CORONAL FISTULA REPAIR UNDER THE GLANSWITHOUT REOPERATIVE HYPOSPADIASGLANSPLASTY OR URINARY DIVERSION

Paulina

INTRODUCTION

Fistulas are one of the most common complications following hypospadias surgery.

Coronal fistulas potentially present a dilemma in management, as repair may sometimes lead to reoperative glansplasty when there is glans dehiscence with only a thin band of tissue separating the urethral meatus from the fistula, or the fistula tract leads under the glans.

However, hypospadias reoperations are associated with higher complication rates than primary repairs, including recurrent fistulas

Initially, postoperative urinary diversion was used as dissection extended under the glans, but subsequently repair was done without a catheter.

We now report results of coronal fistula closure without reoperative glansplasty.

INTRODUCTION

MATERIALS

Patients with fistulas following hypospadias repair between 2001 and 2013 were identified from data entered prospectively at the time of service into a database.

Inclusion criteria were coronal fistula without glans dehiscence.

Patients with concomitant glans dehiscence or those with less than 1 month follow-up were excluded from analysis.

Fistula repairs were scheduled at least 6 months from the prior hypospadias surgery.

Results were reviewed with internal review board approval.

REPAIR TECHNIQUE

In all cases the distal neourethra was calibrated intraoperatively to exclude meatal stenosis, defined as <8Fr in prepubertal patients and <12Fr in post-pubertal patients, and to evaluate glans dehiscence, defined as separation of the glans wings with an intervening band of skin separating the fistula from the meatus.

Saline or methylene blue was injected through a urethral stent while compressing the urethra proximally to confirm the presence of a fistula.

Then a circumferential incision was made around the fistula, and extended down the median raphe.

The fistula tract was dissected to the urethra, elevating the glans cephalad with skin hooks to facilitate exposure of the distal urethra beyond the base of the fistula for subsequent coverage by a ventral dartos flap.

The fistula tract was then excised and the urethral defect closed longitudinally or transversely as needed to avoid narrowing the neourethra, using interrupted subepithelial 7-0 polyglactin.

Saline was again injected into the urethra to confirm watertight closure.

A ventral dartos flap was developed, advanced beyond the urethral repair, and sutured into place using 9-0 polyglactin.

A 6Fr catheter provided urinary drainage for 1 week in all prepubertal patients initially (10e12Fr in postpubertal patients).

Our primary outcome, recurrent fistula rate, was compared in those with and without diversion using Fisher’s exact test (SAS 9.2, Cary, NC, USA), with p < 0.05 considered significant.

RESULT

A total of 122 primary fistula closures were done by WS during the study period. Of these, 78 were coronal, with 45 (58%) having fused glans wings undergoing repair without hypospadias reoperation.

The 45 fistulas without glans dehiscence occurred after a mean of 1.7 (1e6) prior hypospadias operations, comprising 35 TIP, 5 2-stage grafts, 1 Mathieu and 4 unknown prior repairs, and all were ≤ 3 mm in greatest dimension.

Median age at repair was 3 years (range 1-51 years).

During mean follow-up of 18 months (1.6-84) in 37/45 (82%) patients, recurrent coronal fistulas occurred in 2 (5%), 1/17 with urinary diversion and 1/20 without diversion (p Z 1.0).

DISCUSSION

We closed coronal fistulas by dissecting under the glans, avoiding reoperative urethroplasty and glansplasty, in consecutive patients with well-fused glans wings, with a 5% recurrence rate.

There was no difference in recurrent fistulas between the first 17 patients who had postoperative urinary diversion compared with the subsequent 20 who did not;

Ours is the first report on fistula repair using a standardized protocol in consecutive patients, and it is difficult to compare our results to other published series which included fistulas in various locations, heterogeneity in decision-making based on “simple vs “complex” designations, and varied use of urinary diversion. Other reported recurrence rates vary from 4% to 30%.

All our patients had primary fistulas <3 mm in size, and so we cannot comment on use of this technique for recurrent fistulas and/or larger defects.

We report outcomes during a mean of 18 months follow up, and it is possible there will be additional recurrences with longer follow up.

CONCLUSSION

Primary coronal fistulas ≤ 3 mm under well-fused glans wings can be repaired by elevating the glans rather than reopening the wings.

Postoperative urinary diversion did not impact the recurrence rate (5%) and we no longer use this.