- Email: [email protected]
Temporary re-catheterization as a treatment for early fistulas after hypospadias repair
Accepted Manuscript Temporary re-catheterization as a treatment for early fistulas after hypospadias repair V.V.S. Chandrasekharam PII:
S1477-5131(16)00017-6
DOI:
10.1016/j.jpurol.2016.01.005
Reference:
JPUROL 2112
To appear in:
Journal of Pediatric Urology
Received Date: 20 August 2015 Accepted Date: 18 January 2016
Please cite this article as: Chandrasekharam VVS, Temporary re-catheterization as a treatment for early fistulas after hypospadias repair, Journal of Pediatric Urology (2016), doi: 10.1016/j.jpurol.2016.01.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI PT
Temporary re-catheterization as a treatment for early fistulas after hypospadias repair V. V. S. Chandrasekharam a,* a
Pediatric Surgery, Pediatric Urology & MAS, Rainbow Children’s Hsopitals, Hyderabad, Telangana, India
AC C
EP
TE D
M AN U
E-mail address: [email protected]
SC
*Corresponding author: Pediatric Surgery, Pediatric Urology & MAS, Rainbow Children’s Hsopitals, Hyderabad, Telangana, India. Phone Office: 91 40 44665555; mobile: 91 9849010175.
ACCEPTED MANUSCRIPT
Summary Objective: To present the results of temporary urethral re-catheterization in order to
RI PT
aid spontaneous closure of early fistulas after hypospadias repair.
Methods and technique: Children presenting with early fistulas (within 2 weeks of initial catheter removal) after hypospadias repair underwent urethral calibration and re-insertion of a urethral catheter under intravenous anesthesia. The catheter was
SC
removed after 2 weeks.
Results: Nine children (age 1-9 years) with early fistulas had re-catheterization: six
M AN U
(66%) had spontaneous healing of the fistula by 2 weeks, which remained closed at subsequent follow-up.
Conslusion: The simple technique of urethral re-catheterization may allow
TE D
spontaneous healing of some early fistulas after hypospadias repair.
AC C
EP
Keywords: Hypospadias; Fistula; Catheter; Early
ACCEPTED MANUSCRIPT
Introduction Urethro-cutaneous fistula (UCF) is the commonest complication after hypospadias repair [1,2]. Traditionally, UCFs are surgically repaired after 6-12 months [1,2]. Many UCFs present early after surgery [3]; they may be caused by infection, tissue edema or other technical reasons and, in most cases, the fistula tract is not yet completely
RI PT
epithelized [3,4]. In the present study, it was hypothesized that early re-catheterization of the urethra may aid the UCF to heal spontaneously before it becomes epithelized;
SC
the results of this approach are presented.
Methods
All children who underwent hypospadias repair and presented with UCF within 2
M AN U
weeks after initial catheter removal (the catheter is routinely kept in for 7-10 days after primary hypospadias repair) were subjected to urethral calibration and reinsertion of urethral catheter. Under intravenous anesthesia, the urethra was gently calibrated (up to 8-10 F) with metal dilators; no attempt was made to force the dilators. After calibration, an 8-10 F silicone Foley catheter was inserted
TE D
transurethrally into the bladder. The cases with overt wound infections received appropriate antibiotics; others received co-trimoxazole prophylaxis while the catheter was in place. All children received oral anticholinergic medication for 2 weeks. The catheter was removed after 2 weeks, and the children were followed after 1 month, 3
EP
months and yearly thereafter. The closure or persistence of fistula was noted based on
AC C
history and clinical examination.
Results
Over a 2.9-year period, 10 children (aged 1-9 years) presented with early UCF following hypospadias repair; two of them had clinical evidence of wound infection. The size of the fistula ranged from 2-4 mm. Urethral calibration and re-catheterization were successfully performed in nine children; in one child, the dilator could not be easily passed into the proximal urethra, hence, the procedure was abandoned. The initial procedure for hypospadias repair and the location of the fistula are summarized in Table 1. After removal of the catheter, the fistula was healed in six of the nine
ACCEPTED MANUSCRIPT children (66%) at 1-month follow-up, and remained closed at subsequent (3-24 months) follow-up. Of the three children with persistent UCF, two were surgically closed 6 months after the primary repair, while one child was awaiting surgery.
