hypospadias meatoplasty. *J Urol* 1989; 142:1551-3

156:839-41

31

**4. References**

Management of Different Types of Hypspadias 31

over the neourethra with the "Y to I" technique, 4) and application of second layer of vascularized dartos pedicle flap harvested either from the dorsal prepuce or penile shaft

[1] Baskin LS, Colborn T, Himes K. Hypospadias and endocrine disruption: is there a

[2] Snodgrass W. Tubularized incised plate urethroplasty for distal hypospadias.

[3] Snodgrass W, Koyle M, Manzoni G,Horowitz R, Caldamone A, Ehrlich R. Tubularized

[4] Snodgrass W, Koyle M, Manzoni G,Horowitz R, Caldamone A, Ehrlich R. Tubularized

[5] Snodgrass W. Does Tubularized Incised Plate hypospadias repair create neourethra

[6] Borer JG, Bauer SB, Peters CA, DiamondDA, Atala A, Cilento BG. Tubularized incised

[7] Samuel M. and Wilcox DT. Tubularized incised-plate urethroplasty for distal and

[8] Rich MA, Keating MA, Snyder HM III, Duckett JW. Hinging the urethral plate in

[9] Baskin LS, Erol A, Ying WL, Cunha GR.Anatomic studies of hypospadias. *J Uroi* 1998;

[10] Erol A, Baskin LS, Li YW, Liu WH. Anatomical studies of the urethral plate: why

[11] Horasanii K, Perk C, Yesildere T. The effect of catheterization time on tissue

[12] Sozubir S. and Snodgrass W.: A new algorithm for primary hypospadias repair based

[13] Yerkes EB, Adams MC, Miller DA, et al. Y-to-I wrap: Use of the distal spongiosum for

[14] Elbakry A: further experience with Tubularized-incised urethral plate technique for

[15] Lorenzo A and Snodgrass W. Regular dilatation is unnecessary after Tubularized

[16] Snodgrass W.T. and Lorenzo A.J. Tubularized incised-plate urethroplasty for

[17] Yang SS, Chen YT, Hsieh CH, Chen SC. Preservation of the thin distal urethra in

regeneration after a deep urethral plate incision. *BJU int 2000;* 87:20

on tip urethroplasty. *J Pediatric Surg* 2003; 38:1157-1161

incised plate hypospadias repair. *BJU Int*. 2002; 89:94-97

hypospadias reoperation. 2002; *Br J Urol Int* 89:98-100.

hypospadias repair. *J Urol* 2000; 163:1536.

hypospadias repair, 2002; *BJU Int* 89:291-294

hypospadias repair. *J Urol* 2000; 164:151-3.

preservation of the urethral plate is important in hypospadias repair. *BJU Int* 2000;

Incised Plate hypospadias repair, results of a multicenter experience. *J Uro*/1996;

Incised Plate hypospadias repair for proximal hypospadias. *J Uro*/1998; 159:2129-

plate urethroplasty. Expanded use in proximal and repeat surgery for hypospadias.

skin in circumcised patients to cover the suture line after TIP urethroplasty.

connection? *Environ Health Perspect* 2001;109:1175-83.

Fig. 5. Penoscrotal hypospadias with chordee less than 30 degree

Fig. 6. Dorsal plication of the corporal tissue is done in the midline to preserve the urethral plate then, TIP urethrolplasty is performed

over the neourethra with the "Y to I" technique, 4) and application of second layer of vascularized dartos pedicle flap harvested either from the dorsal prepuce or penile shaft skin in circumcised patients to cover the suture line after TIP urethroplasty.

#### **4. References**

30 Current Concepts of Urethroplasty

Fig. 5. Penoscrotal hypospadias with chordee less than 30 degree

Fig. 6. Dorsal plication of the corporal tissue is done in the midline to preserve the urethral

plate then, TIP urethrolplasty is performed

**4**

*1,2Palestine 3Turkey*

**Urethroplasty;**

**Wide Range of Therapeutic**

**Indications and Surgical Techniques**

Mahmoud Mustafa1, Dina Abugaber2, Sacit Nurigorgel3, Ertugrul Sefik3, Ozan Horsanali3 and Wael Sadaqah2

*2Rafidia State Hospital, Intensive Care Unit, Nablus-West-Bank, 3Izmir Ataturk Teaching Hospital, Urology Department, Izmir*

*1An-Najah University, School of Medicine, Urology Department, Nablus-West-Bank,*

Urethroplasty means plastic surgery of the urethra. Herein we are going to describe urethroplasty in terms of; diagnosis, indications, surgical techniques and definition of failure or success. A lot of issues related to urethroplasty remain to be defined, therefore we

There are two main causes which mandate urethroplasty; the first is the congenital anomalies with hypospadias being the most common, and the acquired anomalies with urethral stricture being the most common of them. Hypospadias is found commonly in newborn boys and it seen in approximately 8.2 per 1000 births.  There are more than 200 named surgical procedure to correct hypospadias. Now a days tubularized incised plate (TIP) urethroplasty described by Snodgrass in 1994 is the most common procedure used for repair of hypospadias. The advantages of this technique include its simplicity, high success rate, low rate of complication and excellent cosmetic results. A lot of modifications were introduced on the TIP urethroplasty aiming to improve the success rate and to decrease fistula formation. We were from the firsts who published such modification regarding the use of double- layer dartos flap covering for urethra instead of the classic way

The second cause of urethroplasty is the acquired anomalies. Strictures of urethra is of much clinical important than hypospadias, because it bothers the patients more, unfortunately the results of surgery is not promising as that of hypospadias. The term "urethral stricture" refer to anterior urethral disease or scaring process involving the spongy erectile tissue of the corpus spongiosum (spongiofibrosis). According to World Health Organization posterior urethral stricture are not included in the common definition of urethral stricture

will clarify the debatable issues and highlight the last advances on urethroplasty.

of utilizing dorsal dartos flap (button hole maneuver).

**1. Introduction**

### **Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques**

Mahmoud Mustafa1, Dina Abugaber2, Sacit Nurigorgel3, Ertugrul Sefik3, Ozan Horsanali3 and Wael Sadaqah2 *1An-Najah University, School of Medicine, Urology Department, Nablus-West-Bank, 2Rafidia State Hospital, Intensive Care Unit, Nablus-West-Bank, 3Izmir Ataturk Teaching Hospital, Urology Department, Izmir 1,2Palestine 3Turkey*

#### **1. Introduction**

32 Current Concepts of Urethroplasty

[18] Sarin YK, Manchanda V. Preservation of urethra devoid of corpus spongiosum in

[19] Al-Saied G and Gamal A. Versatility of tubularized incised plate urethroplasty in the

management of different types of hypospadias: 5-year experience. *Afr J Paediatr*

patients undergoing urethroplasty. *Indian J Urol* 2006; 22:326-8

*Surg* 2009; 6:88-92

Urethroplasty means plastic surgery of the urethra. Herein we are going to describe urethroplasty in terms of; diagnosis, indications, surgical techniques and definition of failure or success. A lot of issues related to urethroplasty remain to be defined, therefore we will clarify the debatable issues and highlight the last advances on urethroplasty.

There are two main causes which mandate urethroplasty; the first is the congenital anomalies with hypospadias being the most common, and the acquired anomalies with urethral stricture being the most common of them. Hypospadias is found commonly in newborn boys and it seen in approximately 8.2 per 1000 births.  There are more than 200 named surgical procedure to correct hypospadias. Now a days tubularized incised plate (TIP) urethroplasty described by Snodgrass in 1994 is the most common procedure used for repair of hypospadias. The advantages of this technique include its simplicity, high success rate, low rate of complication and excellent cosmetic results. A lot of modifications were introduced on the TIP urethroplasty aiming to improve the success rate and to decrease fistula formation. We were from the firsts who published such modification regarding the use of double- layer dartos flap covering for urethra instead of the classic way of utilizing dorsal dartos flap (button hole maneuver).

The second cause of urethroplasty is the acquired anomalies. Strictures of urethra is of much clinical important than hypospadias, because it bothers the patients more, unfortunately the results of surgery is not promising as that of hypospadias. The term "urethral stricture" refer to anterior urethral disease or scaring process involving the spongy erectile tissue of the corpus spongiosum (spongiofibrosis). According to World Health Organization posterior urethral stricture are not included in the common definition of urethral stricture

Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques 35

urethra resulted in a significant impairment of erectile function initially which improved in

The second kind of urethroplasty is substitution urethroplasty. Recent advances in tissue graft sources and the introduction of tissue sealants improve surgical outcomes and minimize patients morbidity by decreasing the number of surgical procedures and the potential disfigurement related to graft site morbidity. Substitution urethroplasty can be performed as a one-stage procedure via an augmented anastomotic procedure, patch substitution (onlay procedure) or a circumferential patch, or two-stage procedure which involves the formation of a roof strip followed be second stage tubularization. It has been shown that the efficacy of both grafts and flaps was identical , but there was a much higher morbidity with penile skin flaps which were also more complex with higher morbidity. The graft which has been used included scrotal skin, oral mucosa, extragenital skin, bladder mucosa, and colonic mucosa. The success rate at average follow-up of 53 months was

reported to be 60% for augmented anastomotic repair and 80% for onlay procedure.

