Dermis as an Interposing Reinforcing Layer for Repairing Large Urethrocutaneous Fistula Following Hypospadias Surgery

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Mohammed Bassil Ismail et al., Int. J. Res. Pharm. Sci., 2022, 13(2), 258-262
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I J  R 
P S
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Dermis as an Interposing Reinforcing Layer for Repairing Large
Urethrocutaneous Fistula Following Hypospadias Surgery
Qassim Y N1, Mohammed M J2, Mohammed Bassil Ismail*3
1Department of Surgery, University of Baghdad, College of Medicine, Baghdad, Iraq
2Department of Surgery, University of Anbar, College of Medicine, Ramadi, Iraq
3Urology Department, College of Medicine, University of Baghdad, Baghdad, Iraq
Article History:
Received on: 18 Feb 2022
Revised on: 21 Mar 2022
Accepted on: 22 Mar 2022
Keywords:
Urethrocutaneous
Fistula,
Hypospadias,
Dermis
A
Urethrocutaneous istula (UCF) remains one of the most common complica-
tions following hypospadias repair with variable reported incidence. Avoid-
ance of overlapping of neourethral and skin suture lines by tissue interposi-
tion, signiicantly reduces istula formation. Many techniques for tissue inter-
position have been described. In this study, we evaluated our experience in
using the dermis as interposing layer for repairing large urethrocutaneous
istulas. To evaluate the eficacy of using the dermis in both free graft and
lap forms as an interposing reinforcing layer in repairing large UCF follow-
ing hypospadias surgery. Twenty ive patients with urethrocutaneous istula
complicating hypospadias repair were involved in a prospective study. Their
ages ranged from 4-20 years. All the patients were operated upon under gen-
eral anesthesia. The istula is then closed primarily as a irst layer by turning
the incised margins upside down then dermal lap from the adjacent area or
free dermal graft are used as a second reinforcing layer followed by skin clo-
sure. The patients were scheduled back for regular follow up visits for about 6
months. All the patients presented with istula size more than 4 mm in diam-
eter and the proximal penile shaft was the most frequent site of involvement
(40%). No major complications were observed apart from one case of istula
recurrence in a patient treated by dermal lap.
*Corresponding Author
Name: Mohammed Bassil Ismail
Phone: 07717509371
Email: mohammed_albassil@yahoo.com
ISSN: 0975-7538
DOI: https://doi.org/10.26452/ijrps.v13i2.1264
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INTRODUCTION
Despite the advance in hypospadias repair pro-
cedures, urethrocutaneous istula (UCF) remains
one of most common complications with variable
reported incidence [1]. The reasons why istula
do or do not occur are not fully known. Dei-
ciency in local growth factors in hypospadias skin
might contribute to the high rate of healing com-
plications [2]. Other factors like local infection [2],
local ischemia [3], poor tissue handling [4], distal
obstruction and epithelial interposition between the
edges of neourethra have a signiicant impact on
repair outcome [5].
Avoidance of overlapping of urethral and skin suture
lines by tissue interposition, signiicantly reduces
istula formation [6]. Many techniques for tissue
interposition have been described [7]. Dartos pedi-
cled lap [8]. Tunica vaginalis lap [9] and de-
epithelialized penile skin laps [10] are used fre-
quently. Paucity of local tissue is a challenging issue
in many patients, hence, extra-genital tissues (e.g.
258 © International Journal of Research in Pharmaceutical Sciences

Mohammed Bassil Ismail et al., Int. J. Res. Pharm. Sci., 2022, 13(2), 258-262
fascia lata) are alternative donors [11]. In this study,
we evaluated our experience in using the dermis for
repairing large (≥4 mm) [12] urethrocutaneous is-
tulas both in graft and lap forms.
