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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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ORIGINAL ARTICLE
Year : 2006  |  Volume : 11  |  Issue : 1  |  Page : 24-26
 

Urethroplasty by midline longitudinal incision of the dorsal wall of urethra at the site of the fistula: A useful adjunct to the conventional method of repair of urethrocutaneous fistula developing after hypospadias surgery


Department of Paediatric Surgery, N.R.S. Medical College Hospital, Kolkata, India

Correspondence Address:
Ruchirendu Sarkar
Flat no. d/8, Parui, Government Rental Housing Estate, Biren Roy Road (West), Kolkata - 700 061
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.24633

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   Abstract 

In cases of repair of urethrocutaneous fistulae developing after primary hypospadias surgery, tubularisation often becomes difficult after excision of scar tissue. It is also well-known that this type of fistulae has a high recurrence rate. In this study of 15 cases, the aim is to analyze the results of conventional urethrocutaneous fistula repair, augmented with the principle of Midline longitudinal incision of the dorsal wall of the urethra at the site of the fistula according to the concept of Tubularised Incised Plate Procedure with the hope of preventing recurrence. Here, the excision of scar tissue around the urethrocutaneous fistulae, tubularisation of urethra is done after incising the dorsal urethral plate. Then the mucosa is closed over a 6F/8F catheter and the resultant suture line is covered first with the dartos flap or adjacent tissue and then, the skin. The skin layer is minimally rotated so as to avoid suture-line overlap. Results of this method has been found to be quite satisfactory, as only in two[2] patients the fistula recurred. Thus it may be concluded from this study that the Tubularised Incised Plate Urethroplasty along with conventional urethral fistula repair is a good adjunctive procedure in prevention of their recurrence.


Keywords: Hypospadias, repair, urethro cutaneous fistula


How to cite this article:
Sarkar R, Konar H, Sahabasu K, Saha K, Samanta N. Urethroplasty by midline longitudinal incision of the dorsal wall of urethra at the site of the fistula: A useful adjunct to the conventional method of repair of urethrocutaneous fistula developing after hypospadias surgery. J Indian Assoc Pediatr Surg 2006;11:24-6

How to cite this URL:
Sarkar R, Konar H, Sahabasu K, Saha K, Samanta N. Urethroplasty by midline longitudinal incision of the dorsal wall of urethra at the site of the fistula: A useful adjunct to the conventional method of repair of urethrocutaneous fistula developing after hypospadias surgery. J Indian Assoc Pediatr Surg [serial online] 2006 [cited 2019 Nov 17];11:24-6. Available from: http://www.jiaps.com/text.asp?2006/11/1/24/24633


Urethrocutaneous fistula is a common complication of hypospadias repair with reported incidence being 10-20%. Fistula repair procedures have a high recurrence rate quoted to be as high as 29% in the literature .[11] In the conventional method of repair of urethrocutaneous fistulae, firstly the peri-fistula scar tissue is excised. Then, three layers of tissue are mobilized:

a. margins of urethrocutaneous fistula

b. dartos/surrounding tissue

c. skin.

Finally, these three layers are apposed with or without double-breasting of skin.

Causes of recurrence after repair may be summarized as:

1. Dearth of adequate blood supply to the covering flap.

2. Tension in apposition of tissue margins, either due to shortage of available local tissue or inadequate mobilization, or postoperative oedema.

3. Persistent distal obstruction.

In the present method, midline longitudinal incision of the dorsal wall of the urethra at the site of the fistula, according to the concept of tubularized incised plate method, the tissue tension is minimized by the midline urethral plate incision. The advantage of this procedure is that it helps in adequate and proper apposition of tissue layers.


   Materials and methods Top


The present series consists of 15 cases in total, studied between July 2002 and June 2004 with age range 2-11 years (mean: 6.5 years). All these cases developed secondary urethrocutaneous fistulae after primary hypospadias surgery. The sites of the fistulae are proximal penile-4, mid-penile-7, distal penile-4 [Table - 1].

Out of the 15 cases, seven[7] were follow-up cases of our own department, whereas the rest were referred from other institutions in Kolkata.

Records of previous operations were available in 10 cases only. Mathieu urethroplasty had been performed in two cases, Duckett onlay flap done in six cases and the rest two cases had undergone Snodgras urethroplasty [Table - 2].

The method of urethroplasty followed in this series are:

Step 1 : Dorsal urethral plate was exposed by excision of peri fistula scar tissue.

Step 2 : The urethral plate was incised in the Midline [Figure - 2].

Step 3 : Urethral mucosa surrounding the fistula was mobilized and tabularized over a 6F/8F catheter. The suture material used was a delayed absorbable one.

Step 4 : The coverings over the tube were made with: first dartos and then skin.

Step 5 : The skin was rotated by 10 degrees (approximately) in order to avoid suture line overlap [Figure - 3].


   Results Top


Period of follow-up: 2months to 2 years (average: 13 months).

