Hypospadias surgery is a common procedure performed to correct a congenital condition where the opening of the urethra is not located at the tip of the penis. While generally successful, a potential complication following this surgery is the development of a urethrocutaneous fistula. This complication can be a source of concern for patients and their families, yet it is often manageable with further medical intervention.
What is a Urethrocutaneous Fistula?
A urethrocutaneous fistula is an abnormal connection or opening that forms between the urethra and the skin on the underside of the penis. It commonly occurs as a complication specifically following surgical repair of hypospadias, rather than being a standalone condition.
The formation of this fistula means that after the initial hypospadias surgery, urine may exit through two separate pathways: the newly created urethral opening and the abnormal fistula site. This can result in a split or diverted urine stream and can lead to wetness or leakage in clothing. A fistula is a recognized complication that can occur due to various factors related to the healing process or surgical technique.
Recognizing Signs and Understanding Causes
Identifying a urethrocutaneous fistula involves noticing specific signs related to urination. The most common symptom is urine leaking from an abnormal opening on the underside of the penis, which can lead to persistent wetness in underwear or a split urine stream. Other indicators can include swelling, redness, irritation, or discomfort in the genital area around the abnormal opening.
Several factors can contribute to the formation of a urethrocutaneous fistula after hypospadias surgery. Issues during surgery, such as inadequate tissue closure or poor blood supply to the reconstructed area, can hinder proper healing. Tissue that is fibrotic or unhealthy also carries a higher risk of dehiscence and fistula formation.
Post-operative factors, including infection at the surgical site, can disrupt wound healing. Additionally, factors like a narrow or stenosed urethra (causing increased pressure) or constipation (stressing delicate tissues) may contribute to fistula development. The severity and type of hypospadias, with more complex cases involving longer urethral reconstruction, also influence the risk of fistula formation.
Treatment Options and Recovery
Surgical repair is the primary treatment for a urethrocutaneous fistula. Surgical closure is typically recommended about six months after the initial hypospadias surgery, allowing for complete healing and resolution of local inflammation. For smaller fistulas (generally less than 2 millimeters), a simple closure technique with interrupted inverting sutures may suffice. Larger fistulas, or those with compromised skin, may require more involved techniques, such as layered closure with local skin flaps or a “waterproofing” interposition layer like dartos fascia between the repaired urethra and the skin.
During surgical correction, the fistulous tract is excised, and the urethral defect is closed with absorbable sutures. A second tissue layer, such as dartos fascia, is often used to cover the repaired urethra, providing reinforcement and reducing recurrence risk. In some cases, a urinary catheter may be placed through the urethra for a few days to divert urine and protect the healing site. Recovery involves managing swelling and bruising, which subside within a few weeks, with full recovery expected around six weeks. Patients may have activity restrictions and require specific wound care as advised by their surgeon.
Long-Term Outlook
The long-term outlook after urethrocutaneous fistula repair is generally positive. Success rates for initial surgical repair attempts commonly range from 71% to 89%. If a fistula recurs, subsequent repair attempts often show increased success rates, especially when more complex layered approaches or waterproofing interposition layers are utilized. For instance, studies have shown success rates of 100% with waterproofing procedures.
Recurrence is possible in approximately 10-19% of patients after the initial repair, but most cases are successfully resolved with one or more procedures. Factors such as the size of the fistula, its location, the quality of surrounding tissues, and the number of previous surgeries can influence the success of the repair. Consistent follow-up care is important to monitor for any potential issues and to ensure proper long-term healing and function.