PATIENT AND METHODS
Patients
Twenty ive patients with urethrocutaneous istula
complicating hypospadias repair were involved in a
prospective study using the dermis as a reinforcing
interposing layer (from March 2015 to September
2017). Their ages ranged from 4-20 years. All the
patients underwent surgical repair after at least one
year from the last failed hypospadias repair proce-
dure.
Surgical Technique
All the patients were operated upon under general
anesthesia. After all the essential steps of draping
and sterilization being accomplished, a stay glan-
ular suture using 3-0 silk was applied, then ure-
thral calibration was routinely performed intraop-
eratively with a urethral sound to exclude any dis-
tal stenosis. The essential marking of the proposed
lap and the margins of istula is done using methy-
lene blue dye, then local iniltration of the area with
diluted epinephrine and lidocaine 2% (1:200,000)
performed to ensure bloodless ield. Foleys catheter
of different calibers are used to divert the urine from
the repaired site (Figure 1).
Figure 1: Marking the proposed lap and the
margins of istula with Foleys catheter inserion
A circumferential incision using No.15 blade is made
around the istula involving the skin and dartos fas-
cia. The istula is then closed primarily as a irst
layer by turning the incised margins upside down
using 5/0 or 6/0 polyglycolic acid suture in a con-
tinuous subdermal manner (Figure 2).
Then the adjacent marked lap is de-epithelialized,
incised, raised and turned over the repaired istula
site and ixed in place using 5/0 polyglycolic acid
suture in an interrupted manner as a second rein-
forcing layer (Figure 3).
Figure 2: A circumferential incision and 1st
layer closure
Figure 3: The lap is de-epithelialized, incised,
raised and inset
For those patients with paucity of local pliable tis-
sues due to recurrent istulas, free dermal graft
was taken from medial arm or cubital lexion
crease (avoiding the hairy areas) and inset over
the repaired istula site using 5/0 polyglycolic acid
suture in an interrupted manner as a second rein-
forcing layer. The donor site is closed in one layer
using polypropylene 3/0 suture in a sbcuticular
manner.
Then the skin is closed by redistribution of penile
and/or scrotal skin using 4/0 polyglycolic acid
suture in an interrupted manner (Figure 4). Small
corrugated drain was left in place to prevent any
possible hematoma formation.
The area is dressed using non-adherent layer (gauze
impregnated with antibiotic ointment) as a irst
layer then dry gauze as an absorbent second layer.
Surgical plaster tape is used to maintain the dressing
in place. All the patients are kept on cephalosporin
antibiotic cover for 7 days (3 days parenterally and
4 days orally).
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Mohammed Bassil Ismail et al., Int. J. Res. Pharm. Sci., 2022, 13(2), 258-262
Figure 4: Steps of closing the istula using free dermal graft
Follow up
All the patients were discharged on the irst post-
operative day after removing the dressing to inspect
the wounds and suture lines and assess the viability
of laps.
The drain also removed and the dressing applied
in the same way and changed every other day for
one week, then the Foleys catheter removed and the
patient is left for normal voiding with digital support
of the area of repair.
Then the patients were scheduled back for regular
visits at a weekly interval in the irst postoperative
month, then monthly for 4-5 consecutive months. In
each visit the healing process was assessed, observ-
ing the suture lines closely to assess any wound
dehiscence or urethrocutaneous istula formation,
also ask the parents or the patient about the stream
of urine and instruct them about the frequent dilata-
tion process using a glass probe lubricated with lido-
caine gel on a daily base for at least 3 months.
RESULT
All the patients presented with large istulas (>4
mm in diameter) as shown in (Table 1). Fistula site
was mostly proximal-penile followed by mid-penile
(Table 2). Twelve of the patients were presented
with recurrent istulas after primary hypospadias
repair. For those patients treated with dermal
laps(15 patients); no postoperative complications
were seen apart from one patient who developed
recurrence of istula due to wound dehiscence fol-
lowing local wound infection (Figure 5). All the
patients(10 patients) who treated by free der-
mal graft had successful repair with normal urine
stream.
