Management of urethrocutaneous fistula after hypospadias repair: 10 years' experience

Objectives To report the outcome of managing urethrocutaneous fistula after hypospadias repair over 10 years. Patients and methods Forty-seven patients (mean age 7.6 years, range 2-18) underwent repair of 57 urethrocutaneous fistulae after hypospadias surgery. The fistula was single in 37 patients and multiple in 10; 42 fistulae were small (< 4 mm) and 15 large (>4 mm). Twenty-one fistulae were at the corona, 15 at the anterior shaft, 16 at the mid-shaft and five were penoscrotal. The interval between primary hypospadias repair and the first attempt at fistula repair was 6-12 months. Small fistulae were repaired using a multilayer simple closure technique, and large fistulae repaired using rotational and advancement skin flaps. Suprapubic urinary diversion was used in all patients with large fistulae or small multiple fistulae (25 patients); an overnight urethral catheter was used in the remaining patients. Results Simple closure was successful in 30 of 42 small fistulae (71%); eight were successfully closed by secondary closure, while four needed a third closure. Rotational and advancement skin flaps were successful in 13 of 15 large fistulae; one required secondary flap repair and one was closed simply. Most recurrences (78%) were of coronal fistulae; there was recurrence in four of 25 (16%) patients in whom suprapubic diversion was used, in contrast to 10 of 22 (45%) with no suprapubic diversion. Conclusions Although simple closure of a fistula is easy and not time-consuming it is followed by a significantly higher rate of recurrence than when skin flaps are used. Rotational and advancement flaps are the optimal methods for repairing fistulae after hypospadias, particularly for large and coronal fistulae. Thus, the appropriate indication for simple closure is small fistulae at the penile shaft. Suprapubic diversion is important in those with large or multiple fistulae.