In conclusion urethroplasty especially in patients with urethral stricture required the urologist to be aware of the techniques which offer the patient the best success. Therefore different considerations have to be taken into account like length , location, anatomy and etiology of stricture. In comparison to reconstruction of urethral stricture, urethroplasty done due to hypospadias seems to be less complicated with high success rate at long term

The bulbous urethra is eccentrically placed in relation to urethra to the corpus spongiosum and much closer to the dorsum of the penile structures. As one moves distally, the pendulous or penile urethra becomes more centrally placed within the corpus spongiousm. Any process that injuries the urethral epithelium or the underlining corpus spongiousm to the point that healing results in a scar an anterior urethral stricture. Today, most urethral stricture are the results of trauma (usually straddle trauma). Inflammatory strictures associated with gonorrhea were the most commonly seen in the past and are less common now due to the effective antibiotic treatment. The place of Chlamydia and Ureaplasma urealyticum (non-specific urethritis) in the development of anterior urethral stricture is not clear. To date, no clear association between nonspecific urethritis and the development of anterior urethral stricture has been established. Congenital stricture is used by some to define a stricture for which there is no identifiable cause. We propose, however to define a stricture as congenital only if it is not an inflammatory stricture, it is a short-length stricture and it is not associated with history of or potential for urethral trauma. And it is the rarest encountered. The location of urethral stricture was classified as penile (including navicularis fossa), bulbar or posterior(excluding bladder neck contracture). According to world health organization posterior urethral stricture are not included in the common definition of urethral stricture and the term stricture is limited to the anterior urethra. Posterior urethral stricture commonly caused by traumatic disruption in contrast to that of anterior stricture. Beside urethral stricture, congenital anomalies of urethra mandate reconstructive surgery for urethra. Hypospadias is the most common of these causes. Although the definite cause of hypospadias is still undefined, the management of these patients is the same regardless to etiologies or kinds of hypospadias. There are many classification systems for hypospadias depending on the location of the meatus; coronal, subcoronal, midshaft and penoscrotal hypospadias. Hypospadias is seen in approximately 8.2 per 1000 birth [1]. There are more

the majority of cases with a low of long term erectile dysfunction.

follow-up.

**2. Urethral stricture**

and the term stricture is limited to the anterior urethra. Urethral disruption injuries typically occur in conjunction with multisystem trauma from vehicular accident, falls, or industrial accident. Because the posterior urethra is fixed at both the urogenital diaphragm and the puboprostatic ligaments, the bulbomembranous junction is more vulnerable to injury during pelvic fractures. When the fracture occur the two separated ends fill with scar tissue, resulting in a complete lack of urethral continuity. The location of urethral strictures was classified as penile(including navicularis fossa) , bulbar or posterior (excluding bladder neck contractures).While posterior urethral strictures were commonly caused by traumatic disruption distinctly different from etiology compared to that of anterior strictures disease, recurrence was monitored with the same procedure used for surveillance of anterior urethral reconstruction.

The Urethral disruption is heralded by the triad of blood at the meatus, inability to urinate, and palpably full bladder. When blood at the urethral meatus is discovered, an immediate retrograde urethrogram should be performed to rule out urethral injury.When urethral stricture is diagnosed immediate suprapubic tube placement remains the standard of care.

While the diagnosis of hypospadias needs no radiologic tests, diagnosis of urethral stricture is a matter of discussion. The most common primary diagnostic tests are uroflowmetry (56%), urethrography (51%) and cystourethroscopy (21%). Definition of recurrence of stricture or failure of surgery is also a questionable issue. In 75% of papers regarding urethroplasty, recurrence was defined as the need for additional surgical procedure and in 52% as the need for additional urethral dilation.

 The treatment of urethral strictures is divided in two groups; endoscopic and open surgery. The endoscopic treatment such as direct-vision internal urethrotomy are the best reserved for selected short urethral stricture. However when the defects are 1 cm or longer or when a significant corpus spongiofibrosis is present , endoscopic procedure such as cutting through the pelvic scare"cut-to-light" are ineffective. Despite the popularity of this procedure the failure rate after initial urethrotomy is reported to be at least 50%. The failure rate after the second urethrotomy is considered much higher and can be as high as 100%. Therefore there has been continuing discussion about the most appropriate use of urethrotomy, dilation, stenting, and intermittent self dilation. Question have also surfaced about the best technique for urethrotomy. There is no compelling evidence in the literature that any particular form of urethrotomy is more effective than another, whether using a cold knife or laser.

The second treatment option is open surgical reconstruction. There are two kinds of open surgical techniques used for urethroplasty; anastomotic urethroplasty and substitution urethroplasty. Anastomotic urethroplasty involves excision of the strictures and primary anastomosis of urethral ends. Open posterior urethroplasty through a perineal anastomotic approach is the treatment of choice for the most urethral distraction injuries because it definitely cure the patient without the need for multiple procedure. Care must be taken to carefully and meticulously excise all fibrotic tissue from the proximal urethra margin until at least a 28 french bougie passes without resistance. Free tension end to end anastomosis is the procedure of choice when the scar is 1.5-2 cm long and this is highly successful procedure in more than 95% of cases. Urethroplasty remains the gold standard for the management of urethral stricture offering the lowest rate of stricture recurrence and in some circumstance the most cost-effective compared to repeat dilation or endoscopic incision. The limiting factors with anastomotic urethroplasty is the strictures length, in particular the length of component distal to bulbopenile junction. Anastomatic procedure in the bulbar urethra resulted in a significant impairment of erectile function initially which improved in the majority of cases with a low of long term erectile dysfunction.

The second kind of urethroplasty is substitution urethroplasty. Recent advances in tissue graft sources and the introduction of tissue sealants improve surgical outcomes and minimize patients morbidity by decreasing the number of surgical procedures and the potential disfigurement related to graft site morbidity. Substitution urethroplasty can be performed as a one-stage procedure via an augmented anastomotic procedure, patch substitution (onlay procedure) or a circumferential patch, or two-stage procedure which involves the formation of a roof strip followed be second stage tubularization. It has been shown that the efficacy of both grafts and flaps was identical , but there was a much higher morbidity with penile skin flaps which were also more complex with higher morbidity. The graft which has been used included scrotal skin, oral mucosa, extragenital skin, bladder mucosa, and colonic mucosa. The success rate at average follow-up of 53 months was reported to be 60% for augmented anastomotic repair and 80% for onlay procedure.

In conclusion urethroplasty especially in patients with urethral stricture required the urologist to be aware of the techniques which offer the patient the best success. Therefore different considerations have to be taken into account like length , location, anatomy and etiology of stricture. In comparison to reconstruction of urethral stricture, urethroplasty done due to hypospadias seems to be less complicated with high success rate at long term follow-up.

#### **2. Urethral stricture**

34 Current Concepts of Urethroplasty

and the term stricture is limited to the anterior urethra. Urethral disruption injuries typically occur in conjunction with multisystem trauma from vehicular accident, falls, or industrial accident. Because the posterior urethra is fixed at both the urogenital diaphragm and the puboprostatic ligaments, the bulbomembranous junction is more vulnerable to injury during pelvic fractures. When the fracture occur the two separated ends fill with scar tissue, resulting in a complete lack of urethral continuity. The location of urethral strictures was classified as penile(including navicularis fossa) , bulbar or posterior (excluding bladder neck contractures).While posterior urethral strictures were commonly caused by traumatic disruption distinctly different from etiology compared to that of anterior strictures disease, recurrence was monitored with the same procedure used for surveillance of anterior

The Urethral disruption is heralded by the triad of blood at the meatus, inability to urinate, and palpably full bladder. When blood at the urethral meatus is discovered, an immediate retrograde urethrogram should be performed to rule out urethral injury.When urethral stricture is diagnosed immediate suprapubic tube placement remains the standard of care. While the diagnosis of hypospadias needs no radiologic tests, diagnosis of urethral stricture is a matter of discussion. The most common primary diagnostic tests are uroflowmetry (56%), urethrography (51%) and cystourethroscopy (21%). Definition of recurrence of stricture or failure of surgery is also a questionable issue. In 75% of papers regarding urethroplasty, recurrence was defined as the need for additional surgical procedure and in

 The treatment of urethral strictures is divided in two groups; endoscopic and open surgery. The endoscopic treatment such as direct-vision internal urethrotomy are the best reserved for selected short urethral stricture. However when the defects are 1 cm or longer or when a significant corpus spongiofibrosis is present , endoscopic procedure such as cutting through the pelvic scare"cut-to-light" are ineffective. Despite the popularity of this procedure the failure rate after initial urethrotomy is reported to be at least 50%. The failure rate after the second urethrotomy is considered much higher and can be as high as 100%. Therefore there has been continuing discussion about the most appropriate use of urethrotomy, dilation, stenting, and intermittent self dilation. Question have also surfaced about the best technique for urethrotomy. There is no compelling evidence in the literature that any particular form

of urethrotomy is more effective than another, whether using a cold knife or laser.

