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Management of Urethrocutaneous Fistulas Following Hypospadias Repair
0022-534 7/83/1304-07 43$02.00/0 Vol. 130, October Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
MANAGEMENT OF URETHROCUTANEOUS FISTULAS FOLLOWING HYPOSPADIAS REPAIR EDWARD M. ZAGULA AND VICTOR BRAREN* From the Section of Surgical Sciences, Department of Urology, Vanderbilt University School of Medicine and Vanderbilt Children's Hospital, Nashville, Tennessee
ABSTRACT
Urethrocutaneous fistulas are one of the major causes of morbidity following hypospadias repair. No matter how well designed the initial hypospadias procedure is, how gently the tissues are handled nor how expertly the procedure is done, fistulas continue to occur at an unacceptably high rate. We review our experience with hypospadias repair, with emphasis directed to the management of urethrocutaneous fistulas. Some tiny fistulas will close on prolonged catheter drainage but our experience shows that most need a definitive closure procedure. Although many procedures have been described for the closure of urethrocutaneous fistulas we advocate use of an advancement flap. Our success rate has been excellent with this procedure. Particular attention to well established techniques of hypospadias repair will decrease the incidence of urethrocutaneous fistulas. It has been reported widely and accepted that repair of hypospadias and chordee must be individualized and tailored to each patient. For this reason there is continual introduction of new procedures and modifications of the "accepted" methods in an attempt to reduce further the various difficulties encountered in hypospadias repair. Despite these efforts, fistulas remain a major cause of morbidity after hypospadias repair. Urethrocutaneous fistulas were the most common cause of failure encountered in a review of hypospadias repair at our center. The incidence has been reported elsewhere to range from 4 to 25 per cent 1 and is usually described as the result of distal obstruction, decreased vascular supply, postoperative edema, overlapping suture lines and epithelium inverted into the lumen. While continuously striving to avoid urethrocutaneous fistulas, efforts must be made to master their correction. No 1 method for repair ofurethrocutaneous fistulas has become universally accepted and the literature is replete with different techniques. Herein we propose a protocol for fistula management. In a recent review of the last 8 years of experience with chordee and hypospadias repair performed at our hospital a total of 117 cases was evaluated. The incidence of fistulas in these patients was 23 per cent. In addition, 5 patients were referred to us with urethrocutaneous fistulas secondary to procedures performed by other surgeons (table 1). In all, 48 fistulas in 32 patients were treated. Depending on the severity of the defect, several fistulas required virtually repeat primary surgery (table 2) or less drastic reconstruction involving only the fistula tract and immediately adjacent skin. The initial success rate with all types of fistula closure was 27 per cent. Four patients still have urethrocutaneous fistulas, and repair is planned for the future. We used a lateral advancement flap technique for repair of 24 fistulas, with a success rate of 67 per cent. We believe that this technique offers the highest success rate. SURGICAL TECHNIQUE
Under endotracheal general anesthesia the child is placed in the dorsal lithotomy position, and surgical scrub and drape preparation are performed in the usual sterile fashion. The genitalia are examined carefully. It is most important that this Accepted for publication March 4, 1983. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 28-April 1, 1982. * Requests for reprints: Department of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232. 743
examination be done under general anesthesia because an office examination, due to lack of patient cooperation or poor lighting, may limit the surgeon's observation of the problems, the most common of which is missing multiple fistulas. The family is informed that the decision for the type of correction is reserved until this anesthetic examination is completed to avoid surprise if a procedure chosen before anesthesia is, in fact, not the operation that was done. Occasionally, we have discovered multiple fistulas and have elected to repair only 1 fistula at a time. Injection of sterile saline into the distal urethra with posterior urethral occlusion is helpful to discover tiny fistulas that otherwise may be missed. The addition of indigo carmine to the solution may aid in TABLE 1.
Population
Total No. pts. reviewed: Operated on at Vanderbilt Referred from outside with urethrocutaneous fistula No. pts. with urethrocutaneous fistulas operated on at Vanderbilt(%) Total No. pts. with urethrocutaneous fistulas Total No. fistulas repaired
TABLE 2.