Out of the total of 15 cases, 13 showed no recurrence of urethro cutaneous fistula. Only 2 developed fistula at the same site again.


   Discussion Top


It has been widely reported and accepted that the 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 further reduce the various difficulties encountered in hypospadias repair and to achieve a good cosmetic configuration. As a part of this process, tubularized incised plate urethroplasty was first introduced by Snodgrass for repair of distal hypospadias in 1993.[1] Now its application has been extended to more proximal forms of hypospadias.[3] The advantage of this procedure is the provision of a generously mobile plate for tubularization without the use of supplemental flaps and also the creation of a functional neo-urethra with a vertical, slit-like meatus. The technique had been presented as an alternative to meatal-based and onlay island flap procedures for hypospadias repair, but it was not initially considered a viable alternative for a secondary procedure. With the refinement of surgical techniques during the last decade, most paediatric hypospadias repairs can now be performed with minimal morbidity.

Secondary procedures to correct complications remain challenging, especially for those patients who have had a complication from a previous penile surgery, resulting in shortage of local skin for a local flap procedure. Free graft substances, such as extragenital skin and bladder mucosa have been used previously to create a neo-urethra. Significant complications such as excessive stricture formation, graft shrinkage and unsightly scarification of the donor site have been reported in larger follow-up studies of extra-genital skin grafts. The bladder mucosa graft tends to prolapse in an exfoliative fashion, causing splaying of the stream and stenosis of the meatus[5],[6]. Buccal mucosa has been used for urethral reconstruction in recent years with promising early results[7], but extended follow up studies are needed to confirm its success in the long run. On this background, during the last two years, a method of urethroplasty, based on the tubularised incised plate procedure, in which a midline longitudinal incision of the dorsal wall of the urethra at the site of the fistula was made, has been used at our institution to repair urethro cutaneous fistulae resulting from hypospadias surgery. Out of the 15 cases treated, 13 did well with complete correction of the previous complications. Recurrence rate was low (13.33%) considering the complex clinlcal situation.

Although our follow up period is short, we believe that this method based on tubularized incised plate urethroplasty procedure may turn out to be a good alternative, especially in complex secondary urethro cutaneous fistula repair where there is dearth of adequate local penile and prepucial tissue for repairing the neo-urethra[13][Figure - 1].

 
   References Top

1.Snodgrass W. Tubularised Incised Plate Urethroplasty for distal. Hypospadias J Urol 1994;151:464-5.  Back to cited text no. 1  [PUBMED]  
2.Snodgrass W, Koyle M, Manzoni G. Tubularised Incised Plate hypospadias repair, results of a multicentre experience. J Urol 1996;186:839-41.  Back to cited text no. 2    
3.Snodgras W, Koyle M, Manzoni G, Hurwitz R, Caldamone A, Ehrlich R. Tubularised Incised Plate hypospadias repair for proximal hypospadias. J Urol 1998;159:2129-31.  Back to cited text no. 3    
4.Burbige KA, Hensle TW, Edgerton P. Extragenital split-thickness skin graft for urethral reconstruction. J Urol 1984;131:1137-9.  Back to cited text no. 4  [PUBMED]  
5.Kinkead TM, Borzi PA, Duffy PG, Ransley PG. Long term follow up of bladder mucosa graft for male urethra reconstruction. J Urol 1994;151:1056-8.  Back to cited text no. 5  [PUBMED]  
6.Hendren WH, Reda EF. Bladder mucosa graft for construction of male urethra. J Paediatr Surg 1986;21:189-91.  Back to cited text no. 6    
7.Duckett JW, Coplen D, Ewalt D. Buccal mucosal urethral replacement. J Urol 1994;153:1660-3.   Back to cited text no. 7    
8.Riccabona M, Oswald J, Koen M, Beckers G, Schrey A, Lusuardi L. Comprehensive analysis of six years experience in Tubularised Incised Plate Urethroplasty and its extended application in primary and secondary hypospadias repair. Eur Urol 2003;44:714-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Luo CC, Lin JN. Repair of hypospadias complications using the tubularised incised plate urethroplasty. J Paediatr Surg 1999;34:1665-7.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.Hayashi Y, Kojima Y, Misuno K, et al. Tubularised Incised Plate urethroplasty for secondary hypospadias surgery. Int J Urol 2001;8:444-8.  Back to cited text no. 10    
11.Shankar KR, Losty PD, Hopper M, Wong L, Rickwood AM. Outcome of hypospadias fistula repair. BJU Int 2002:89;103-5.  Back to cited text no. 11    
12.Latifoglu O, Yavuzer R, Unal S, Cavusoglu T, Atabay K. Surgical treatment of urethral fistulas following hypospadias repair. Ann Plast Surg 2000;44:381-6.  Back to cited text no. 12  [PUBMED]  
13.Eardly I, Whitaker RH. Surgery for hypospadias fistula. Br J Urol 1992;69:306-10.  Back to cited text no. 13    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

    Tables

[Table - 1], [Table - 2]



 

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