Figure 5: Wound dehiscence
DISCUSSION:
During the last decade, many surgical techniques
have been adopted to repaire or prevent the recur-
rent of UCF. All of these techniques were based
on multilayered repair using tissue interposition
between neourethra (irst layer) and the skin to
avoid suture line overlap [12]. However, it is obvi-
ous that these efforts were effective in decreasing
the incidence of UCF but didn′t completely prevent
it [13]. In clinical practice dartos pedicled lap has
the widest application as an interposing reinforc-
ing layer [14]. Similarly tunica vaginalis lap [15].
Both provide additional blood supply for neourethra
and promote healing. But dartos fascia is not always
available in generous amount especially in those
with recurrent istulas and dermal necrosis may
ensure if skin vascularity is compromised [9]. The
use of tunica vaginalis has also some limitations. Its
proximal extent provides some dificulty to obtain
long pedicle to address distal shaft istulas and this
shortage in length can provide secondary chordee.
Beside that, if cremasteric ibers are included with
the lap, penile torque can occur [7].
Deepitheliazed turnover lap (dermal dartos lap)
260 © International Journal of Research in Pharmaceutical Sciences

Mohammed Bassil Ismail et al., Int. J. Res. Pharm. Sci., 2022, 13(2), 258-262
Table 1: Size of Fistula
Size in (mm) No. of Cases (%)
>4-6 2 (8)
>6-8 8 (32)
>8-10 12 (48)
>10-12 2 (8)
>12 1 (4)
Table 2: Site of Fistula
Site No. of Fistula (%)
Penoscrotal 5 (20)
Proximal penile 10 (40)
Mid-penile 7 (28)
Distal penile 3 (12)
was used by Ahuja to repair ten patients with UCF.
Nine of them healed without complications and only
one patient suffered pin point istula that was closed
spontaneousely [10].
In our series of patients, we adopted Ahuja′s
approach (dermal dartos lap as an interposing rein-
forcing layer) to repair ifteen patients with large
UCF. Our results were promising and comparable
with that of Ahuja. Fourteen patients were healed
without complications and only one suffered recur-
rent istula due to local wound infection. These
promising result can be explained by the strength
of interposing layer that is composed of composite
structure, the dermis and its underlying dartos, that
can be designed at any site along the penile shaft.
Similar lap can also be designed to repair istulae
at scrotal area inspite of hair bearing skin because
this lap is small and it is unlikely that more than 3-4
hair follicles will be buried [10]. However, we pre-
fer using tunica vaginalis as interposing layer at the
scrotal region.
All of the above methods may be dificult to apply
in those patients with recurrent large UCF due to
paucity of local pliable tissue that is provided by
scarring process [16]. Hence, it is better to think
of using distant extragenital tissue as an interpos-
ing layer [17]. The promising results of using the
dermis as free patch graft in reconstructive pey-
ronies disease [18] encouraged us to use free dermal
patch graft as an interposing reinforcing layer. We
adopted this technique in ten patients with recur-
rent large UCF. In all of these patients, the istu-
lae were closed successfully. We attributed these
promising results to two points: First to the gener-
ous amount of dermal graft that can cover the whole
neourethra and surrounded area without any ten-
sion and second to well vascularised skin lap that
covers the neourethra and dermal graft because the
dartose fascia is not dissected off the skin. The need
for another incision at the donor site of dermal graft
seems to be the only disadvantage of this technique;
however, the donor site incision is small and can be
camoulaged in the cubital crease or medial arm.
CONCLUSION
In conclusion, dermis seems to be an acceptable
and effective tissue substitute as an interposing and
reinforcing layer in repairing large UCF. However,
larger series of patients and longer period of fellow
up are required to accurately prove these results.
Funding Support
The authors declare that they have no funding sup-
port for this study.
Conlict of Interest
The authors declare that there is no conlict of inter-
est.
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