstruction: a preliminary report. J Urol 147: 662–664, 1995. 16. Fichtner J, Fisch M, Filipas D, et al: Refinements in buccal mucosal graft urethroplasty for hypospadias repair. World J Urol 16: 192–194, 1998. 17. Majesky I, Stojkovic J, Payer J. Zum Verschluss von Fisteln nach denis-Browne’scher Hypospadie-Korrektur. Urol Int 24: 135–138, 1969. 18. Hinderer UT: Secondary repair of hypospadias failures: another use of the penis tunnelization technique. Plast Reconstr Surg 50: 13–24, 1972. 19. Fatah MF: A method of closing urethral fistulae using a purse-string or interrupted silk sutures. Br J Plast Surg 35: 102–103, 1982.
451
MANAGEMENT OF RECURRENT URETHRAL FISTULAS AFTER HYPOSPADIAS REPAIR FRANK RICHTER, PETER A. PINTO, JEFFREY A. STOCK,
AND
MONEER K. HANNA
ABSTRACT 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. UROLOGY 61: 448–451, 2003. © 2003, Elsevier Science Inc.
U
rethrocutaneous fistulas may complicate any form of hypospadias repair, but in most cases can be closed successfully. However, a recurrent fistula is a frustrating complication for the child, From the Section of Urology, University of Medicine and Dentistry-New Jersey Medical School, Newark, New Jersey; Department of Urology, Long Island Jewish Medical Center, Brooklyn, New York; Childrens Hospital of New Jersey, St. Barnabas Medical Center, Livingston, New Jersey; and New York Hospital Cornell Medical Center, New York, New York Reprint requests: Frank Richter, M.D., Department of Urology, Humboldt University (Charite) Berlin, Schumannstrasse 20-22, Berlin 10117, Germany Submitted: March 13, 2002, accepted (with revisions): September 9, 2002
448
© 2003, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
parents, and surgeon. Their reported incidence varies from 5% to as much as 55%, depending on the severity of the initial deformity.1,2 Kass and Bolong3 reported on about 206 primary hypospadias repairs, with only one fistula in a case of perineal hypospadias. The investigators stressed the importance of single-stage reconstruction and a two-layer closure of the neourethra. However, urethrocutaneous fistulas after hypospadias repair remain a problem, even with meticulous surgical technique, and may be the reflection of another underlying cause, such as a urethral diverticulum or a distal urethral stricture.4 We report on our experience in the management of recurrent urethrocutaneous fistulas to understand the etiology 0090-4295/03/$30.00 doi:10.1016/S0090-4295(02)02146-5
TABLE I. Age distribution and number of repairs for urethrocutaneous fistulas Patients (n ⴝ 28)
Age (yr)
Procedures (n ⴝ 50)
4 5 5 9 3 1 1
3 3 4 4 8 15 18
1 3 4 6 9 12 15
and the outcome of secondary repair of the failed fistula closure. MATERIAL AND METHODS We reviewed the records of 28 children between 28 months and 19 years of age, who underwent surgery between January 1990 and December 1998. We performed the primary hypospadias repair in 7 children, and 21 children were referred after surgery elsewhere. In all patients, urethrocutaneous fistulas developed postoperatively, and the number of operations for their closure ranged from 2 to 15 attempts (Table I). In 17 children, a single large fistula was present, and in 11 children, multiple fistulas were present. The causes of failure based on the chart review were believed to be the fistula site in 12 (coronal fistulas), urethral diverticula in 7, and distal urethral strictures in 4 cases. In 5 children, the cause of fistula formation was unclear (Table II). Fistula repair was performed 6 months after hypospadias surgery, when the tissue was supple and not indurated or inflamed on examination. Treatment success was defined as the absence of a urethrocutaneous stricture or recurrent fistula and a cosmetically favorable reconstruction. Functionally, a uniform and straight urinary stream of adequate caliber for the patient’s age was required to categorize a repair as successful. Follow-up ranged from 1.5 to 10.5 years (median 6).