RI PT
Discussion
Lapointe, et al. [4] treated early UCFs by cyanoacrylate glue application, followed by an indwelling urethral catheter for 7 days, and reported success in 62.5% cases. In the present study, simple re-catheterization for 2 weeks also resulted in similar success
SC
with spontaneous UCF closure. Temporary re-catheterization may help spontaneous UCF closure in many ways: it gives rest to the neourethral suture line, keeps the UCF dry, gives time for neourethral edema and inflammation to subside, and allows
M AN U
healing of infected wounds. Daher, et al. [5] reported that following primary hypospadias repair, 3-weeks of catheterization resulted in significantly less complications than 1-week of catheterization. Experimental studies have also demonstrated that urethral healing is a slow process and may continue for 21 days [5]. Thus, at least in some cases, increasing the duration of catheterization may help better
TE D
healing of the neourethra.
In conclusion, this simple technique may allow spontaneous healing of some early
EP
UCFs, thus avoiding another formal surgical procedure in these children.
Conflict of interest: nil.
AC C
Funding: nil.
Ethical approval: none required.
RI PT
ACCEPTED MANUSCRIPT
References
1. Muruganandham K, Ansari MS, Dubey D, Mandhani A, Srivastava A, Kapoor
SC
R, et al. Urethrocutaneous fistula after hypospadias repair: outcome
of three types of closure techniques. Pediatr Surg Int 2010; 26: 305-8.
2. Elbakry A Management of urethrocutaneous fistula after hypospadias
M AN U
repair: 10 years’ experience. BJU Int 2001; 88: 590-5.
3. Wood HM, Kay R, Angermeier KW, Ross JH. Timing of the presentation of urethrocutaneous fistulas after hypospadias repair in pediatric patients. J Urol 2008; 180: 1753-6.
4. Lapointe SP, N-Fekete C, Lortat-Jacob S. Early closure of fistula after hypospadias
TE D
surgery using N-Butyl Cyanoacrylate: preliminary results. J Urol 2002; 168: 1751-3. 5. Daher P, Khoury A, Riachy E, Atallah B. Three-week or one-week catheterization for hypospadias repair: a retrospective-prospective study of 189 patients. J Pediatr
AC C
EP
Surg 2015; 50: 1063-66.
ACCEPTED MANUSCRIPT Table 1.
Location of fistula
9
6
Success of recatheterization (%) 60 75 50 66 100 66
AC C
EP
TE D
M AN U
SC
Total
Closed after recatheterizaion (n) 3 3 2 2 2
RI PT
Initial procedure
Number of cases (n) Duplay 5 Onlay island flap 4 Coronal 4 Midpenile 3 Penoscrotal 2
S1477-5131(16)00017-6
DOI:
10.1016/j.jpurol.2016.01.005
Reference:
JPUROL 2112
To appear in:
Journal of Pediatric Urology
Received Date: 20 August 2015 Accepted Date: 18 January 2016
Please cite this article as: Chandrasekharam VVS, Temporary re-catheterization as a treatment for early fistulas after hypospadias repair, Journal of Pediatric Urology (2016), doi: 10.1016/j.jpurol.2016.01.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI PT
Temporary re-catheterization as a treatment for early fistulas after hypospadias repair V. V. S. Chandrasekharam a,* a
Pediatric Surgery, Pediatric Urology & MAS, Rainbow Children’s Hsopitals, Hyderabad, Telangana, India
AC C
EP
TE D
M AN U
E-mail address: [email protected]
SC
*Corresponding author: Pediatric Surgery, Pediatric Urology & MAS, Rainbow Children’s Hsopitals, Hyderabad, Telangana, India. Phone Office: 91 40 44665555; mobile: 91 9849010175.
ACCEPTED MANUSCRIPT
Summary Objective: To present the results of temporary urethral re-catheterization in order to
RI PT
aid spontaneous closure of early fistulas after hypospadias repair.
Methods and technique: Children presenting with early fistulas (within 2 weeks of initial catheter removal) after hypospadias repair underwent urethral calibration and re-insertion of a urethral catheter under intravenous anesthesia. The catheter was
SC
removed after 2 weeks.
Results: Nine children (age 1-9 years) with early fistulas had re-catheterization: six
M AN U
(66%) had spontaneous healing of the fistula by 2 weeks, which remained closed at subsequent follow-up.
Conslusion: The simple technique of urethral re-catheterization may allow
TE D
spontaneous healing of some early fistulas after hypospadias repair.
AC C
EP
Keywords: Hypospadias; Fistula; Catheter; Early
ACCEPTED MANUSCRIPT
Introduction Urethro-cutaneous fistula (UCF) is the commonest complication after hypospadias repair [1,2]. Traditionally, UCFs are surgically repaired after 6-12 months [1,2]. Many UCFs present early after surgery [3]; they may be caused by infection, tissue edema or other technical reasons and, in most cases, the fistula tract is not yet completely
RI PT
epithelized [3,4]. In the present study, it was hypothesized that early re-catheterization of the urethra may aid the UCF to heal spontaneously before it becomes epithelized;
SC
the results of this approach are presented.
