Tag Archives: fistula surgery in hypospadias

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%.

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%.

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%.