The second treatment option is open surgical reconstruction. There are two kinds of open surgical techniques used for urethroplasty; anastomotic urethroplasty and substitution urethroplasty. Anastomotic urethroplasty involves excision of the strictures and primary anastomosis of urethral ends. Open posterior urethroplasty through a perineal anastomotic approach is the treatment of choice for the most urethral distraction injuries because it definitely cure the patient without the need for multiple procedure. Care must be taken to carefully and meticulously excise all fibrotic tissue from the proximal urethra margin until at least a 28 french bougie passes without resistance. Free tension end to end anastomosis is the procedure of choice when the scar is 1.5-2 cm long and this is highly successful procedure in more than 95% of cases. Urethroplasty remains the gold standard for the management of urethral stricture offering the lowest rate of stricture recurrence and in some circumstance the most cost-effective compared to repeat dilation or endoscopic incision. The limiting factors with anastomotic urethroplasty is the strictures length, in particular the length of component distal to bulbopenile junction. Anastomatic procedure in the bulbar

urethral reconstruction.

52% as the need for additional urethral dilation.

The bulbous urethra is eccentrically placed in relation to urethra to the corpus spongiosum and much closer to the dorsum of the penile structures. As one moves distally, the pendulous or penile urethra becomes more centrally placed within the corpus spongiousm. Any process that injuries the urethral epithelium or the underlining corpus spongiousm to the point that healing results in a scar an anterior urethral stricture. Today, most urethral stricture are the results of trauma (usually straddle trauma). Inflammatory strictures associated with gonorrhea were the most commonly seen in the past and are less common now due to the effective antibiotic treatment. The place of Chlamydia and Ureaplasma urealyticum (non-specific urethritis) in the development of anterior urethral stricture is not clear. To date, no clear association between nonspecific urethritis and the development of anterior urethral stricture has been established. Congenital stricture is used by some to define a stricture for which there is no identifiable cause. We propose, however to define a stricture as congenital only if it is not an inflammatory stricture, it is a short-length stricture and it is not associated with history of or potential for urethral trauma. And it is the rarest encountered. The location of urethral stricture was classified as penile (including navicularis fossa), bulbar or posterior(excluding bladder neck contracture). According to world health organization posterior urethral stricture are not included in the common definition of urethral stricture and the term stricture is limited to the anterior urethra. Posterior urethral stricture commonly caused by traumatic disruption in contrast to that of anterior stricture.

 Beside urethral stricture, congenital anomalies of urethra mandate reconstructive surgery for urethra. Hypospadias is the most common of these causes. Although the definite cause of hypospadias is still undefined, the management of these patients is the same regardless to etiologies or kinds of hypospadias. There are many classification systems for hypospadias depending on the location of the meatus; coronal, subcoronal, midshaft and penoscrotal hypospadias. Hypospadias is seen in approximately 8.2 per 1000 birth [1]. There are more

Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques 37

The most common complication seen in hypospadias correction is urethrocutanous fistula [8,9,10,11]. The rate of fistula was reported to be 3.5% in the present series [12,13]. Several modifications have been introduced on TIP urethroplasty to decrease the rate of fistula, especially regarding the usage of the dorsal dartos flap and we are from the first who applied this novel modification [6,14] (Figure 1). We introduced the usage of double layers dartos flap for the neourethra instead of one layer covering (Figure 1). There were different techniques concerning one layer covering. Retik and Borer described covering the neourethra with an asymmetric rotational subcutaneous dartos tissue flap [15], Yer-kes et al used a Y-to-I warp spongiosum for neourethra reinforcement [16]. Sozubir and Snodgrass [17] also used a dorsal dartos pedicle flap obtained from dorsal prepuce with buttonhole

 Urethral stricture differed from hypospadias in terms of; etiology, diagnosis, management, success rate and postoperative follow up. The etiology of hypospadias is congenital, however in urethral stricture, wide range of causes are present, traumatic, infectious and congenital cause as we mentioned before. While the physical examination is enough to diagnose hypospadias, the diagnosis of urethral stricture is not so much simple(we will discuss this issue in the coming sections). The surgical management of hypospadias is more simple and lead to more success in comparison to urethroplasty done due to urethral

Urethral stricture refer to anterior urethral disease scaring process involving the spongy erectile tissue of the corpus spongiosum. According to world health organization posterior urethral stricture are not included in the common definition of urethral stricture and the term stricture is limited to the anterior urethra. Because the posterior urethra is fixed at both the urogenital diaphragm and the puboprostatic ligaments, the bulbomembranous junction is more vulnerable to injury during pelvic fracture. In children, injuries are more likely to

Diagnosis of urethral stricture begins by physical examination, the triad of blood at urethral meatus, inability to urinate, and palpably full bladder. Urethral disruption is often first detected when urethral catheter cannot be placed or when it is misplaced into pelvic hematoma. Females with urethral injuries presents with vulvar edema and blood at the vaginal introitus, thus indicating the need for careful vaginal examination in all female patients with pelvic fracture. Retrograde Urethrography (RGU) should be done when the blood at urethral meatus is discovered. Small-bore urethral catheter (16 French) is placed unlibricated 1 cm into the fossa navicularis and the balloon is filled with 1 cm of water or Brodney clamp or rolled gauze bandage can be used to provide penile traction. Regarding the usage of local anesthetic jel during retrograde urethrography, recently we published study regarding the usage lidocaine and we concluded that although usage of local anesthetic jel may lead to statistically significant dilatation of urethral diameter, clinically no false negative results in the diagnosis of urethral stricture were observered. [18]. Patients should be placed in an oblique or lateral decubitus position, and it is preferable to perform the study under fluorography, 28 ml of contrast material is injected gently by a 60-ml catheter-tip syringe and the film is taking during injection. The sensitivity and specificity to identify stricture by RGU are 67% to 100% and 93% to 97% with positive and negative predictive values of 50% and 97% to 100% respectively for anterior urethral stricture 3 to 5 cm long [19]. Limitation of RUG and VCUG include readily available fluoroscopic equipment and radiation exposure(1.1 mSV average for VCUG ie equivalent to approximately 11 chest x-rays [20]. Antegrade urethrography can be performed through suprapubic tube placed

stricture. We will discuss in detail the surgical treatment of urethral stricture.

extend proximally to the bladder because of the rudimentary nature of the prostate.

maneuver transposition of flap.

than 200 named surgical procedures for correction of hypospadias with a few common general concept.  Tubularized incised plate (TIP) urethroplasty has gained widespread acceptance for repairing hypospadias and has become the therapy of choice for many kinds of hypospadias [2,3,4,5,6]. Tubularized incised urethroplasty was introduced by Snodgrass in 1994, for coronal and subcoronal (distal) cases of hypospadias [3]. Latter on a lot of papers tested the validity of this technique for more complicated hypospadias i.e midshaft and penoscrotal hypospadias and we were from those who claimed such validity [7]. The superiority of TIP urethroplasty technique comes from few key points, midline incision by which the urethral plate is widened to create tension free neourethra, subcutaneous flap which reinforced the neourethra and decrease incidence of fistula (Figure 1 a,b,c,d).

