Hypospadias is a common congenital condition in which the urethral opening is located on the underside of the penis rather than at the tip. Surgical repair is required to correct this and to restore both function and appearance of the penis. One of the most frequent complications following hypospadias repair is the development of a urethral fistula which is an abnormal channel that forms between the urethra and the overlying skin after surgery, resulting in leakage of urine. So, there is urine coming from 2-3 places instead of from the tip. In the hands of an expert hypospadias surgeon, the incidence of urethral fistula should be less than 5%.
Picture showing multiple fistula in the distal penile region and urine video showing stream from the meatus and from the fistula site
Why Do Urethral Fistula Form After Hypospadias Repair Surgery
The most common cause of urethral fistula post hypospadias repair surgery is tight urethroplasty or tension on the stitches. The other common causes are creation of a narrow urethra, poor vascularity of tissues or infection. Fistulas can occur anywhere along the neourethra but are most common at the site of maximal tension or poor tissue quality. In distal hypospadias most common site of fistula formation is coronal region (just below the head of penis) while in proximal hypospadias repairs- the common sites are at start of urethroplasty, penoscrotal region or the coronal region. A urethral fistula commonly presents as persistent dribbling or leakage of urine from the fistula site after surgery. Symptoms usually present within a few weeks to months after surgery.
Diagnosis
The diagnosis of urethral fistula is typically clinical, based on observation of urine leakage from the repaired site. Documentation of the urine stream is important in fistula after hypospadias repair to rule out presence of stricture or diverticulum in the urethra beyond the site of fistula. The number of leaks also has to be documented before planning the surgical repair. Sometimes, we also place a urethral catheter to check the calibre of urethra beyond the fistula.
Timing of Fistula Repair
It is standard practice to wait at least 6 months after the initial repair before attempting urethral fistula closure surgery, as this allows inflammation to subside, tissues to soften, and vascularity to improve. Also, small fistulas may close spontaneously hence it’s recommended to wait for atleast 6 months before planning anything.
Surgical Principles for Successful Urethral Fistula Repair
The goal of surgery is to close the urethral fistula and restore the integrity of the neourethra while minimizing the risk of recurrence. Key steps include:
- Fistula tract excision: The tract is identified, excised, and the edges are refreshed to healthy tissue.
- Layered closure without tension: Multi-layered closure is crucial, typically involving the urethral mucosa, spongiosum (if available), dartos fascia, local tissues and skin. A hypospadias surgeon must make sure that the layers are not under any tension.
- Use of vascularized tissue: An intervening vascularized tissue flap (such as dartos fascia or tunica vaginalis in proximal fistula) is often placed between the urethra and skin to prevent recurrence.
- Fine absorbable sutures: Used to minimize tissue reaction and foreign body response.
- Catheterization: A urethral catheter is left in place for 7-10 days postoperatively todivert urine and protect the repair.
Techniques for Urethral Fistula Repair Surgery
Urethral Fistula closure can be performed in various ways.
- Simple closure: Reserved for small, well-defined fistulas with healthy surrounding tissue. Remember in these repairs also a layered closure with well vascularised tissues is important. One can utilize dartos or tunica vaginalis flap for additional coverage and vascular support.
- V-Y Flap Repair: In large fistulae, we often use a skin advancement flap from surrounding skin to provide non-overlapping suture lines. The flap can be laterally based or proximally based.
- Complex repairs: For large or recurrent fistulas, entire urethral reconstruction may be required which is done using local flaps or oral mucosa graft. Staged repair may be required in fistula cases with unhealthy urethra beyond the site of fistula.
Postoperative Care
Meticulous postoperative care is pivotal to ensure successful healing:
- Maintain catheter patency, monitor for obstruction or kinking.
- Keep the surgical site clean and dry. Gentle wound care as instructed by the surgical team.
- Monitor for signs of infection: swelling, redness, discharge, or fever.
- Avoid strenuous activity, straining or pressure on the site until fully healed.
- Follow up as recommended with your surgical team for wound checks and early detection of complications.
Prevention of Urethral Fistula Formation
Preventing fistula formation is an important aspect of hypospadias surgery
- Use of meticulous surgical technique with tension-free, multi-layered closure.
- Ensuring well-vascularized tissue coverage over the neourethra.
- Surgical site care and managing infection if any in the post operative period
- Make sure the passage beyond the fistula site is not narrow and of adequate calibre
- The meatus should be checked and if found to be narrow, meatotomy should be performed.
Prognosis and Outcomes
With appropriate timing and technique, most urethral fistulas can be successfully repaired. Prognosis depends on several factors:
- Location of the fistula site: Fistula far away from the coronal region can be repaired by simple closure.
- Tissue quality: Healthy, non-scarred tissue improves the likelihood of long-term closure.
- Number of previous repairs: Each additional surgery slightly reduces the success rate due to increasing tissue scarring and reduced vascularity.
- Surgeon’s experience: Experienced pediatric urologists have higher success rates for complex repairs.
Conclusion
Urethral fistula is the most common complication after hypospadias repair, but with proper diagnosis, patient selection, and surgical technique, most cases can be effectively managed. Families and patients should be reassured that while the development of a fistula is distressing, it can often be successfully treated, and most children go on to have normal urinary and functional outcomes. If you suspect a urethral fistula or have concerns about post-hypospadias surgery care, it is important to consult a pediatric urologist or specialized hypospadias surgery team for
individualized assessment and management.
About Hypospadias Foundation
Hypospadias foundation is a centre located in Kharghar, Navi Mumbai, Maharashtra, India with best 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 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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