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CHOICE OF A METHOD FOR ELIMINATION OF URETHRALCUTANEOUS
URINARY FISTULA AFTER CORRECTION OF HYPOSPADIAS
Nadjimitdinov Ya.S.,
Associate Professor, PhD, Department of Urology, Tashkent Medical Academy
Rakhimzhanov M.A.
Master's student of the Department of Urology, Tashkent Medical Academy
Abstract:
An analysis was conducted on the treatment outcomes of 46 patients from
January 2021 to August 2023 who developed urethrocutaneous fistulas following
hypospadias repair. In 25 patients (54.3%) with fistula sizes less than 10 mm, closure was
performed using local penile tissues and the tunica vaginalis of the testis. In 21 patients
(43.8%) with fistulas larger than 10 mm, scrotal skin was used to close the penile skin defect.
During a three-month follow-up period, no recurrence of urethrocutaneous fistulas was
observed in any case.
Keywords:
hypospadias, tunica vaginalis of the testis, urethrocutaneous fistula
ВЫБОР СПОСОБА ЛИКВИДАЦИИ КОЖНО-УРЕТРАЛЬНОГО МОЧЕВОГО
СВИЩА ПОСЛЕ КОРРЕКЦИИ ГИПОСПАДИИ
Аннотация:
Выполнен анализ результатов лечения 46 пациентов за период с января
2021 по август 2023 года с кожно-уретральными мочевыми свищами,
сформировавшимися после коррекции гипоспадии. При размере свища менее 10 мм у
25 (54,3%) пациентов выполнено ушивание свища с использованием местных тканей
полового члена и вагинальной оболочки яичка. Закрытие дефекта кожи полового
члена кожей мошонки выполнили у 21 (43,8%) больного, когда диаметр кожно-
уретрального свища был более 10 мм. Во всех случаях при наблюдении в течение трех
месяцев рецидива кожно-уретрального мочевого свища не было.
Ключевые слова:
гипоспадия, вагинальная оболочка яичка, кожно-уретральный
свищ
Introduction
More than 300 surgical procedures have been proposed for the treatment of patients with
hypospadias [1]. The reason for such a large number of procedures is the fact that none of
them provide consistently good results for different types of hypospadias. However, in
recent years, with improvements in surgical techniques and the use of modern suture
materials that contribute to the successful correction of hypospadias, the number of surgeries
performed in various centers has significantly increased.
Nevertheless, the complication rate following different types of urethroplasty remains high.
The most frequently observed complication after hypospadias repair is urethrocutaneous
fistula formation, with an incidence ranging from 3% to 33%, regardless of the type of
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surgical intervention [1]. Factors influencing fistula formation include the type of
hypospadias, the patient’s age at the time of surgery, the width of the urethral plate, and the
quality of the suture material used for urethroplasty. Kwon T. et al. demonstrated that the
complication rate in hypospadias repair is lower in children aged 4 to 6 months [4]. Another
unfavorable factor is a narrow urethral plate, which is used to form the urethra [5].
The choice of surgical method for managing complications remains an issue. Some
urologists advocate for multi-stage reconstructive surgeries [6], while others prefer single-
stage procedures using various tissues from adjacent areas, such as the peritoneal vaginal
tunic or the dartos fascia of the scrotum [7]. Thus, there is no consensus on this matter to
date.
The aim of this study is to evaluate the treatment outcomes of patients with urethrocutaneous
fistulas that developed after primary urethroplasty for hypospadias using different fistula
closure methods.
Materials and Methods
An analysis was conducted on the treatment outcomes of 46 patients from January 2021 to
August 2023 who developed urethrocutaneous fistulas following hypospadias repair.
The fistulas were located in the coronal sulcus in 11 patients and in the penoscrotal junction
in 8 cases. The distribution of urethrocutaneous fistula openings along the penile shaft was
as follows:
Distal part of the penis – 9 patients
Midshaft – 10 patients
Proximal part of the penis – 8 patients
The fistula opening size (largest diameter) was less than 10 mm in 25 patients (54.3%), with
an average size of 8.3±0.3 mm. In contrast, fistulas larger than 10 mm were observed in 21
cases (43.8%), with an average size of 23.3±0.5 mm.