(a) (b)

(c) (d)

Fig. 1. (a) A 17-year-old patient with penoscrotal hypospadiac meatus where the the main key points of TIP urethroplasty are demonstrated; U-shaped insicion, midline incision in urethroplate, (b) Posterior dartos flap prepared from subcutanous tissue, (c) Dorsal dartos flap is incised from the middle thus both of layer can be rotated ventrally, (d) Shows how both of the layers of the flap covered the neourethra

than 200 named surgical procedures for correction of hypospadias with a few common general concept.  Tubularized incised plate (TIP) urethroplasty has gained widespread acceptance for repairing hypospadias and has become the therapy of choice for many kinds of hypospadias [2,3,4,5,6]. Tubularized incised urethroplasty was introduced by Snodgrass in 1994, for coronal and subcoronal (distal) cases of hypospadias [3]. Latter on a lot of papers tested the validity of this technique for more complicated hypospadias i.e midshaft and penoscrotal hypospadias and we were from those who claimed such validity [7]. The superiority of TIP urethroplasty technique comes from few key points, midline incision by which the urethral plate is widened to create tension free neourethra, subcutaneous flap which reinforced the

neourethra and decrease incidence of fistula (Figure 1 a,b,c,d).

circumcision incision

U incision

hypospadiac meatus

(a) (b)

(c) (d)

both of the layers of the flap covered the neourethra

Fig. 1. (a) A 17-year-old patient with penoscrotal hypospadiac meatus where the the main key points of TIP urethroplasty are demonstrated; U-shaped insicion, midline incision in urethroplate, (b) Posterior dartos flap prepared from subcutanous tissue, (c) Dorsal dartos flap is incised from the middle thus both of layer can be rotated ventrally, (d) Shows how

traction suture

midline incision

The most common complication seen in hypospadias correction is urethrocutanous fistula [8,9,10,11]. The rate of fistula was reported to be 3.5% in the present series [12,13]. Several modifications have been introduced on TIP urethroplasty to decrease the rate of fistula, especially regarding the usage of the dorsal dartos flap and we are from the first who applied this novel modification [6,14] (Figure 1). We introduced the usage of double layers dartos flap for the neourethra instead of one layer covering (Figure 1). There were different techniques concerning one layer covering. Retik and Borer described covering the neourethra with an asymmetric rotational subcutaneous dartos tissue flap [15], Yer-kes et al used a Y-to-I warp spongiosum for neourethra reinforcement [16]. Sozubir and Snodgrass [17] also used a dorsal dartos pedicle flap obtained from dorsal prepuce with buttonhole maneuver transposition of flap.

 Urethral stricture differed from hypospadias in terms of; etiology, diagnosis, management, success rate and postoperative follow up. The etiology of hypospadias is congenital, however in urethral stricture, wide range of causes are present, traumatic, infectious and congenital cause as we mentioned before. While the physical examination is enough to diagnose hypospadias, the diagnosis of urethral stricture is not so much simple(we will discuss this issue in the coming sections). The surgical management of hypospadias is more simple and lead to more success in comparison to urethroplasty done due to urethral stricture. We will discuss in detail the surgical treatment of urethral stricture.

Urethral stricture refer to anterior urethral disease scaring process involving the spongy erectile tissue of the corpus spongiosum. According to world health organization posterior urethral stricture are not included in the common definition of urethral stricture and the term stricture is limited to the anterior urethra. Because the posterior urethra is fixed at both the urogenital diaphragm and the puboprostatic ligaments, the bulbomembranous junction is more vulnerable to injury during pelvic fracture. In children, injuries are more likely to extend proximally to the bladder because of the rudimentary nature of the prostate.

Diagnosis of urethral stricture begins by physical examination, the triad of blood at urethral meatus, inability to urinate, and palpably full bladder. Urethral disruption is often first detected when urethral catheter cannot be placed or when it is misplaced into pelvic hematoma. Females with urethral injuries presents with vulvar edema and blood at the vaginal introitus, thus indicating the need for careful vaginal examination in all female patients with pelvic fracture. Retrograde Urethrography (RGU) should be done when the blood at urethral meatus is discovered. Small-bore urethral catheter (16 French) is placed unlibricated 1 cm into the fossa navicularis and the balloon is filled with 1 cm of water or Brodney clamp or rolled gauze bandage can be used to provide penile traction. Regarding the usage of local anesthetic jel during retrograde urethrography, recently we published study regarding the usage lidocaine and we concluded that although usage of local anesthetic jel may lead to statistically significant dilatation of urethral diameter, clinically no false negative results in the diagnosis of urethral stricture were observered. [18]. Patients should be placed in an oblique or lateral decubitus position, and it is preferable to perform the study under fluorography, 28 ml of contrast material is injected gently by a 60-ml catheter-tip syringe and the film is taking during injection. The sensitivity and specificity to identify stricture by RGU are 67% to 100% and 93% to 97% with positive and negative predictive values of 50% and 97% to 100% respectively for anterior urethral stricture 3 to 5 cm long [19]. Limitation of RUG and VCUG include readily available fluoroscopic equipment and radiation exposure(1.1 mSV average for VCUG ie equivalent to approximately 11 chest x-rays [20]. Antegrade urethrography can be performed through suprapubic tube placed

Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques 39

stricture was defined as the need for an additional surgical procedure or dilatation in 75% and 52% of articles respectively . Clearly standardization is required and the methods used to determine stricture recurrence after urethroplasty remain widely variable. There are many objective and subjective procedures to evaluate for stricture recurrence. Standardization of A surveillance protocol after urethroplasty is needed to more effectively

In our opinion both objective and subjective patients satisfaction outcomes should be evaluated. Objective measures should be ideally involve urethrography or cystourethroscopy, flow rate is a poor indicator of urethral lumen diameters and a significant impact on flow

The management of urethral stricture disease in adult males has a wide range of possible therapeutics treatments. Urethral stricture are often treated with urethrotomy most commonly direct vision internal urethrotomy (DVIU) [34,35]. The popularity of this procedure has been attributed to the ease of performance, a perceived low complication rate and the fact that many north American urologists don not perform open urethroplasty so they may be forced to perform repeat urethrotomy[34,36]. The failure after initial urethrotomy is reported to be 50% [37,38]. The failure after second urethrotomy is considered much higher and can be as high as 100% [35,37,38]. Santucci R et al [39] performed retrospective review of more than 100 patients as a first study in north America, to evaluate the stricture free rate not only after single urethrotomy but after 2 through 5 procedure. He concluded that urethrotomy is a popular treatment for male urethral stricture. However the performance characteristics are poor. The Success rates after 1 urethrotomy was a mere 8% and after multiple urethrotomies was close to 0%. Because urethroplasty has long-term success rate ranging from 75-100 , increased use of this more effective treatment may be warranted[40]. Urethrotmoy should be reserved as a temporizing measure for poor surgical candidates until further reconstruction can be planned and executed. The majority of the base evidence base for the management of urethral strictures dos not reach level 1 according to the oxford classification. With the rarity of significantly powered randomized controlled trials, we have to look to observational studies and expert opinion for guidance. In recent years there has been continuing discussion about the most appropriate use of urethrotomy, dilatation, stenting and intermittent self dilatation. We believe that self intermittent dilatation may be beneficial at least in prolonging the period between urethrotomies. There is no compelling evidence in literature that any particular from of urethrotomy is more effective than another, whether using a cold knife or laser. Heyns et al looked at whether repeated dilatation or urethrotomy was useful and noted that after single treatment 70% would be stricture free at three months, 35-40% would be remain stricture free at 24 months, but not at 48 months. A third treatment was of no benefit at all

Successful out comes from urethrotomy or dilatation requires adequate vascularity within the under lining corpus spongiusom and is more likely to be successful in the bulbar urethra. Whilest et al [42] found up to two internal urethrotomy did not affect the outcomes or likelihood of subsequent anastomotic urethroplasty in patients with posterior injuries. For the anterior urethra using cox hazards regression analysis, failed internal urethrotomy

compare outcomes among institutions.

**3.1 Endoscopic management**

[41].

rate is not observered until the urethral diameters is below 11F.

**3. Treatment of urethral stricture; Endoscopic or open surgery?**

after reconstruction. The initial management after the immediate diagnosis of urethral trauma is suprapubic catheter. The preoperative evaluation of urethral stricture before reconstructive procedure is planned, are imaging studies are necessary to delineate the characteristics of urethral stricture defect. A cystogram and retrograde urethrogram should be obtained simultaneously. Besides these mains method of diagnosis a lot of methods can help in detecting urethral stricture; voiding symptoms and questionnaires described in the clinical history of the patient is the most basic and essential screening procedure to detect stricture. Multiple studies have evaluated the correlation between the AUA-SS and the presence of urethral stricture. The AUA-SS has been inversely correlated with urethral diameters by retrograde urethrogram and flow rates by uroflowmetry [21] .Morey et al demonstrated significant improvement in AUA-SS after successful urethroplasty that correlated with radiographic evidence of a patent urethra by retrograde urethrogram in 41of 50 patients [22]. Urine culture/ urinary tract infection occurred due to increased post-void residual (PVR) and urinary stasis in patients with stricture. Urinary tract infection (UTI) is a common complication immediately after urethroplasty at reported rate of 6% [23]. To our knowledge no study has correlated postoperative UTI with stricture recurrence. Further studies are needed to determine the usefulness of urine culture as screening methods and the correlation between symptomatic UTI and stricture recurrence. Ultrasound PVR measurement is noninvasive technique that provide objective measurement of bladder emptying [24]. One may predict that high PVR volume would predict stricture. Unfortunately sonographic measurement are often user dependent with high interest variability [25] and up to two-third of patients may demonstrate daily variability in PVR of greater than 600m [26]. Uroflowmetry is one of the most used measures to evaluate stricture. It is easily performed noninvasive and may allow quantitive data regarding voiding patterns[27]. Similar to ultrasound PVR, flow rates may be affected by operator error, benign prostate hyperplasia (BPH), lower urinary tract symptom, bladder dysfunction and variation in bladder capacity [28]. Further limitation of uroflowmetry include the needed for a minimum voided volume of 125 to 150 ml to reach a voided flow rate that reliably predicts an abnormality. Urethral ultrasound is relatively new technique for the evaluation of urethral stricture disease. First described by the McAninch et al in 1988 [29], urethral ultrasound(UU) to identify stricture has a reported sensitivity of 66% to 100%, specificity of 97% to 98%, and positive and negative predictive values of 50% to 80% and 96% to 98% respectively for anterior stricture 3 to 5 cm long. The usefulness of UU is limited by stricture location as it is more sensitive to stricture in the penile urethra than in bulbar portion [30]. It is also user dependency and the semi-invasive nature of the procedure often requiring local or general anesthesia for full urethra distention. It is benefit it can give three dimensional information about the stricture location and length. Magnetic resonance (MR) urethrography is a promising tool for defining male urethral strictures. It has comparable results with the combined RUG and SUG in diagnosing the anterior and posterior urethral strictures as regard the site and extension and degree of spongiofibrosis but MR is superior in diagnosis of associated pathologies with stricture as it can provide extra-guidance for treatment planning that cannot be obtained with RUG [31,32].