Methods
All children who underwent hypospadias repair and presented with UCF within 2
M AN U
weeks after initial catheter removal (the catheter is routinely kept in for 7-10 days after primary hypospadias repair) were subjected to urethral calibration and reinsertion of urethral catheter. Under intravenous anesthesia, the urethra was gently calibrated (up to 8-10 F) with metal dilators; no attempt was made to force the dilators. After calibration, an 8-10 F silicone Foley catheter was inserted
TE D
transurethrally into the bladder. The cases with overt wound infections received appropriate antibiotics; others received co-trimoxazole prophylaxis while the catheter was in place. All children received oral anticholinergic medication for 2 weeks. The catheter was removed after 2 weeks, and the children were followed after 1 month, 3
EP
months and yearly thereafter. The closure or persistence of fistula was noted based on
AC C
history and clinical examination.
Results
Over a 2.9-year period, 10 children (aged 1-9 years) presented with early UCF following hypospadias repair; two of them had clinical evidence of wound infection. The size of the fistula ranged from 2-4 mm. Urethral calibration and re-catheterization were successfully performed in nine children; in one child, the dilator could not be easily passed into the proximal urethra, hence, the procedure was abandoned. The initial procedure for hypospadias repair and the location of the fistula are summarized in Table 1. After removal of the catheter, the fistula was healed in six of the nine
ACCEPTED MANUSCRIPT children (66%) at 1-month follow-up, and remained closed at subsequent (3-24 months) follow-up. Of the three children with persistent UCF, two were surgically closed 6 months after the primary repair, while one child was awaiting surgery.
RI PT
Discussion
Lapointe, et al. [4] treated early UCFs by cyanoacrylate glue application, followed by an indwelling urethral catheter for 7 days, and reported success in 62.5% cases. In the present study, simple re-catheterization for 2 weeks also resulted in similar success
SC
with spontaneous UCF closure. Temporary re-catheterization may help spontaneous UCF closure in many ways: it gives rest to the neourethral suture line, keeps the UCF dry, gives time for neourethral edema and inflammation to subside, and allows
M AN U
healing of infected wounds. Daher, et al. [5] reported that following primary hypospadias repair, 3-weeks of catheterization resulted in significantly less complications than 1-week of catheterization. Experimental studies have also demonstrated that urethral healing is a slow process and may continue for 21 days [5]. Thus, at least in some cases, increasing the duration of catheterization may help better
TE D
healing of the neourethra.
In conclusion, this simple technique may allow spontaneous healing of some early
EP
UCFs, thus avoiding another formal surgical procedure in these children.
Conflict of interest: nil.
AC C
Funding: nil.
Ethical approval: none required.
RI PT
ACCEPTED MANUSCRIPT
References
1. Muruganandham K, Ansari MS, Dubey D, Mandhani A, Srivastava A, Kapoor
SC
R, et al. Urethrocutaneous fistula after hypospadias repair: outcome
of three types of closure techniques. Pediatr Surg Int 2010; 26: 305-8.
2. Elbakry A Management of urethrocutaneous fistula after hypospadias
M AN U
repair: 10 years’ experience. BJU Int 2001; 88: 590-5.
3. Wood HM, Kay R, Angermeier KW, Ross JH. Timing of the presentation of urethrocutaneous fistulas after hypospadias repair in pediatric patients. J Urol 2008; 180: 1753-6.
4. Lapointe SP, N-Fekete C, Lortat-Jacob S. Early closure of fistula after hypospadias
TE D
surgery using N-Butyl Cyanoacrylate: preliminary results. J Urol 2002; 168: 1751-3. 5. Daher P, Khoury A, Riachy E, Atallah B. Three-week or one-week catheterization for hypospadias repair: a retrospective-prospective study of 189 patients. J Pediatr
AC C
EP
Surg 2015; 50: 1063-66.
ACCEPTED MANUSCRIPT Table 1.
Location of fistula
9
6
Success of recatheterization (%) 60 75 50 66 100 66
AC C
EP
TE D
M AN U
SC
Total
Closed after recatheterizaion (n) 3 3 2 2 2
RI PT
Initial procedure
Number of cases (n) Duplay 5 Onlay island flap 4 Coronal 4 Midpenile 3 Penoscrotal 2