Surgical treatment of urethral fistulas following hypospadias repair.

Development of urethral fistulas is one of the most common late complications of hypospadias surgery. A total of 161 male patients who had 186 urethrocutaneous fistulas were first classified according to the fistula classification of Horton and colleagues and then treated with three types of procedures: simple closure, local rotation flaps, or tube graft reconstruction. With initial surgical intervention, 156 of 186 fistulas were treated successfully. The remaining 30 fistulas (16.1%) recurred during the follow-up period. In the recurrent cases, immediate closure was not preferred, and an average of 6 months was waited before considering any additional surgical attempt. Distal cases had a higher failure rate, and the simple closure technique failed to show a success rate as high as local flap or tube graft repair. The high recurrence of distal cases was attributed mainly to the lack of adequate soft tissue adjacent to the fistula, which is vital for safe closure. In addition, the traction effect of erection on the skin and urethra, which is more prominent distally than proximally, is also believed to play an additive role. To increase success, the selection of appropriate treatment modality and customization of techniques for each patient cannot be overemphasized. However, the authors conclude that careful presurgical assessment of the patient, a 6-month delay before any secondary surgical attempt, inversion of the urethral mucosa, avoidance of any overlapping suture lines, urinary diversion proximal to the repair site for 5 to 11 days, and usage of thin, absorbable suture materials are the main criteria that should be met for a satisfactory hypospadias fistula repair.