In one of the most large systematic review for the diagnosis for recurrence stricture recurrence after urethroplasty conducted by Meeks et al [33] in their analysis of urethroplasty publication since 2000 found urethroplasty outcomes was determined by up to eight different diagnostics tests. The most common were uroflowmetry 56%,and retrograde urethrography 51%. Cystourethrography was used in 25% of patients. Recurrence of stricture was defined as the need for an additional surgical procedure or dilatation in 75% and 52% of articles respectively . Clearly standardization is required and the methods used to determine stricture recurrence after urethroplasty remain widely variable. There are many objective and subjective procedures to evaluate for stricture recurrence. Standardization of A surveillance protocol after urethroplasty is needed to more effectively compare outcomes among institutions.

In our opinion both objective and subjective patients satisfaction outcomes should be evaluated. Objective measures should be ideally involve urethrography or cystourethroscopy, flow rate is a poor indicator of urethral lumen diameters and a significant impact on flow rate is not observered until the urethral diameters is below 11F.

#### **3. Treatment of urethral stricture; Endoscopic or open surgery?**

#### **3.1 Endoscopic management**

38 Current Concepts of Urethroplasty

after reconstruction. The initial management after the immediate diagnosis of urethral trauma is suprapubic catheter. The preoperative evaluation of urethral stricture before reconstructive procedure is planned, are imaging studies are necessary to delineate the characteristics of urethral stricture defect. A cystogram and retrograde urethrogram should be obtained simultaneously. Besides these mains method of diagnosis a lot of methods can help in detecting urethral stricture; voiding symptoms and questionnaires described in the clinical history of the patient is the most basic and essential screening procedure to detect stricture. Multiple studies have evaluated the correlation between the AUA-SS and the presence of urethral stricture. The AUA-SS has been inversely correlated with urethral diameters by retrograde urethrogram and flow rates by uroflowmetry [21] .Morey et al demonstrated significant improvement in AUA-SS after successful urethroplasty that correlated with radiographic evidence of a patent urethra by retrograde urethrogram in 41of 50 patients [22]. Urine culture/ urinary tract infection occurred due to increased post-void residual (PVR) and urinary stasis in patients with stricture. Urinary tract infection (UTI) is a common complication immediately after urethroplasty at reported rate of 6% [23]. To our knowledge no study has correlated postoperative UTI with stricture recurrence. Further studies are needed to determine the usefulness of urine culture as screening methods and the correlation between symptomatic UTI and stricture recurrence. Ultrasound PVR measurement is noninvasive technique that provide objective measurement of bladder emptying [24]. One may predict that high PVR volume would predict stricture. Unfortunately sonographic measurement are often user dependent with high interest variability [25] and up to two-third of patients may demonstrate daily variability in PVR of greater than 600m [26]. Uroflowmetry is one of the most used measures to evaluate stricture. It is easily performed noninvasive and may allow quantitive data regarding voiding patterns[27]. Similar to ultrasound PVR, flow rates may be affected by operator error, benign prostate hyperplasia (BPH), lower urinary tract symptom, bladder dysfunction and variation in bladder capacity [28]. Further limitation of uroflowmetry include the needed for a minimum voided volume of 125 to 150 ml to reach a voided flow rate that reliably predicts an abnormality. Urethral ultrasound is relatively new technique for the evaluation of urethral stricture disease. First described by the McAninch et al in 1988 [29], urethral ultrasound(UU) to identify stricture has a reported sensitivity of 66% to 100%, specificity of 97% to 98%, and positive and negative predictive values of 50% to 80% and 96% to 98% respectively for anterior stricture 3 to 5 cm long. The usefulness of UU is limited by stricture location as it is more sensitive to stricture in the penile urethra than in bulbar portion [30]. It is also user dependency and the semi-invasive nature of the procedure often requiring local or general anesthesia for full urethra distention. It is benefit it can give three dimensional information about the stricture location and length. Magnetic resonance (MR) urethrography is a promising tool for defining male urethral strictures. It has comparable results with the combined RUG and SUG in diagnosing the anterior and posterior urethral strictures as regard the site and extension and degree of spongiofibrosis but MR is superior in diagnosis of associated pathologies with stricture as it can provide extra-guidance for treatment

planning that cannot be obtained with RUG [31,32].

In one of the most large systematic review for the diagnosis for recurrence stricture recurrence after urethroplasty conducted by Meeks et al [33] in their analysis of urethroplasty publication since 2000 found urethroplasty outcomes was determined by up to eight different diagnostics tests. The most common were uroflowmetry 56%,and retrograde urethrography 51%. Cystourethrography was used in 25% of patients. Recurrence of The management of urethral stricture disease in adult males has a wide range of possible therapeutics treatments. Urethral stricture are often treated with urethrotomy most commonly direct vision internal urethrotomy (DVIU) [34,35]. The popularity of this procedure has been attributed to the ease of performance, a perceived low complication rate and the fact that many north American urologists don not perform open urethroplasty so they may be forced to perform repeat urethrotomy[34,36]. The failure after initial urethrotomy is reported to be 50% [37,38]. The failure after second urethrotomy is considered much higher and can be as high as 100% [35,37,38]. Santucci R et al [39] performed retrospective review of more than 100 patients as a first study in north America, to evaluate the stricture free rate not only after single urethrotomy but after 2 through 5 procedure. He concluded that urethrotomy is a popular treatment for male urethral stricture. However the performance characteristics are poor. The Success rates after 1 urethrotomy was a mere 8% and after multiple urethrotomies was close to 0%. Because urethroplasty has long-term success rate ranging from 75-100 , increased use of this more effective treatment may be warranted[40]. Urethrotmoy should be reserved as a temporizing measure for poor surgical candidates until further reconstruction can be planned and executed. The majority of the base evidence base for the management of urethral strictures dos not reach level 1 according to the oxford classification. With the rarity of significantly powered randomized controlled trials, we have to look to observational studies and expert opinion for guidance. In recent years there has been continuing discussion about the most appropriate use of urethrotomy, dilatation, stenting and intermittent self dilatation. We believe that self intermittent dilatation may be beneficial at least in prolonging the period between urethrotomies. There is no compelling evidence in literature that any particular from of urethrotomy is more effective than another, whether using a cold knife or laser. Heyns et al looked at whether repeated dilatation or urethrotomy was useful and noted that after single treatment 70% would be stricture free at three months, 35-40% would be remain stricture free at 24 months, but not at 48 months. A third treatment was of no benefit at all [41].