122 117 5 27 (23)
32 48
Types of repair used for urethrocutaneous fistula closure Advancement flap Simple excision-closure Cecil-Culp Thiersch-Duplay Johanson Davis Other
24 5 5 5 3 2 4
Initial success rate in all types of closure was 27 per cent and success rate for advancement flap technique was 67 per cent.
further clarifying small fistulas. A 3-zero silk suture is placed through the glans penis and left approximately 6 inches long, then clamped with a hemostat and used for upward traction. We have elected to divert the urine in almost all patients by use of standard perineal urethrostomy with a 14F Foley catheter. Attention is then directed toward fistula closure. Depending on the position of the fistula and the penile skin available, an advancement flap is outlined that ends approximately 6 mm. beyond the fistula. The advancement flap itself is usually 1 cm. in each dimension (fig. 1). Dimensions <1 cm. are inadequate, since there will be a high rate of fistula recurrence through the edges of the flap. The use of a sterile surgical marking pen will
744
ZAGULA AND BRAREN
_.__....
I
I
I ....-.. I
~ I
~--: I
FIG. 1. A, fistula is outlined with marking pencil, and area around fistula (at least 5 mm. in any radius from edge of fistula excision) and flap are all undermined. B, all hash marked lines show areas where skin has been removed completely in middle of which fistula has been closed. Again, one should be reminded that minimum acceptable margin from edge of fistula to skin edge is 5 mm. Flap has been undermined completely so that it is mobile in direction of arrow. C, flap has been advanced over fistula and is sewn in place again so that all suture margins of flap are well away from fistula.
FIG. 2. A, "trap door" variation when fistula is large. Procedure begins similarily to figure 1, A except that area of skin outlined on left side of patient is undermined so that it will be flipped over fistula defect. B, skin has been removed completely once again from around fistula except for "trap door," which is undermined and then flipped over and sutured in place. Again, margins from all sides of fistula to skin should never be <5 mm. Flap is then undermined and moved over defect as in figure 1, C.
outline the fistula excision and flap advancement. The area from which the flap will be taken is chosen by the criteria of selecting the most free, least scarred and most mobile tissue. Usually, a lateral or distal-lateral flap is used. Penile skin is best for this, although scrotal skin has been used successfully in many of our cases.
The fistula is then circumscribed and the skin, but not the subcutaneous tissue, is dissected off the penis in an area at least 5 mm. in radius around the fistula. The fistula itself is then cored out down to the urethra, excising the entire fistula tract. It should be pointed out that the fistula tract may be a tiny outpouching of the lumen of the fistula, a long narrow
745 tract or diverticular in nature. "'1,rnsc1.,s,"~'"" the entire fistula tract must be excised. Enough urethral tissue must be left for closure of the lumen without either decreasing the urethral lumen size at that roi·n,,,,.,,,,1v leaving a diverticulum. The urethral defect is VALmce,ccu with 7-zero nolvc.-Ju,~ol acid suture using a Castroviejo needle holder pointing into the urethral lumen. Next, using skin hooks to hold the edges of the previously outlined skin flap, the flap is freed from the surrounding tissue so that it can be advanced easily over the closed fistula. Skin margins of at least 5 mm. in each direction as previously mentioned are obtained. If the best area has been chosen for the flap, preparation of the flap and freedom of its base are usually easy to obtain. The delicate dissection and handling of the skin flap must be emphasized. It should be managed throughout only with skin hooks, never using forceps. The margins of the flap are then sewn in place and anchored using 5-zero polyglycolic acid atraumatic sutures. If the flap and the tissue sunounding the fistula excision are thick enough, subcutaneous sutures are taken first to anchor the flap and then the skin layer is dosed separately. This will vary depending on the location of the fistula and the thickness of the perifistula skin and tissue of the flap. Closure of each edge of the flap to the penile skin is then accomplished with the same suture. The wound is dressed with povidone-iodine ointment and an appropriate-sized compression dressing is applied. We believe that the best dressing for this is fine mesh cotton gauze cotton fluffs and elastic wrapped around the penis followed taping. The is then sutured to the abdomen with the previously mentioned silk stitch, the catheter is hooked to straight drain, and the child is awakened and taken to the recovery room.