The next step in the study involved analyzing the frequency and distribution of fistulas along
the penile shaft and their sizes (Table 1).
Table 1.
Distribution of patients with cojno-urethral cysts and their size and
distribution (n=46).
Up to 10 mm
More than 10 mm
Distal part of penis
6 (13,0%)
3 (6,5%)
Mid part of penis
5 (10,8%)
5 (10,8%)
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Proximal part of penis
3 (6,5%)
5 (10,8%)
Penoscrotal angle
5 (10,8%)
3 (6,5%)
Coronal sulcus
6 (13,0%)
5 (10,8%)
Total
25 (54,3%)
21 (43,8%)
Results
The choice of surgical method for the closure of urethrocutaneous fistulas depended on their
diameter (Table 2).
For fistulas smaller than 10 mm (25 patients), closure was performed using local penile
tissues and the tunica vaginalis of the testis.
For fistulas larger than 10 mm (21 patients), due to the higher risk of recurrence, the penile
skin defect was closed using scrotal skin. After creating a penoscrotal anastomosis,
separation of the penile shaft from the scrotum was performed three months later.
During the three-month follow-up period, no recurrence of urethrocutaneous fistulas was
observed in any of the cases.
Table 2.
Surgical interventions in patients with cutaneous urethral urinary fistulas depending
on size (n=16).
Urethral-Cutaneous Fistula
Diameter less than 10 mm
Diameter over 10 mm
Fistula closure using local tissue or vaginal
membrane of the testicle
Fistula suturing using scrotal skin
Discussion
The exact reasons for the recurrence of urinary fistulas remain unclear. In addition to
surgical technique errors or postoperative management issues, a plausible explanation for
recurrent fistula formation is impaired local vascularization and the development of scar
tissue on the ventral surface of the penile skin. Efforts to improve the success rate of fistula
repair have led to the development of various surgical techniques, including "simple"
closure, skin flap transposition, multilayer reconstruction, and staged urethroplasty.
Karabulut R. et al. found that in cases where additional tissues (such as the tunica vaginalis
of the testis or others) were not used for urethrocutaneous fistula repair, the recurrence rate
was as high as 50% [3]. However, when the tunica vaginalis was used as an additional layer
in secondary surgeries, no cases of fistula recurrence were observed. This suggests that the
likelihood of recurrence increases due to scarring in the surrounding tissues. Based on our
experience, the use of the tunica vaginalis as an additional layer in the primary fistula repair
significantly reduces recurrence rates, thereby minimizing the psychological trauma of
repeated surgeries for the patient.
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For large urethrocutaneous fistulas, Gapany C. et al. used preputial skin and achieved an
89% success rate [2]. However, due to religious and cultural practices in Uzbekistan, where
circumcision is performed on all male children, preputial skin was unavailable for surgical
use. Instead, for fistulas larger than 10 mm, we closed the skin defect by embedding the
penile shaft into a scrotal incision, followed by subsequent separation of the penoscrotal
anastomosis. This approach resulted in zero cases of fistula recurrence.
Conclusion
The choice of surgical technique for urethrocutaneous fistula repair depends on its size and
location.
For fistulas larger than 10 mm, the preferred method is closure with skin defect
reconstruction by embedding the penile shaft into the scrotum, followed by staged
separation.
For fistulas smaller than 10 mm, simple closure is appropriate; however, it is advisable to
use the tunica vaginalis as an additional reinforcing layer to prevent recurrence.
References:
1.
Chung J.W., Choi S.H., Kim B.S., Chung S.K. Risk Factors for the development of
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2.
Gapany C., Grasset N., Tercier S., Ramseyer P., Frey P., Meyrat B.J. A lower fistula
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Twenty-Four Genes are Upregulated in Patients with Hypospadias. Balkan J Med Genet.
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