Successful out comes from urethrotomy or dilatation requires adequate vascularity within the under lining corpus spongiusom and is more likely to be successful in the bulbar urethra. Whilest et al [42] found up to two internal urethrotomy did not affect the outcomes or likelihood of subsequent anastomotic urethroplasty in patients with posterior injuries. For the anterior urethra using cox hazards regression analysis, failed internal urethrotomy

Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques 41

dorsal onlay graft urethroplasty and reported a series of 38 patients in which 65.8% were considered successful over a mean follow up of 111 months. The majority of the recurrence in this study occurred in the first year. Certainly in the long term follow up it is clear that the recurrence rate after a substitution is far worse than many would otherwise have considered likely based on the existing literature, with a reported rate of 42% at 15 years for substitution procedure and 14% for anastomotic procedure [57]. Barbagli et al [53] analyzed a cohort of 375 patients who underwent one of the three different one –stage procedure for bulbar strictures. He found that at an average follow up of 53 months the success rate for anastomotic urethroplasty was 90.9% and the augmented anastomotic repair was 60% and the onlay procedure was 80%. The Asopa technique, involving dorsal placement of a buccal mucosal graft via a ventral approach, has also been evaluated with 87% success rate at mean follow up of 42 months [58]. Another group found better success rate when applying a dorsal lingual mucosal graft via a ventral urethrotomy approach than a conventional barbagli approach of urethral mobilization [59]. However the preoperative characteristics of the patients in the group that underwent the balbagli approach include patients with higher proportion of patients with pan-urethral disease and balanitis Xerotica obliterans /infective causes potentially confounding interpretation of the results. Kulkarni et al have interestingly described better success rat with a one two stage oral mucosal urethroplasty 91 vs 73% respectively for penile stricture associated with lichen sclerosis [60]. However the number of the cases was low 8 and 15 respectively also the follow up period was short thus its difficult to draw any definite conclusion. Recently Kulkarini et al [61] have described the use of the one-sided anterior urethroplasry utilizing oral mucosa to preserve the lateral vascular supply to the urethra. Of 24 patients 92% had a successful outcomes at the mean of 22 months follow up. However the preservation of the lateral vascular supply of the urethra is of clinical values or not is still under debate. Barbagli et al [62] described a step to spare the bulbospongiosus nerves and muscles when gaining access for urethroplasty in series of sex patients. In all sex patients no evidence of stricture recurrence was noted at 12 months. Type of the grafts which have been used include scrotal skin [63], extragenital skin [64] and bladder mucosa [65]. In contemporary practice genital skin or oral mucosa are the most used, although there is interest in the future in the potential for tissue engineering [66]. Genital skin is flap are particularly useful when dealing with stricture in the penile urethra when an onlay flap of penile skin can be particularly helpful. Oral mucosa was first described in 1941 by Humby and Higgins [67]. This mucosa is used to being wet and is resilient to skin diseases such as lichen sclerosis and has a privileged immunology. Barbagli et al [68] in their retrospective review of 350 patients undergoing oral mucosa harvest from a single check showed the majority of patients had no pain 85.2% or major complication. Mathur et al [69] described the successful use of the tunica albugina from the corpora for the urethroplasty with re-operation rate of 9.2% at 3 years in 206 patients . In 36 cases ranging between 10 and 20 cm in length, Xu et al [70] described success rates of 85.7% at a mean of 53.6 months using colonic mucosa . Similarly Munday and Andrich [71] described the use of grafts from the stomach, ileum and colon in complex patients with bulbomembranous strictures showing some success in otherwise unsalvageable cases. Tissue-engineering grafts of urethra offers a promising alternative to current grafts and minimize the risk of donor site morbidity [72]. A cellular grafts have undergone clinical assessment with mixed results [73,74]. Contemporary work is concentrated upon developing a cellular tissue engineered graft and Li et al [75] have shown a reduced inflammatory response and no recurrence of stricture up to 6 months in a rabbit model. Lu at al [76] have reported on the in-vitro success

has been found to conform increased risk of failure for consequent urethroplasty [43]. Morey concluded that carful preoperative evaluation should be undertaken prior to internal urethrotomy and a patient should not need to have failed minimally invasive therapy prior to being considered for urethroplasty [44]. The current evidence suggests that the success is dependent upon stricture position, cause and length with success decline as the length of the stricture increases as clearly demonstrated by heyns et al [41]. Altaf et al reported that one attempt at direct vision internal urethrotomy can be considered in the most bulbar stricture, unless they are complicated. For example by previous open surgery or fistulae, whilst a primary urethroplasty may be more appropriate in penile stricture [45]. This algorithm of considering an initial urethrotomy has been also been reiterated by Wessells to be the most cost effective [46]. Injection of triamcinolone (antifibroblast and anticollagen properties) was submucosally in 25 patients undergoing urethroplasty, reduced recurrence rates to 21.7% as compared to 50% in a control group at one year [47]. All the patients had stricture less than 1.5 cm and the author randomized the treatment with no mention of blinding.

Stents were introduced a number of years ago but unfortunately have not stayed the test of time since they have been clearly shown to be associated with complications [48]. Particularly if they are inserted as management of the a failed urethroplasty following a urethral distraction injuries [49]. Failure of a permanently implanted urethral stent represents a significant therapeutic challenge which often leads to difficult substitution procedure with consequent limitation of the success of the procedure [49,50]. Therefore usage of stent should be limited to exceptional cases i.e difficult recalcitrant posterior urethral stenosis [51].

#### **3.2 Open surgical techniques**

The second treatment option is open surgical techniques or urethroplasty. Urethroplasty remain the most effective therapy for the management of most cases of anterior urethral stricture. Anastomatic urethroplasty involves excision of the stricture and the primary anastomosis of urethral ends. Traditionally strictures up to 3 cm have been considered as suitable for primary anastomosis. The limiting factors with anastomotic urethroplasty is the stricture length, in particular the length of the component distal to the bulbopenile junction. Open posterior urethroplasty through a perineal anastomotic approach is the treatment of choice for the most urethral distraction injuries because it definitely cure the patients without the need for multiple surgeries. One must be caution of the risk of penile curvature and shortening, so mobilization of the urethra must not encroach upon the penile urethra. For bulbar stricture, by freeing up the urethra from the corpora and separating the two corpora another few centimeters may be gained in length depending on the individual circumstances. If the anastomotic urethroplasty is possible it is the procedure of choice having a success rate of approximately 90% at the intermediate follow-up [52,53]. In the patients with a 2-5 cm stricture undergoing an anastomotic procedure the risk erectile dysfunction is increased [54]. A prospective study of erectile function posturethroplasty showed anastomotic procedure in the bulbar urethra resulted in a significant impairment of erectile function initially which improved in the majority of cases. With low risk of longterm [55].

Substitution urethroplasty; this technique can be performed as one stage procedure via an augmented anastomotic procedure, (patch substitution onlay procedure) or a circumferential patch, or two stage procedure which involves the formation of a roof strip followed by second-stage tubularization. Balbagli and colleagues [56] reported their results in using

has been found to conform increased risk of failure for consequent urethroplasty [43]. Morey concluded that carful preoperative evaluation should be undertaken prior to internal urethrotomy and a patient should not need to have failed minimally invasive therapy prior to being considered for urethroplasty [44]. The current evidence suggests that the success is dependent upon stricture position, cause and length with success decline as the length of the stricture increases as clearly demonstrated by heyns et al [41]. Altaf et al reported that one attempt at direct vision internal urethrotomy can be considered in the most bulbar stricture, unless they are complicated. For example by previous open surgery or fistulae, whilst a primary urethroplasty may be more appropriate in penile stricture [45]. This algorithm of considering an initial urethrotomy has been also been reiterated by Wessells to be the most cost effective [46]. Injection of triamcinolone (antifibroblast and anticollagen properties) was submucosally in 25 patients undergoing urethroplasty, reduced recurrence rates to 21.7% as compared to 50% in a control group at one year [47]. All the patients had stricture less than

1.5 cm and the author randomized the treatment with no mention of blinding.

urethral stenosis [51].

term [55].

**3.2 Open surgical techniques**

Stents were introduced a number of years ago but unfortunately have not stayed the test of time since they have been clearly shown to be associated with complications [48]. Particularly if they are inserted as management of the a failed urethroplasty following a urethral distraction injuries [49]. Failure of a permanently implanted urethral stent represents a significant therapeutic challenge which often leads to difficult substitution procedure with consequent limitation of the success of the procedure [49,50]. Therefore usage of stent should be limited to exceptional cases i.e difficult recalcitrant posterior

The second treatment option is open surgical techniques or urethroplasty. Urethroplasty remain the most effective therapy for the management of most cases of anterior urethral stricture. Anastomatic urethroplasty involves excision of the stricture and the primary anastomosis of urethral ends. Traditionally strictures up to 3 cm have been considered as suitable for primary anastomosis. The limiting factors with anastomotic urethroplasty is the stricture length, in particular the length of the component distal to the bulbopenile junction. Open posterior urethroplasty through a perineal anastomotic approach is the treatment of choice for the most urethral distraction injuries because it definitely cure the patients without the need for multiple surgeries. One must be caution of the risk of penile curvature and shortening, so mobilization of the urethra must not encroach upon the penile urethra. For bulbar stricture, by freeing up the urethra from the corpora and separating the two corpora another few centimeters may be gained in length depending on the individual circumstances. If the anastomotic urethroplasty is possible it is the procedure of choice having a success rate of approximately 90% at the intermediate follow-up [52,53]. In the patients with a 2-5 cm stricture undergoing an anastomotic procedure the risk erectile dysfunction is increased [54]. A prospective study of erectile function posturethroplasty showed anastomotic procedure in the bulbar urethra resulted in a significant impairment of erectile function initially which improved in the majority of cases. With low risk of long-

