Needling for Suture Track Fistula.

A day care procedure for ablation of epithelium of suture track fistula (STF) is described with a tip of hypodermic needle under surface anesthesia. STF is a minor but annoying and frustrating complication following hypospadias surgery. Parents and patients are worried of soiling of dress from dribbling of urine through STF during urination. It is embarrassing particularly in the presence of peers. Nevertheless, no specific treatment is found in literature for its remedy other than the conventional procedures for repair of fistula. Here, we describe a simple day care procedure under surface anesthesia with prilocaine ointment. Thirty-five out of 42 STFs healed in single or repeat attempts with this 'needling' procedure. Copyright:

INTRODUCTION

Suture track fistula (STF) develops from the growth of epithelium scaffolded by the suture material and usually manifests at around 1 month to few years following urethroplasty. Urine leaks through STF in drops [Video 1] or in dew drops, difficult to identify without urination [Figure 1]. STF is “minor” but an annoying and frustrating complication following urethroplasty in hypospadias with otherwise an acceptable outcome. Parents grumble due to pant-wetting with urine during urination and which is much of disgrace in the presence of peers.

Figure 1

Dew drop of suture track fistula

Recently, the incidence of non-STF has dropped significantly with dartos flap[1] or tunica vaginalis flap (TVF) as second-layer vascular coverage.[2] However, the incidence of STF is still around 43%,[3] and nothing is found discussed about its remedy excepting its prevention.[34] Most surgeons, out of compulsion, do conventional procedure, which is actually indicated for repair of bigger fistula.

We attempted a short procedure under surface anesthesia as day care for repair of STF.

PATIENTS AND METHODS

Since February 2006–January 2018, we included 42 patients, age ranged from 1.5 to 24 years (mean, 33.2 months), and the Institute Ethical committee approved this study. We explained the procedure to all the parents for their consent. Parents were counseled that three attempts of needling might be necessary at the intervals of 3 months, and on failure, conventional repair of fistula would be necessary.

Usually, all STFs manifested after 1 month following urethroplasty. One patient presented after 9 years of urethroplasty. All of those urethroplasties were done with the suture material of 5–0 or 6–0 polyglycolic acid. Thirty-two of them were operated with tubularised incised plate urethroplasty procedure, six with Mathieu, and four with Thiersch–Duplay urethroplasty. Out of 42 urethroplasties, 20 got TVF as second-layer coverage, and 13 had dartos as mentioned in operative notes. The remainder nine had incomplete operative notes regarding second-layer coverage.

Sometimes, it would be difficult to identify STF clinically, if it is not examined during urination [Figure 1]. Hence, parents were advised to get videograph done during urination. On examination, six patients had only 'dew drop' on STF during urination [Figure 1], and 36 had drops coming out of STF [Video 1]. None had obvious distal narrowing and uroflowmetry study for all patients were at normal range. All of them were advised to 'stop the flow' at STF with a tip of finger during micturition and to carry on calibration of neomeatus for 6 months. Two patients were excluded as they had STFs very close to the neomeatus. Five STFs healed either spontaneously or with calibration. However, STF in 42 patients persisted beyond 6 months and 26 of them had the STF in penile shaft and 12 had in corona and four in the glans.

Patients were premedicated with sedatives and analgesics and prilocaine ointment was applied on penis and kept for around 45 min. Tracks were identified with methylene blue [Figure 2] or by infusing normal saline through urethra [Figure 3]. Otherwise, it would be difficult to identify the STF in the midst of black heads, skin pits, etc. Epithelium of track was ablated with hypodermic needle [Figure 4]. PVC catheter was kept in urethra for compressed dressing to stop minor bleeding and for diversion of urine for 5–7 days.

Figure 2

Methylene blue stained suture track fistula

Figure 3

Saline stream from suture track fistula

Figure 4

Needling of suture track fistula

RESULTS

Twenty out of 42 were cured in single attempt of 'needling' and another 15 STF needed second or third attempts. Two out of four STFs in glans were cured in repeat attempts and two persisted. Four patients improved as flow through STF changed from drops to dew drops [Table 1]. No recurrence was found till date.

Table 1

Outcome table

Position of fistulas (2nd-layer cover) (n=42)	Outcome of needling in number of attempts
	1st	2nd	3rd	Improved	No response
Penile Shaft 26 (TVF=10, dartos=8 , none=8)	20	06	0	0	0
Coronal 12 (TVF=7, dartos=4, none=1)	00	4	3	2	3
Glandular 4 (TVF=3, dartos=1, none=0)	0	1	1	2

TVF: Tunica vaginalis flap

DISCUSSION

STF develops from growth of epithelium scaffolded by the suture material before the suture materials are dissolved. Long-lasting suture material and the suture material causing inflammatory reactions may be more likely to produce the tracks.

Absorbable suture materials, subcuticular closure decrease incidence,[3] and surrounding paucity of vascularity are supposed to be factors in developing of suture track.

Cure rate was found high in penile STF even in single attempt. Possibly due to better vascularity and adequate subcutaneous tissue in penile area compared to corona.

Similarly, 'needling' got better outcome in those STFs in which preceding urethroplasties were done with TVF as vascularized second layer [Table 1].

Stovsky et al. cured small vesicovaginal fistulous track by coagulation of tracks by electrocauterization,[4] causing destruction of epithelium of fistulous track. Similar principle is extrapolated in this study for the treatment of STF. Epithelium of STF is miscreant, and needling is targeted to that offender.

CONCLUSION

The overall outcome is satisfactory and encouraging. We recommend 'needling' for STF before making decision on conventional procedures for repair.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.