Hypospadias is a condition seen in 1 in 150 to 200 newborn boys. Surgical repair is the primary treatment for hypospadias, aiming to reposition the urethral opening to the tip of the penis, straighten any abnormal curvature and to improve the overall appearance of the penis. Like any other surgery, complications can occur even after hypospadias repair. The common complications which occur are urethrocutaneous fistula, meatal stenosis, glans dehiscence and rarely urethral diverticulum or urethral stricture. Among this the most common and notorious complication is the urethral fistula.
Urethrocutaneous fistula refers to the development of an abnormal opening between a newly constructed urethra and the skin on the underside of the penis. When this occurs the child or the adult will have more than one urine stream. There will be one stream from the tip of the penis (the newly created opening) and the other stream or leak of urine from the fistula site. The leaking of urine from the fistula site tends to fall on the legs or can wet the clothing causing inconvenience to the children and the adult. In our centre, we see lot of children coming for urethral fistula treatment after first surgery somewhere else like the case below.
Post hypospadias surgery fistula can occur due to multiple reasons. Some of them are as follows:
1. Intraoperative factors:
a. Poor blood supply: Poor blood supply also called as ischemia is one of the most common factors that can severely impair and delay tissue healing. The process of wound healing is complex and heavily relies on the continuous supply of essential nutrients along with oxygen via the blood stream. During urethroplasty if the blood supply of the tissues is poor then fistula formation can occur post-surgery due to poor healing.
b. Inadequate tissue closure: During urethroplasty, we must take care that there should be a watertight closure of the newly reconstructed passage. And this urethral passage should be reinforced with multiple layers of tissues such as local tissues or dartos flap so that the risk of fistula formation decreases. Gaps in the urethral closure with deficient overlying tissue layers can increase the risk of fistula formation.
c. Tight closure of tissues: The urethroplasty and overlying tissue closure in hypospadias should never be under tension. If the tissue closure is tight then the vascularity is affected and can cause ischaemia of the tissues leading to skin necrosis and fistula formation.
d. Narrow or stenosed urethra: The newly reconstructed urethra in hypospadias should be of good calibre. If the urethra becomes narrow, then there can be increased pressure within the urethra proximal to the narrow segment leading to a weaker point which gives away causing urine leaking from this pointwhich becomes a fistula.
e. Type and severity of hypospadias: Severe hypospadias or complex hypospadias is usually associated with severe penile curvature along with urinary opening situated far from the head of the penis. Longer urethral reconstruction is inherently more complex with higher risk of complications and hence higher chance of fistula formation compared to milder forms of hypospadias.
f. Fibrotic or unhealthy tissues: Fibrotic tissues are associated with poor blood supply and using such tissues for urethral reconstruction can be disastrous with higher possibility of dehiscence and fistula formation.
g. Surgeon experience: The risk of fistula formation will be higher at a centre performing very few hypospadias repairs compared to a centre performing more than 50-60 repairs every year. The technique, tissue handling etc gets better only once the surgeon performs more than 50 hypospadias surgeries every year.
2. Post operative factors:
1.Infection: If the operated hypospadias site gets infected in the post-surgery period, then there is a possibility of dehiscence at the site of infection which in turn can cause fistula formation.
2.Poor nutrition: Optimal nutrition is not just beneficial but fundamental for wound healing. Deficiency in key nutrients can cripple the body’s ability to repair itself leading to weakened tissue, increased infection risk and ultimately wound breakdown and higher chance of fistula formation
3.Presence of constipation: Constipation can indirectly contribute to wound breakdown. Straining to pass stool can put pressure on the penile area and can put undue stress on the delicate tissues and new sutures which can give away and cause fistula formation.
Inspite of the best efforts of the hypospadias surgeon, fistula can occur after hypospadias repair. Even if fistula occurs, there is a possibility that the fistula can close spontaneously. At Hypospadias Foundation, we wait for 6 months to assess the same and if it does not close then surgery in the form of fistula closure may be required. Before urethral fistula closure it is mandatory to check the urinary passage beyond the site of fistula. If the passage beyond the site of fistula is narrow, then simple urethral fistula closure may not suffice, and reconstruction of the entire distal passage (distal urethroplasty) may be necessary.
Hypospadias foundation is a centre located in Kharghar, Navi Mumbai, Maharashtra, India with surgeons having expertise in hypospadias repair in children and adults. We regularly manage both primary hypospadias repairs and complex cases including those with previous multiple failed repairs. A significant focus of our patient base consists of children and adults who have had failed hypospadias surgeries elsewhere, including persistent fistulas. Our approach involves not just good surgical technique but also diligent pre-operative assessment, focussed post-surgery care and critical decision making for good long-term outcomes.
Dr A.K. Singal is the founder and head of hypospadias foundation, India. He is considered the best hypospadias surgeon in India and the world and has successfully treated more than thousands of children and adults with hypospadias with excellent results.
Dr Ashwitha Shenoy is an expert hypospadias surgeon with special interest in the field of hypospadias and pediatric urology. Both Dr Singal and Dr Shenoy strive to achieve excellent outcomes in adults and children with hypospadias. Our success rate at hypospadias foundation for all types of repairs including complex and failed repairs are more than 95%.
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