Substitution urethroplasty; this technique can be performed as one stage procedure via an augmented anastomotic procedure, (patch substitution onlay procedure) or a circumferential patch, or two stage procedure which involves the formation of a roof strip followed by second-stage tubularization. Balbagli and colleagues [56] reported their results in using dorsal onlay graft urethroplasty and reported a series of 38 patients in which 65.8% were considered successful over a mean follow up of 111 months. The majority of the recurrence in this study occurred in the first year. Certainly in the long term follow up it is clear that the recurrence rate after a substitution is far worse than many would otherwise have considered likely based on the existing literature, with a reported rate of 42% at 15 years for substitution procedure and 14% for anastomotic procedure [57]. Barbagli et al [53] analyzed a cohort of 375 patients who underwent one of the three different one –stage procedure for bulbar strictures. He found that at an average follow up of 53 months the success rate for anastomotic urethroplasty was 90.9% and the augmented anastomotic repair was 60% and the onlay procedure was 80%. The Asopa technique, involving dorsal placement of a buccal mucosal graft via a ventral approach, has also been evaluated with 87% success rate at mean follow up of 42 months [58]. Another group found better success rate when applying a dorsal lingual mucosal graft via a ventral urethrotomy approach than a conventional barbagli approach of urethral mobilization [59]. However the preoperative characteristics of the patients in the group that underwent the balbagli approach include patients with higher proportion of patients with pan-urethral disease and balanitis Xerotica obliterans /infective causes potentially confounding interpretation of the results. Kulkarni et al have interestingly described better success rat with a one two stage oral mucosal urethroplasty 91 vs 73% respectively for penile stricture associated with lichen sclerosis [60]. However the number of the cases was low 8 and 15 respectively also the follow up period was short thus its difficult to draw any definite conclusion. Recently Kulkarini et al [61] have described the use of the one-sided anterior urethroplasry utilizing oral mucosa to preserve the lateral vascular supply to the urethra. Of 24 patients 92% had a successful outcomes at the mean of 22 months follow up. However the preservation of the lateral vascular supply of the urethra is of clinical values or not is still under debate. Barbagli et al [62] described a step to spare the bulbospongiosus nerves and muscles when gaining access for urethroplasty in series of sex patients. In all sex patients no evidence of stricture recurrence was noted at 12 months. Type of the grafts which have been used include scrotal skin [63], extragenital skin [64] and bladder mucosa [65]. In contemporary practice genital skin or oral mucosa are the most used, although there is interest in the future in the potential for tissue engineering [66]. Genital skin is flap are particularly useful when dealing with stricture in the penile urethra when an onlay flap of penile skin can be particularly helpful. Oral mucosa was first

described in 1941 by Humby and Higgins [67]. This mucosa is used to being wet and is resilient to skin diseases such as lichen sclerosis and has a privileged immunology. Barbagli et al [68] in their retrospective review of 350 patients undergoing oral mucosa harvest from a single check showed the majority of patients had no pain 85.2% or major complication. Mathur et al [69] described the successful use of the tunica albugina from the corpora for the urethroplasty with re-operation rate of 9.2% at 3 years in 206 patients . In 36 cases ranging between 10 and 20 cm in length, Xu et al [70] described success rates of 85.7% at a mean of 53.6 months using colonic mucosa . Similarly Munday and Andrich [71] described the use of grafts from the stomach, ileum and colon in complex patients with bulbomembranous strictures showing some success in otherwise unsalvageable cases. Tissue-engineering grafts of urethra offers a promising alternative to current grafts and minimize the risk of donor site morbidity [72]. A cellular grafts have undergone clinical assessment with mixed results [73,74]. Contemporary work is concentrated upon developing a cellular tissue engineered graft and Li et al [75] have shown a reduced inflammatory response and no recurrence of stricture up to 6 months in a rabbit model. Lu at al [76] have reported on the in-vitro success

Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques 43

[7] Mustafa M.The concept of tubularized incised plate hypospadias repair for different

[8] Sugarman ID,Trevett J, Malone PS. Tubularization of the incised plate(Snodgrass procedure) for the primary hypospadias surgery. BJU Int 1999; 83:88-90. [9] Jayanthi VR. The modified Snodgrass hypospadias repair: reducing the risk of fistula and

[10] Djordjevic ML, Perovic SV, Slavkovic Z, Djarovic N: longitudinal dorsal dartos flap for preventing of fistula after a Snodgrass hypospadias. Eur Urol 2006; 53-57. [11] Djordjevic ML, Perovic SV, Vukadinovic VM: Dorsal dartos flap for preventing fistula

[12] Sondgrass W: Tubularized incised plate urethroplasty for distal hypospadias. J Urol

[13] Sondgrass W, Koyle M, Manzoni G, et al: Tubularized incised plate for hypospadias

[14] Mustafa M, Wadie BS, Abol-Enein H . Dorsal dartos flap in Snodgrass hypospadias

[15] Retik A B, Borer JG: Primary and reoperative hypospadias repair with the Snodgrass

[16] Yerkes EB, Adams MC, Miller DA, Pope JC, Rink RC, Brock JW 3rd: Y-to-I warp: use of the distal spongiosum for hypospadias repair. J Urol 2000; 163:1536-1539. [17] Sozubir S, Snodgrass W: A new algorithm for primary hypospadias repair based on TIP

[18] Mustafa M, Ali-El-Dein B, Mohsen T, Ibrahiem el-HI.The use of local anesthetic gel

[19] Choudhary S, Singh P, Sundar E et al: A comparison of sonourethrography and

[20] Arbique 13M, 13illeran JP, 13uild JB et al: Radiation exposure during standing voiding

[21] Heyns CF and Marais DC: Prospective evaluation of the American Urological

[22] Morey AF, McAninch JW, Duckett CP et al: American UrologicalAssociation symptom index in the assessment of urethroplasty outcomes. J Urol1998; 159: 1192. [23] Navai N, Erickson BA, Zhao LC et al: Complications following urethral reconstructive

[24] Kaplan SA, Wein AJ, Staskin DR et al: Urinary retention and post-void residual urine in

[25] Rule AD, Jacobson DJ, Mc13ree ME et al: Longitudinal changes in post-void residual and voided volume among community dwelling men. J Urol 2005; 174: 1317. [26] Dunsmuir WD, Feneley M, Corry DA et al: The day-to-day variation (test-retest

[27] Feneley MR, Dunsmuir WD, Pearce J et al: Reproducibility of uroflow measurement:

experience during a double-blind, placebo-controlled study of doxazosin in benign

during retrograde urethrography: does it cause a false negative result? Int Urol

retrograde urethrography in evaluation of anterior urethral strictures. Clin Radiol

Association symptom index and peak urinary flow rate for the followup of men

in the Snodgrass hypospadias repair. BJU Int 2005; 95:1303-1309.

repair : result of a multicenter experience. J Urol 1996; 156:839-841.

types of hypospadias.Int Urol Nephrol. 2005; 37(1):89-91.

meatal stenosis J Urol 2003; 170:1603-1605.

repair: how to use it?.Urol Int. 2008; 81(2):215-7.

urethroplasty. J Pediatr Surg 2003; 38:1157-1161.

cystourethrography in women. Urology 2006; 67: 269.

with known urethral stricture disease. J Urol 2002; 168: 2051.

surgery: a six year experience. Int Braz J Urol 2008; 34: 594.

men: separating truth from tradition. J Urol 2008; 180: 47.

prostatic hyperplasia. Urology 1996; 47: 658.

reliability) of residualurine measurement. Br J Urol 1996; 77: 192.

technique. World J Urol 1998; 16:186-191.

Nephrol. 2007; 39(2):513-6.

2004; 59: 736.

1994:151:464-465.

of culturing urothelial cells on a cellular bladder matrix making the cellular graft histologically like urothelium.

 In the future and in order to aid the decision-making process for the managements of stricture disease, randomized controlled studies (RCT) should be conducted [77,78]. Most of the current evidence comes from observational studies and due to the low qualities of cases available for RCT selection numbers are often increased by widening the inclusion criteria and thus comparing cases of different causes, locations and strictures size. It is clear that a more homogenous patients selection may guide clinical decisions better. Many factors have been found to affect urethroplasty outcomes and should thus be accounted for preoperatively [43,79]. Moreover, it must be noted that although evidence may support one technique over another, the situation during urethroplasty requires a dynamics assessment and adoption of an achievable procedure leading to patient-centered success.

#### **4. Conclusion**

 The plastic surgery of urethra include wide range of indications, operative techniques and outcomes. Urethroplasty done due to hypospadias is of more success rates in comparison to urethroplasty done due to urethral strictures. The surgeons have consensus on the preferable technique for hypospadias repair, however the situation is not similar regarding the management of urethral strictures. The contemporary evidence for the management of urethral strictures provides a practice-based algorithm which a reconstructive urologist may utilize when dealing with strictures based on location, length, anatomy and etiology. Moreover every case is unique and often different consideration have to be taken into account in carrying out surgery , with urologist being aware of the entire armamentarium of techniques and needing to use them to provide the best result for each patient. Therefore we believe that there is a need for a multi-center international database with outcomes standardization to adequately develop higher levels of comparative evidence. The development of validate patient-reported outcome measures is going to be very important in achieving this goal.

