A 2-year male child was brought to us with passing urine through an abnormal opening in the mid region of the penis. On clinical examination, the penis size was small, and this was confirmed on measurements of penile length and glans width. Child received three doses of Injection Testosterone. Since the child had a severe chordee, we decided to do the repair in two stages, including urethrocutaneous fistula repair using tunica vaginalis flap.
In first stage, chordee was completely corrected (chordee correction) and Byar’s flaps were made. After chordee correction, his urethral opening came down to penoscrotal location. The child healed well and was planned for second stage urethroplasty 6 months following the first stage. Following the stage 2 repair, the child developed a small urethral fistula in penoscrotal region. We waited for 6 months and explained to the parents that though the distal urethra was patent, the fistula will need a closure surgery.
These fistulae in severe hypospadias cases are difficult to repair, hence we planned a novel technique of augmenting the repair with a tunica vaginalis flap from the testis.
Fistula Repair Surgery:
The fistula repair using tunica vaginalis flap was started by confirming the presence of fistula under anaesthesia by injection betadine solution through the meatus at the tip of penis. The betadine solution was seen coming out through an opening at the site of previous opening, which is the site of urethrocutaneous fistula repair using tunica vaginalis flap. This ruled out any other fistula as well. We also did a cystoscopy to make sure that the new urethra distal to fistula was well healed and not narrow at any place.
We dissected the fistula circumferentially down to the urethra and the urethrocutaneous fistula site was excised transversely. The closure of this fistula site was done in a vertical way with 6-0 PDS.
Second layer using Tunica Vaginalis flap
To prevent the recurrence of the fistula, the site was closed using flap which was harvested from the layers around left testis. Left scrotal skin incision was given, dartos layer opened. Testis was delivered out. The tunica vaginalis flap was harvested carefully from the left testis. This flap was placed over the fistula site and sutured all around. The scrotum closed in 2 layers.
Skin was closed over the tunica vaginalis flap and a 7Fr catheter was placed for urine drainage for a week. The child was discharged after 24 hours. The dressing and catheter were removed on day 6. Suture line was healthy and he was passing urine in good stream only through the tip of penis from the new opening which was created and no leak from the site of fistula. At 3 months follow-up, the child was passing urine well and the parents were very happy.
Clinical picture showing penoscrotal fistula
Clinical picture showing tunica vaginalis flap raised from left testis
Clinical picture showing good fistula closure with tunical flap
About hypospadias urethral fistula and tunica vaginalis flap
The fistula (or urine leak from an unintended site) which forms following the hypospadias repair surgery is called urethrocutaneous fistula. This is the most common complication which occurs after hypospadias repair procedure. The reported incidence of urethral fistula is around 4 to 25%.
When the child develops a urethrocutaneous fistula he will pass urine through the fistula and from urethral opening at the tip of penis. Sometimes if the new urethra becomes tight during surgery, then there may be no urine passage from tip, rather all the urine will leak out from the fistula.
A small number of urethral fistulas close spontaneously, and they do not need any form of surgery but most of urethrocutaneous fistula need surgery.
Various options are available for closure of the fistula. It depends on the size of fistula, the vascularity at the site, need for extra layers after closure of the fistula site to prevent recurrence. The method we followed is the tunica vaginalis flap after closure of the fistula. The tunica vaginalis flap is harvested from the testis. The flap is well vascularized hence can be used as a second layer during the repair. The use of tunica vaginalis flap can lead to decrease in the recurrence of the fistula. The technique of fistula repair must be chosen wisely since the recurrence rate is high. The need for extra layers in closing the fistula must be taken into consideration while closing the fistula.
About Dr A.K. Singal and Hypospadias Foundation
Hypospadias foundation is amongst the most reputed and one of the best hospital centres for hypospadias repair surgery in India and the world. Children with failed hypospadias and complications of hypospadias repairs are welcome to our centre.
Based on his two decades of experience, Dr A.K.Singal has refined the techniques and procedures for failed hypospadias repair, leading to better results and lesser complications. Children and adults from all over Mumbai, India and other countries come to Hypospadias Foundation at Navi Mumbai, India for the best treatment and care for hypospadias.
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