RESULTS Coronal fistulas were found in 12 children. They were converted to coronal hypospadias by dividing the bridge of tissue between the fistula and the meatus. After dividing the inadequately vascularized glans bridge, a redo of the glansplasty was performed in the same setting. Then, the urethral plate was tubularized using a wider strip (Thiersch tube) with a midline relaxing incision (ReddySnodgrass) in 3 and without the incision in 9 children. Of the 12 repairs, 11 (92%) 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. The diverticulum was excised, and a multilayer closure was performed. Overlapping suture lines were avoided to prevent an epithelial connection between the reconstructed urethra and the skin. All these repairs were successful (voiding well and no stricture or fistula). UROLOGY 61 (2), 2003
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 children achieved a successful outcome. In all fistula repairs, 6-0 or 7-0 Vicryl suture was used for the repair of the urethra, as well as the covering skin flaps. 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. Therefore, we used Dartos flaps to cover the repair in 18 patients and tunica vaginalis flaps in 6 children. The hairless scrotal island or rotational scrotal flap is more reliable for these cases. When repairing recurrent urethral fistulas, the principles of unopposed suture lines and the interposition of Dartos or tunica vaginalis flaps between suture lines are important aspects of a successful repair. The use of catheters for urinary diversion varied dependent on the nature of the case. In simple cases (eg, tubularization), a urethral catheter was left in place for 2 to 5 days. In more complex cases (eg, onlay flaps or buccal mucosal grafts), a urethral stent was left in place for 7 to 9 days. COMMENT Hypospadias surgery is not free of complications, and fistula formation is one of the most frequent. The reported incidence of fistula formation in published reports varies considerably, depending on the severity of the initial deformity (0% to 50%).1–3 Because fistula formation after hypospadias repair continues to be a frustrating complication, surgeons have evaluated their technique, as well as the possible underlying causes that may put the patient at risk of a postoperative fistula.4 Secrest et al.1 reported on the successful urethrocutaneous fistula repair in 53 (91.4%) of 58 patients after hypospadias repair. The investigators emphasized the use of magnification. From a technical standpoint, we do not believe that the use of a microscopic repair will give an advantage over Loupe magnification and routinely use 3.5-fold Loupe magnification. Concerning the use of stents, our approach has been to stent only in complex repairs, as suggested by Waterman et al.4 A recurrent urethral fistula after hypospadias repair may be the manifestation of another underlying problem, such as a urethral stricture and/or a urethral diverticulum. Distal urethral obstruction can lead to increased pressure in the proximal urethra, with subsequent leakage of urine through the suture line.5 Urethral dilation/diverticulum causes a turbulent flow of urine and increases the incidence of fistula formation.5 Intraoperative calibra449
TABLE II. Etiology of urethrocutaneous fistulas after hypospadias repair, method of repair, and outcome Etiology
Patients (n)
Procedure
Coronal hypospadias
12
Urethral diverticulum
7
Transformation into coronal hypospadias; Thiersch-tube-repair with (n ⫽ 3) and without (n ⫽ 9) relaxing midline incision Excision and multilayer closure (n ⫽ 7)
Distal urethral stricture
4
Island-onlay flap (n ⫽ 2)
Other
5
Buccal mucosal graft (n ⫽ 2) Excision and multilayer closure (n ⫽ 5)
tion of the distal urethra and distension of the repaired hypospadias to search for a diverticulum or stenosis are therefore recommended.6 – 8 Coronal fistulas are notoriously difficult to repair by layered closure, because the distal glandular tissue is fixed.4 This often causes some degree of tension on the suture line, hence the high failure rate of coronal fistula repairs. In our experience, 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. The Thiersch tube repair with or without the relaxing urethral plate incision, as described by Reddy,8 Rich et al.,9 and Snodgrass,10 had a success rate of 92%. In resurfacing the operative site, the traditional transposition flaps (Y-V and advancement), as described by Saad et al.11 and Moscone et al.,12 may be unreliable, because their vascularity may be compromised by previous surgery. The hairless scrotal island or rotation scrotal flaps are more reliable for