e
recurrence. ,_w,!laLur.,,,,,ie; rrorD s::reas urnnvolved in we assure adequate tissue coverage and no suture line apposition. The urethml repair is at least 5 mm. circumferentially from the flap edge this technique. Stenting of the urethra may occasionally be This is indicated if the surgeon is concerned about the size of the lumen or an increased chance of scarring. Small caliber silicone rubber tubing is best for this. It is stressed that this stent should not be a form of catheter drainage, urinary diversion being accomplished proximal to the repair site. Selection of suture material for any surgical technique is a highly individualized matter and depends on the preference and experience of the surgeon. We have been pleased with our results using polyglycolic acid suture for the urethral and skin portions of this procedure. This suture material is absorbed by hydrolysis and we have had no problems with the absorption of the urethral suture, probably because it is so small. Occasionally, the larger 5-zero suture will fail to absorb at the skin and this is simply dipped at a postoperative office visit: the penis is held and with straight Iris scissors the suture is snipped and removed. This occurrence has not been a problem in any of our cases. The dressing is left intact for 5 days. During this time the patient is able to ambulate. To preserve the original dressing oral paregoric is prescribed to minimize bowel movements. On postoperative day 5 the dressing is removed completely and if the repair is healing well the urethrostomy catheter is removed, In some cases the catheter remains for a few more days. When the patient voids he is discharged from the hospital on antiseptics. Initial visit is 2 weeks later.
Dr. Robert K. Rhamy allowed us to include his patients in this study.
DISCUSSION
When fistulas first appear many surgeons advocate prolonged catheter drainage and observation or immediate closure. If the fistula is small immediate closure may be accomplished under local anesthesia, Others have advocated the approximation of the skin edges of the fistula with sterile strips. 2 We have found that these 3 techniques are manifestly unsuccessful. If this initial attempt fails to resolve the problem a minimum of 6 months is allowed for maturation of the tissues, bringing about resolution of edema and inflammation. Then the surgeon may perform a definitive fistula closure. Preoperative calibration of the methra is done to rule out obstruction. As mentioned previously, the surgeon must the attention to the of multiple u:-,,,ma:o, we believe the basic tenets that to fistula are delicate tissue inversion urethral mucosa, the urethra SO as not to the lumen the fistula with well vascularized skin, suture lines and diversion of the the fistula site for a minimum of 5 days. tissue is not available for urethral closure a door" variation of the technique can be used (fig, is not acceptable one must then use a more radical is Cecil-Culp 01' Denis-Browne n,-,oHw,ml There are several methods avail.able to cover the fistula. 3-s We advocate the advancement flap technique because we are able to cover the defect with an unscarred, well vascularized layer of subcutaneous tissue and skin in such a way that no suture lines overlap. While there are those who suggest closure by multiple layers of subcutaneous tissue, we believe that this only opens the possibility of suture line overlap and, hence, uu,u~,u•,•F,;
REFERENCES
L Creevy, C, D.: The correction of hypospadias: a review. UroL Smv., 8: 2, 1958. 2, Culp, 0, S" Struggles and triumphs with hypospadias and associated anomalies: review of 400 cases. J. Ul'ol., 96: 339, 1966. 3. Devine, C. J., Jr., Franz, J. P, and Ho1ton, C. K: Evaluation and treatment of patients with failed hypospadias repair. J, UroL, 119: 223, 1978. 4, Duckett, J, W., Jr., Kaplan, G, W., Woodard, J. R. and J., Jr.: Panel: complications of hypospadias repair, UroL N. Amer., 7: 443, 1980. 5, Duckett, cl. W.: Hypospadias, Clin, P!ast. Surg., 7: 149, 1980. 6, Goldstein, H, R. and Hensle, T, W,: Simplified closure of hypofistu!as. Urolog-y, Hl: 504, 198L 7, RD,: ;:epair of urethral fistulae. Urol. Clin. N.
