Single stage Redo hypospadias repair in a child with recurrent distal penile fistula
3-and-a-half-year-old male was diagnosed with penoscrotal hypospadias at birth. He underwent single stage urethroplasty at 1 and half year of age at another centre. Following the urethroplasty, he developed urine leak from the distal penile region. A second surgery was done to close the fistula. Unfortunately, the fistula recurred. Parents were disappointed and visited hypospadias foundation for treatment of their child.
We examined the child in the OPD and noted that there was a small fistula in the distal penile region with a normal meatus on the glans. He was passing urine mainly from the meatus (95%) and with a leak from the distal penile region (5%).
At hypospadias foundation, after examination we counselled the family for surgical repair which would be dependent on the quality of urethra, any residual chordee and blood supply to the tissues. While we aim to do a single stage repair for such cases, in some cases a decision to do a staged repair may be made during surgery.
On cystoscopy, a ledge was noted at the junction of normal urethra and reconstructed urethra. On artificial erection test, there was no residual chordee. The tissues were also healthy around the fistula. The findings were in favour of single stage fistula closure; hence we proceeded with the same.
Fistula site was marked. Local anesthesia with adrenaline was infiltrated at the marked site. Incision was given around the fistula site. Fistula site was mobilized all around and tract was completely excised. Fistula site was closed in 2 layers with 6-0 PDS over a 7Fr infant feeding tube. Local flap along with underlying dartos tissue was raised and sutured over the fistula site to decrease the risk of recurrent fistula formation. Skin was closed in 2 layers with 6-0 PDS and 6-0 vicryl rapide. The ledge in the distal urethra was incised. Post surgery, the dressing along with the catheter was removed on post operative day 7. Post catheter removal, he was passing urine in single straight stream with no pain or leak.
Pic 1: Pre surgery urine stream – Passing from meatus at the tip and from the fistula at distal penile region
Pic 2: Preoperative assessment shows fistula in the distal penile region.
Pic 3: Artificial erection test showed no chordee
Pic 4: Incision given around the fistula site and fistula mobilized all around
Pic 5: Fistula site closed in 2 layers. Skin along with dartos flap closed over the fistula closure site.
Pic 6: Post operative – good outcome at 2 months after surgery- passing urine in single straight stream with no leak
Click on this link to watch this video of fistula repair in redo hypospadias with recurrent fistula Fistula closure in redo hypospadias with recurrent fistula – Dr A.K.Singal/ Dr Ashwitha Shenoy – YouTube
Single stage hypospadias repair in a child with recurrent distal penile fistula
A urethral fistula after hypospadias repair is an abnormal communication that forms between the newly reconstructed urethra and the skin on the underside of the penis. This is the most common complication that occurs after hypospadias surgery. In this condition, the urine comes from the tip of the penis and leaks from the fistula site.
This fistula mostly occurs due to issues with healing of the urethra. The common reasons include tension on the newly reconstructed urethra, poor blood supply at the operated site, gaps during closure, infection at the operated site, narrowing or stricture formation in the new urethra or straining while passing stool in the post operative period.
Children who form fistula after hypospadias surgery come with leaking or dribbling of urine from the fistula site. Symptoms usually appear within a few weeks to months after the initial hypospadias repair.
The primary treatment is surgical repair if they do not close on their own. It is standard practice to wait for atleast 6 months after the initial hypospadias repair before attempting fistula closure. This allows the tissues at the urethral fistula site to soften, improve blood supply and increase the success rate of second surgery. The fistula tract is identified and excised to create healthy tissue edges for repair.
The urethral fistula site is closed in multiple layers as done in the above-mentioned case to ensure a watertight seal and prevent recurrence. Before closing the fistula, it is always necessary to confirm that the urethra beyond the fistula site is not narrow or tight. In the presence of distal obstruction, the urethral fistula closure surgery may fail.
If your child has developed urethral fistula after hypospadias repair, then it’s necessary that you see a hypospadias specialist who will assess what is best for your child and choose the best technique minimizing the risk of complications and improving the chances of success.
About Hypospadias Foundation
Hypospadias Foundation is a centre specialized for treatment of children with hypospadias. Hypospadias foundation is located at MITR Hospital in Kharghar, Navi Mumbai in the state of Maharashtra. Our expertise in hypospadias makes us one of the best centres for hypospadias repair in the world. We treat children from more than 25 countries in the world and from all over India. Our dedication in this field has helped us achieve excellent outcomes.
Dr A K Singal is an expert and top hypospadias surgeon in India. He is a gifted surgeon and his expertise in this area has helped us achieve excellent outcomes in primary and failed hypospadias in children as well as adults.
Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults.