Urethral fistulae following surgery for scrotal or perineal hypospadias: A 20-year review.
INTRODUCTION
Urethral fistulae (UF) following hypospadias surgery can be a frustrating complication with reports of even 15 attempts to close a difficult fistula (Richter 2003). UF occurring in scrotal or perineal hypospadias (SPH) pose a further challenge because of the under-virilised penis.


OBJECTIVE
To review the outcomes of a single surgeon's experience over 20 years of managing UF in SPH. To analyse the traditional approach of fistula closure and three alternative techniques.


MATERIALS AND METHODS
A prospectively maintained database of patients who underwent hypospadias surgery for SPH from January 1997 to September 2018 was reviewed. Patients with UF were identified and their data recorded. The techniques of fistula closure were: a-Traditional approach. b Purse-string closure. c. Right angle intersection technique where the skin and urethra are closed at right angles to each other. d Anchoring skin to corpora away from the fistula closure.


RESULTS
32 patients with 41 fistulae were identified. Follow-up ranged from 1 to 18 years. 10/32 (31%) had concomitant meatal stenosis or urethral strictures. The sites of UF were: penoscrotal 19/41 (46%), midpenile 14/41 (34%), coronal or subcoronal in 8/41 (20%). One fistula resolved spontaneously after a single urethral dilatation. 4 patients with a coronal fistula were laid open to the glandular meatus creating a coronal hypospadias, with redo-urethroplasty later (in 2 a buccal graft was used). Of the rest, 29 fistulae were cured after one surgery, while 7 needed two attempts. No patient needed more than two surgeries to close the fistula. The recurrence rates were as follows- Purse-string suture: 10%, Right angle intersection technique: 14.3%, Anchoring skin to corpora: 16.7%, Traditional approach: 21.7%. Although the purse-string suture technique had the lowest recurrence rate, the figures did not reach statistical significance (P-0.95).


CONCLUSION
Urethral fistulae occurring in SPH pose challenges because of the under-virilised penis. A third of patients may have meatal stenosis or urethral strictures which must be identified and dealt with. The three novel techniques we employed helped drive down our recurrence rate. Purse string sutures reduce the weak area to a dot and are an excellent way to deal with small fistulae (<5 mm). Other innovations include offsetting the skin suture line by anchoring it to the penile shaft well away from the fistula repair or closing the fistula and skin at right angle to each other. The fact that no patient needed more than two operations to lose the UF, was gratifying.