Amer., 8: 8. Smith, K D.: use of a ae1,piirnimm2:eo in the repair of hypospadias,
f'ATI<'HW,Sm
~u,vv,,~u,vv
EDITORIAL COMMENT The authors have chosen to update and carefully technique ofCreevy to achieve a successful 1muu,s;~rn,,ac noxious problem (reference 1 in articie), This, coupled the Davis technique,
the work of Walker (reference 7 in article) and Smith (reference 8 in article) will provide any surgeon with an appropriate armamentarium for success. With fmther extension of these skills, patient selection and preservation of vessels I would anticipate that the incidence of fistulas would decrease to low percentages and secondary repair, when necessary, would succeed in the upper 90 percentage. Norman B. Hodgson Department of Urology Medical College of Wisconsin Milwaukee, Wisconsin
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
MANAGEMENT OF URETHROCUTANEOUS FISTULAS FOLLOWING HYPOSPADIAS REPAIR EDWARD M. ZAGULA AND VICTOR BRAREN* From the Section of Surgical Sciences, Department of Urology, Vanderbilt University School of Medicine and Vanderbilt Children's Hospital, Nashville, Tennessee
ABSTRACT
Urethrocutaneous fistulas are one of the major causes of morbidity following hypospadias repair. No matter how well designed the initial hypospadias procedure is, how gently the tissues are handled nor how expertly the procedure is done, fistulas continue to occur at an unacceptably high rate. We review our experience with hypospadias repair, with emphasis directed to the management of urethrocutaneous fistulas. Some tiny fistulas will close on prolonged catheter drainage but our experience shows that most need a definitive closure procedure. Although many procedures have been described for the closure of urethrocutaneous fistulas we advocate use of an advancement flap. Our success rate has been excellent with this procedure. Particular attention to well established techniques of hypospadias repair will decrease the incidence of urethrocutaneous fistulas. It has been reported widely and accepted that repair of hypospadias and chordee must be individualized and tailored to each patient. For this reason there is continual introduction of new procedures and modifications of the "accepted" methods in an attempt to reduce further the various difficulties encountered in hypospadias repair. Despite these efforts, fistulas remain a major cause of morbidity after hypospadias repair. Urethrocutaneous fistulas were the most common cause of failure encountered in a review of hypospadias repair at our center. The incidence has been reported elsewhere to range from 4 to 25 per cent 1 and is usually described as the result of distal obstruction, decreased vascular supply, postoperative edema, overlapping suture lines and epithelium inverted into the lumen. While continuously striving to avoid urethrocutaneous fistulas, efforts must be made to master their correction. No 1 method for repair ofurethrocutaneous fistulas has become universally accepted and the literature is replete with different techniques. Herein we propose a protocol for fistula management. In a recent review of the last 8 years of experience with chordee and hypospadias repair performed at our hospital a total of 117 cases was evaluated. The incidence of fistulas in these patients was 23 per cent. In addition, 5 patients were referred to us with urethrocutaneous fistulas secondary to procedures performed by other surgeons (table 1). In all, 48 fistulas in 32 patients were treated. Depending on the severity of the defect, several fistulas required virtually repeat primary surgery (table 2) or less drastic reconstruction involving only the fistula tract and immediately adjacent skin. The initial success rate with all types of fistula closure was 27 per cent. Four patients still have urethrocutaneous fistulas, and repair is planned for the future. We used a lateral advancement flap technique for repair of 24 fistulas, with a success rate of 67 per cent. We believe that this technique offers the highest success rate. SURGICAL TECHNIQUE
Under endotracheal general anesthesia the child is placed in the dorsal lithotomy position, and surgical scrub and drape preparation are performed in the usual sterile fashion. The genitalia are examined carefully. It is most important that this Accepted for publication March 4, 1983. Read at annual meeting of Southeastern Section, American Urological Association, New Orleans, Louisiana, March 28-April 1, 1982. * Requests for reprints: Department of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232. 743
examination be done under general anesthesia because an office examination, due to lack of patient cooperation or poor lighting, may limit the surgeon's observation of the problems, the most common of which is missing multiple fistulas. The family is informed that the decision for the type of correction is reserved until this anesthetic examination is completed to avoid surprise if a procedure chosen before anesthesia is, in fact, not the operation that was done. Occasionally, we have discovered multiple fistulas and have elected to repair only 1 fistula at a time. Injection of sterile saline into the distal urethra with posterior urethral occlusion is helpful to discover tiny fistulas that otherwise may be missed. The addition of indigo carmine to the solution may aid in TABLE 1.
Population
Total No. pts. reviewed: Operated on at Vanderbilt Referred from outside with urethrocutaneous fistula No. pts. with urethrocutaneous fistulas operated on at Vanderbilt(%) Total No. pts. with urethrocutaneous fistulas Total No. fistulas repaired
TABLE 2.
