11-year male was diagnosed to have chordee without hypospadias after birth. When he was seven years old, he underwent chordee repair and urethroplasty (done elsewhere), but the procedure was unsuccessful. Following the urethroplasty he developed urinary leak due to urethral fistula at the proximal penile region and a second surgery was done to close this fistula. Unfortunately, the fistula recurred. Distressed parents visited hypospadias foundation for further treatment of their child.
When examined in the OPD, he had a large proximal penile urethral fistula and was passing urine mainly from the fistula site. He was passing small amount of urine from the meatus at glans. He had an associated penile torsion to the right with minor residual chordee
At hypospadias foundation, after thorough examination family was counselled that two-stage redo hypospadias repair would be ideal to correct the complications from previous surgeries. However, we also discussed that the final decision of type of repair will be decided during the surgery based on the cystoscopy findings (calibre of proximal and distal urethra) and assessment of chordee by artificial erection test.
On cystoscopy, we found that the proximal urethra was normal and the urethra between the meatus and the fistula was of good calibre. On artificial erection test there was minor residual chordee of less than 20 degrees. The findings were in favour of doing a single stage repair – fistula closure and skin rearrangement for correction of penile torsion hence we decided to go ahead with the fistula closure.
We decided to leave the minor chordee uncorrected at this stage as family was keen to wait and watch. We also planned to assess the chordee after puberty and if required chordee correction at a later date. The family was happy with this plan, and we went ahead with fistula closure.
Fistula site was marked. Local anaesthesia lignocaine with adrenaline was infiltrated all around. Fistula site was mobilized all around and closed using 5-0 vicryl continuous fashion over an 8Fr infant feeding tube. Local tissues were closed over the urethroplasty using 5-0 vicryl. Local flap along with dartos was harvested and sutured over the site of fistula closure to decrease the risk of recurrent fistula formation. Flaps were rearranged to correct the penile torsion. Skin was closed in 2 layers using 6-0 PDS and 6-0 vicryl rapide.
Post operative dressing was done on day 7 and catheter removal was done on day 10. Post catheter removal he was passing urine in straight stream with no leak or pain.
Fig 1: Clinical examination showing glanular meatus with a large proximal penile fistula
Fig 2: Artificial erection test showed minor residual chordee of less than 20 degrees
Fig 3: Fistula site was mobilized all around
Fig 4: Fistula closure done in multiple layers using 5-0 vicry
Fig 5: Fistula closure and cosmetic correction completed
Fig 6: Dressing and catheter removal done 10 days after surgery
Fig 7: Passing urine in single straight stream after catheter removal.
Urethral Fistula closure after multiple previous hypospadias surgeries
Hypospadias is a birth defect where the opening of the urethra (the tube that carries urine from the bladder out of the body) is on the underside of the penis instead of at the tip. Hypospadias repair surgery corrects this abnormality. After urethroplasty during the process of healing, a fistula can occur between the urethra and the skin of the penis. This can cause urine to leak from the fistula opening. Fistula formation is the most common complication after hypospadias surgery. In the presence of a urethral fistula the child or adult will pass urine from the meatus and from the fistula sites.
Fistula can close spontaneously sometimes but if it doesn’t then a fistula closure surgery may be required. We typically wait for 6 months after the initial surgery to allow for any inflammation or swelling to subside before performing the fistula closure.
There are different techniques used for fistula closure, depending on the size and location of the fistula. The surgeon will discuss the best approach for you. Before the fistula closure, we check the calibre of the urethra beyond the fistula. If the distal urethra is normal without any obstruction, then fistula closure will suffice. If distal urethra is narrow, then the entire urethra may have to be replaced which needs to be planned in one or two stages.
Success rates for fistula closure surgery are generally high, with most studies reporting success rates of over 90% when done by an experienced hypospadias surgeon. However, there is a small chance that the fistula may recur.
If you are concerned about a fistula after hypospadias repair, it is important to see a doctor to discuss your options. A pediatric urologist or a hypospadias surgeon will guide you and advice appropriate treatment options.
About hypospadias foundation
Hypospadias Foundation located in Kharghar, Navi mumbai, Maharashtra is the topmost and the best centre in india and one of the leading centres in the world for hypospadias treatment. Children and adults not only from India but from all over the world visit and get treated successfully at hypospadias foundation. Over the last 15 years we have been performing more than 200 surgeries per year with complication rate of less than 5%. Our expertise in this area has helped us achieve the success in this field.
Dr A K Singal is one of the best hypospadias surgeons in India and world who has dedicated his life in treating children and adults with hypospadias.
Dr Ashwitha Shenoy is an expert pediatric surgeon with special interest in pediatric urology and hypospadias. Both Dr Singal and Dr Shenoy work together to give best results for hypospadias surgery in India for both children and adults. Their expertise in this area has helped us achieve excellent outcomes in adults and children with hypospadias.
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MITR hospital & Hypospadias Foundation, Kharghar, Navi Mumbai, India – Tue/Saturday 4:00pm-6:00pm, Call for appointments: +91-9324180553. Or email us at hypospadiasfoundationindia@gmail.com
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