these cases, because these are random flaps with a good vascular supply, provided a width/length ratio of 1:2 is maintained. If local tissue cannot be used because of extensive scar formation or a compromised vascular supply, buccal mucosal grafts provide a reliable option for repair of urethrocutaneous fistulas.13–16 Researchers from Mainz described the technique of buccal mucosal grafting after experiments on dogs in 6 patients, without evidence of stricture or fistula formation.13 A report from the same group in 1998 demonstrated the successful use of buccal mucosal grafts in 62 children with complex hypospadia repairs followed up for 23 months.16 Two of our patients who developed urethrocutaneous fistulas in conjunction with distal urethral stenoses required buccal mucosa onlay grafts. Both 450
Result 11/12 without recurrence; good functional result; wound separation in 1 case with formation of a megameatus All without recurrence; good functional result All without recurrence; good functional result All without recurrence; good functional result
children experienced cosmetically and functionally favorable results. Finally, when repairing recurrent urethral fistulas, a meticulous suture technique is important. If the suture passes through the urethral epithelium or epidermis, urine leakage under the skin flap may result. We try to avoid long through-and-through suture lines during the primary hypospadias repair. Instead, we prefer a subcuticular suture whenever possible. The principles of unopposed suture lines and interposition of Dartos or tunica vaginalis flaps between suture lines are additional important considerations for a successful outcome.17–19 With strict adherence to plastic surgery principles of avoiding overlapping suture lines and a search for possible underlying factors, such as a urethral diverticulum or distal urethral stricture, a successful repair of a urethrocutaneous fistula can be performed. REFERENCES 1. Secrest CL, Jordan GH, Winslow BH, et al: Repair of the complications of hypospadias surgery. J Urol 150: 1415–1418, 1993. 2. Smith PJB, Townsend PLG, Hiles JRW, et al: Hypospadias—problems of postoperative fistula formation and a modified 2-stage procedure to reduce these. Br J Urol 48: 703–707, 1976. 3. Kass EJ, and Bolong D: Single stage hypospadias reconstruction without fistula. J Urol 144: 520 –522, 1990. 4. Waterman BJ, Renschler T, Cartwright PC, et al: Variables in successful repair of urethrocutaneous fistula after hypospadias surgery. J Urol 168: 726 –730, 2002. 5. Scherz HC, Kaplan GW, Packer MG, et al: Post-hypospadias repair of urethral strictures: a review of 30 cases. J Urol 140: 1253–1255, 1988. 6. Lau JT, and Ong GB: Double-breasted technique for the repair of urethral fistulas after hypospadias repair. Br J Urol 54: 111–113, 1982. 7. Lau JT, Saing H, Tam PK, et al: Interposing fascial pedicle flap for the repair of urethral fistulae after hypospadias surgery. Plast Reconstr Surg 70: 206 –209, 1982. UROLOGY 61 (2), 2003
8. Reddy LN: One-stage repair of hypospadias. Urology 5: 475–478, 1975. 9. Rich MA, Keating MA, Snyder HM, et al: Hinging the urethral plate in hypospadias meatoplasty. J Urol 142: 1551– 1553, 1989. 10. Snodgrass W: Tubularized, incised plate urethroplasty for distal hypospadias. J Urol 151: 464 –465, 1994. 11. Saad MN, Khoo CT, and Lochaitis AS: A simple technique for repair of urethral fistulae by Y-V-advancement. Br J Plast Surg 33: 410 –412, 1984. 12. Moscone AR, Govrin-Yehudain J, and Hirshowitz B: Closure of urethral fistulae by transverse Y-V-advancement flap. Br J Urol 56: 313–315, 1984. 13. Burger RA, Muller S, Damanhoury HE, et al: Buccal mucosal graft for urethral reconstruction: a preliminary report. J Urol 147: 662–664, 1992. 14. Ahmed S, and Gough DC: Buccal mucosal graft for sec-
UROLOGY 61 (2), 2003
ondary hypospadias repair urethral replacement. Br J Urol 80: 328 –330, 1997. 15. Burger RA, Muller SC, El-Damanhonny H, et al: The buccal mucosal graft for urethral reconstruction: a preliminary report. J Urol 147: 662–664, 1995. 16. Fichtner J, Fisch M, Filipas D, et al: Refinements in buccal mucosal graft urethroplasty for hypospadias repair. World J Urol 16: 192–194, 1998. 17. Majesky I, Stojkovic J, Payer J. Zum Verschluss von Fisteln nach denis-Browne’scher Hypospadie-Korrektur. Urol Int 24: 135–138, 1969. 18. Hinderer UT: Secondary repair of hypospadias failures: another use of the penis tunnelization technique. Plast Reconstr Surg 50: 13–24, 1972. 19. Fatah MF: A method of closing urethral fistulae using a purse-string or interrupted silk sutures. Br J Plast Surg 35: 102–103, 1982.
451