122 117 5 27 (23)
32 48
Types of repair used for urethrocutaneous fistula closure Advancement flap Simple excision-closure Cecil-Culp Thiersch-Duplay Johanson Davis Other
24 5 5 5 3 2 4
Initial success rate in all types of closure was 27 per cent and success rate for advancement flap technique was 67 per cent.
further clarifying small fistulas. A 3-zero silk suture is placed through the glans penis and left approximately 6 inches long, then clamped with a hemostat and used for upward traction. We have elected to divert the urine in almost all patients by use of standard perineal urethrostomy with a 14F Foley catheter. Attention is then directed toward fistula closure. Depending on the position of the fistula and the penile skin available, an advancement flap is outlined that ends approximately 6 mm. beyond the fistula. The advancement flap itself is usually 1 cm. in each dimension (fig. 1). Dimensions <1 cm. are inadequate, since there will be a high rate of fistula recurrence through the edges of the flap. The use of a sterile surgical marking pen will
744
ZAGULA AND BRAREN
_.__....
I
I
I ....-.. I
~ I
~--: I
FIG. 1. A, fistula is outlined with marking pencil, and area around fistula (at least 5 mm. in any radius from edge of fistula excision) and flap are all undermined. B, all hash marked lines show areas where skin has been removed completely in middle of which fistula has been closed. Again, one should be reminded that minimum acceptable margin from edge of fistula to skin edge is 5 mm. Flap has been undermined completely so that it is mobile in direction of arrow. C, flap has been advanced over fistula and is sewn in place again so that all suture margins of flap are well away from fistula.
FIG. 2. A, "trap door" variation when fistula is large. Procedure begins similarily to figure 1, A except that area of skin outlined on left side of patient is undermined so that it will be flipped over fistula defect. B, skin has been removed completely once again from around fistula except for "trap door," which is undermined and then flipped over and sutured in place. Again, margins from all sides of fistula to skin should never be <5 mm. Flap is then undermined and moved over defect as in figure 1, C.
outline the fistula excision and flap advancement. The area from which the flap will be taken is chosen by the criteria of selecting the most free, least scarred and most mobile tissue. Usually, a lateral or distal-lateral flap is used. Penile skin is best for this, although scrotal skin has been used successfully in many of our cases.
The fistula is then circumscribed and the skin, but not the subcutaneous tissue, is dissected off the penis in an area at least 5 mm. in radius around the fistula. The fistula itself is then cored out down to the urethra, excising the entire fistula tract. It should be pointed out that the fistula tract may be a tiny outpouching of the lumen of the fistula, a long narrow
745 tract or diverticular in nature. "'1,rnsc1.,s,"~'"" the entire fistula tract must be excised. Enough urethral tissue must be left for closure of the lumen without either decreasing the urethral lumen size at that roi·n,,,,.,,,,1v leaving a diverticulum. The urethral defect is VALmce,ccu with 7-zero nolvc.-Ju,~ol acid suture using a Castroviejo needle holder pointing into the urethral lumen. Next, using skin hooks to hold the edges of the previously outlined skin flap, the flap is freed from the surrounding tissue so that it can be advanced easily over the closed fistula. Skin margins of at least 5 mm. in each direction as previously mentioned are obtained. If the best area has been chosen for the flap, preparation of the flap and freedom of its base are usually easy to obtain. The delicate dissection and handling of the skin flap must be emphasized. It should be managed throughout only with skin hooks, never using forceps. The margins of the flap are then sewn in place and anchored using 5-zero polyglycolic acid atraumatic sutures. If the flap and the tissue sunounding the fistula excision are thick enough, subcutaneous sutures are taken first to anchor the flap and then the skin layer is dosed separately. This will vary depending on the location of the fistula and the thickness of the perifistula skin and tissue of the flap. Closure of each edge of the flap to the penile skin is then accomplished with the same suture. The wound is dressed with povidone-iodine ointment and an appropriate-sized compression dressing is applied. We believe that the best dressing for this is fine mesh cotton gauze cotton fluffs and elastic wrapped around the penis followed taping. The is then sutured to the abdomen with the previously mentioned silk stitch, the catheter is hooked to straight drain, and the child is awakened and taken to the recovery room.
e
recurrence. ,_w,!laLur.,,,,,ie; rrorD s::reas urnnvolved in we assure adequate tissue coverage and no suture line apposition. The urethml repair is at least 5 mm. circumferentially from the flap edge this technique. Stenting of the urethra may occasionally be This is indicated if the surgeon is concerned about the size of the lumen or an increased chance of scarring. Small caliber silicone rubber tubing is best for this. It is stressed that this stent should not be a form of catheter drainage, urinary diversion being accomplished proximal to the repair site. Selection of suture material for any surgical technique is a highly individualized matter and depends on the preference and experience of the surgeon. We have been pleased with our results using polyglycolic acid suture for the urethral and skin portions of this procedure. This suture material is absorbed by hydrolysis and we have had no problems with the absorption of the urethral suture, probably because it is so small. Occasionally, the larger 5-zero suture will fail to absorb at the skin and this is simply dipped at a postoperative office visit: the penis is held and with straight Iris scissors the suture is snipped and removed. This occurrence has not been a problem in any of our cases. The dressing is left intact for 5 days. During this time the patient is able to ambulate. To preserve the original dressing oral paregoric is prescribed to minimize bowel movements. On postoperative day 5 the dressing is removed completely and if the repair is healing well the urethrostomy catheter is removed, In some cases the catheter remains for a few more days. When the patient voids he is discharged from the hospital on antiseptics. Initial visit is 2 weeks later.
Dr. Robert K. Rhamy allowed us to include his patients in this study.
DISCUSSION
When fistulas first appear many surgeons advocate prolonged catheter drainage and observation or immediate closure. If the fistula is small immediate closure may be accomplished under local anesthesia, Others have advocated the approximation of the skin edges of the fistula with sterile strips. 2 We have found that these 3 techniques are manifestly unsuccessful. If this initial attempt fails to resolve the problem a minimum of 6 months is allowed for maturation of the tissues, bringing about resolution of edema and inflammation. Then the surgeon may perform a definitive fistula closure. Preoperative calibration of the methra is done to rule out obstruction. As mentioned previously, the surgeon must the attention to the of multiple u:-,,,ma:o, we believe the basic tenets that to fistula are delicate tissue inversion urethral mucosa, the urethra SO as not to the lumen the fistula with well vascularized skin, suture lines and diversion of the the fistula site for a minimum of 5 days. tissue is not available for urethral closure a door" variation of the technique can be used (fig, is not acceptable one must then use a more radical is Cecil-Culp 01' Denis-Browne n,-,oHw,ml There are several methods avail.able to cover the fistula. 3-s We advocate the advancement flap technique because we are able to cover the defect with an unscarred, well vascularized layer of subcutaneous tissue and skin in such a way that no suture lines overlap. While there are those who suggest closure by multiple layers of subcutaneous tissue, we believe that this only opens the possibility of suture line overlap and, hence, uu,u~,u•,•F,;
REFERENCES
L Creevy, C, D.: The correction of hypospadias: a review. UroL Smv., 8: 2, 1958. 2, Culp, 0, S" Struggles and triumphs with hypospadias and associated anomalies: review of 400 cases. J. Ul'ol., 96: 339, 1966. 3. Devine, C. J., Jr., Franz, J. P, and Ho1ton, C. K: Evaluation and treatment of patients with failed hypospadias repair. J, UroL, 119: 223, 1978. 4, Duckett, J, W., Jr., Kaplan, G, W., Woodard, J. R. and J., Jr.: Panel: complications of hypospadias repair, UroL N. Amer., 7: 443, 1980. 5, Duckett, cl. W.: Hypospadias, Clin, P!ast. Surg., 7: 149, 1980. 6, Goldstein, H, R. and Hensle, T, W,: Simplified closure of hypofistu!as. Urolog-y, Hl: 504, 198L 7, RD,: ;:epair of urethral fistulae. Urol. Clin. N.
Amer., 8: 8. Smith, K D.: use of a ae1,piirnimm2:eo in the repair of hypospadias,
f'ATI<'HW,Sm
~u,vv,,~u,vv
EDITORIAL COMMENT The authors have chosen to update and carefully technique ofCreevy to achieve a successful 1muu,s;~rn,,ac noxious problem (reference 1 in articie), This, coupled the Davis technique,
the work of Walker (reference 7 in article) and Smith (reference 8 in article) will provide any surgeon with an appropriate armamentarium for success. With fmther extension of these skills, patient selection and preservation of vessels I would anticipate that the incidence of fistulas would decrease to low percentages and secondary repair, when necessary, would succeed in the upper 90 percentage. Norman B. Hodgson Department of Urology Medical College of Wisconsin Milwaukee, Wisconsin