#### **5. References**

of culturing urothelial cells on a cellular bladder matrix making the cellular graft

 In the future and in order to aid the decision-making process for the managements of stricture disease, randomized controlled studies (RCT) should be conducted [77,78]. Most of the current evidence comes from observational studies and due to the low qualities of cases available for RCT selection numbers are often increased by widening the inclusion criteria and thus comparing cases of different causes, locations and strictures size. It is clear that a more homogenous patients selection may guide clinical decisions better. Many factors have been found to affect urethroplasty outcomes and should thus be accounted for preoperatively [43,79]. Moreover, it must be noted that although evidence may support one technique over another, the situation during urethroplasty requires a dynamics assessment and adoption of

 The plastic surgery of urethra include wide range of indications, operative techniques and outcomes. Urethroplasty done due to hypospadias is of more success rates in comparison to urethroplasty done due to urethral strictures. The surgeons have consensus on the preferable technique for hypospadias repair, however the situation is not similar regarding the management of urethral strictures. The contemporary evidence for the management of urethral strictures provides a practice-based algorithm which a reconstructive urologist may utilize when dealing with strictures based on location, length, anatomy and etiology. Moreover every case is unique and often different consideration have to be taken into account in carrying out surgery , with urologist being aware of the entire armamentarium of techniques and needing to use them to provide the best result for each patient. Therefore we believe that there is a need for a multi-center international database with outcomes standardization to adequately develop higher levels of comparative evidence. The development of validate patient-reported outcome measures is going to be very important

[1] Sweet RA, Schortt HG, Kurland R et al. Study of incidence of hypospadias in Rochester,

[2] Snodgrass W, Koyle M, Manzoni G et al. Tubularized incised plate hypospadias repair

[3] Sondgrass W. Tubularized incised plate urethroplasty for distal hypospadias. J Urol

[4] Sondgrass W, Koyle M, Manzoni G et al. Tabularized incised plate for hypospadias

[5] Sondgrass WT, Lorenzo A. Tubularized incised plate urethroplasty for hypospadias

[6] Mustafa M, Wadie BS, Abol-Enein H. Standard Snodgrass technique in conjunction with

double-layer covering of the neourethra with dorsal dartos flap is the therapy of

repair: result of a multicenter experience. J Urol 1996; 156:839-841.

first choice for hypospadias.. Int Urol Nephrol. 2008; 40(3):573-6.

for proximal hypospadias. J Urol 1998; 159:2129-2131.

reoperation. Br J Urol Int 2002; 89:98-100.

Minnesota 1940-1970 and a case control comparison of possible etiologic factors.

histologically like urothelium.

**4. Conclusion**

in achieving this goal.

Mayo Clin Proc 1974; 49: 52.

1994; 151:464-465.

**5. References**

an achievable procedure leading to patient-centered success.

Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques 45

[46] Wessells H. Cost-effective approach to short bulbar urethral strictures supports single internal urethrotomy before urethroplasty. J Urol 2009; 181:954– 955. [47] Mazdak H, Izadpanahi MH, Ghalamkari A, et al. Internal urethrotomy and

[48] Hussain M, Greenwell TJ, Shah J, Mundy A. Long-term results of a self-expanding wallstent in the treatment of urethral stricture. BJU Int 2004; 94:1037–1039. [49] Chapple CR, Bhargava S. Management of the failure of a permanently implanted

[50] Palminteri E, Gacci M, Berdondini E, etal. Management of urethral stent failure for

[51] Eisenberg ML, Elliott SP, McAninch JW. Preservation of lower urinary tract function in

[52] Lumen N, Piet H, Willem O. Urethroplasty for urethral strictures: quality assessment of

[53] Barbagli G, Guazzoni G, Lazzeri M. One-stage bulbar urethroplasty: retrospective

[54] Xie H, Xu YM, Xu XL, et al. Evaluation of erectile function after urethral reconstruction:

[55] Erickson BA, Granieri MA, Meeks JJ, et al. Prospective analysis of erectile dysfunction

[56] Barbagli G, Morgia G, Lazzeri M. Dorsal onlay skin graft bulbar urethroplasty: long-

[57] Andrich DE, Dunglison N, Greenwell TJ, Mundy AR. The long-term results of

[58] Pisapati VL, Paturi S, Bethu S, etal. Dorsal buccal mucosal graft urethroplasty for anterior urethral stricture by Asopa technique. Eur Urol 2009; 56:201 – 205. [59] Singh PB, Das SK, Kumar A, et al. Dorsal onlay lingual mucosal graft urethroplasty:comparison of two techniques. Int J Urol 2008; 15:1002– 1005. [60] Barbagli G, De AM, Romano G, Lazzeri M. Clinical outcome and quality of life

[61] Kulkarni S, Barbagli G, Sansalone S, Lazzeri M. One-sided anterior urethroplasty: a new

[62] Barbagli G, De SS, Annino F, et al. Muscle- and nerve-sparing bulbar urethroplasty:a

[63] Jordan GH. Scrotal and perineal flaps for anterior urethral reconstruction. Urol Clin

[64] Vyas PR, Roth DR, Perlmutter AD. Experience with free grafts in urethral

[65] Xu YM, Qiao Y, Sa YL, et al. Urethral reconstruction using colonic mucosa graft for

[66] Bhargava S, Patterson JM, Inman RD, et al. Tissue-engineered buccal mucosa

urethroplasty-clinical outcomes. Eur Urol 2008; 53:1263–1269.

after anterior urethroplasty:incidence and recovery of function. J Urol 2010;

assessment in patients treated with perineal urethrostomy for anterior urethral

posterior urethral stenosis: selection of appropriate patients for urethral stents. J

urethral stent-a therapeutic challenge. Eur Urol 2008; 54:665– 670.

recurrent anterior urethral strictures. Eur Urol 2010; 57:615-21.

analysis of the results in 375 patients. Eur Urol 2008; 53:828–833.

an in-home algorithm. Int J Urol 2010; 17:167–174.

a prospective study. Asian J Androl 2009; 11:209–214.

term follow-up. Eur Urol 2008; 53:628–633.

stricture disease. J Urol 2009; 182:548–557.

new technique. Eur Urol 2008; 54:335–343.

reconstruction. J Urol 1987; 137:471 –474.

complex strictures. J Urol 2009; 1 82:1040–1043.

North Am 2002; 29:411–416.

dorsal onlay graft technique. BJU Int 2009; 104:1150–1155.

urethroplasty. J Urol 2003; 170:90–92.

strictures. Int Urol Nephrol 2009.

Urol 2007; 178:2456–2460.

183:657–661.

intraurethral submucosal injection of triamcinolone in short bulbar urethral

[28] Colomb J, Lindner A, Siegel Y et al: Variability and circadian changes in home

[29] McAninch JW, Laing FC and Jeffrey RB Jr: Sonourethrography in the evaluation of

[30] Nash PA, McAninch JW, Bruce JE et al: Sonourethrography in the evaluation of anterior

[31] Osman Y, El-Ghar MA, Mansour O, Refaie H, El-Diasty T. Magnetic resonance

[33] Meeks JJ, Erickson BA, Granieri MA, Gonzalez CM. Stricture recurrence after

[34] Greenwell TJ, Castle C, Andrich DE et al: Repeat urethrotomy and dilation for the

[35] Naude AM and Heyns CF: What is the place of internal urethrotomy in the treatment of

[36] Bullock TL and Brandes SB: Adult anterior urethral strictures: a national practice

[37] Heyns CF, Steenkamp JW, De Kock ML et al: Treatment of male urethral strictures: is repeated dilation or internal urethrotomy useful? J Urol 1998; 160: 356. [38] Pansadoro V and Emiliozzi P: Internal urethrotomy in the management of anterior

[39] Santucci R., Eisenberg L: Urethrotomy has a much lower success rate than previously

[40] Santucci RA: Male urethral stricture disease. In: Urologic Diseases in America. Edited

[41] Heyns CF, Steenkamp JW, de Kock ML, Whitaker P. Treatment of male urethral

[42] Singh BP, Andankar MG, Swain SK, et al. Impact of prior urethral manipulation on

[43] Breyer BN, McAninch JW, Whitson JM, et al. Multivariate analysis of risk factors for

[44] Morey A. Urethral stricture is now an open surgical disease. J Urol 2009; 181 :953–954. [45] Mangera A, Christopher C. Management of anterior urethral stricture: an evidence-

by MS Litwin and CS Saigal. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, D.C.: US Government Publishing

strictures: is repeated dilation or internal urethrotomy useful? J Urol 1998; 160:356–

outcome of anastomotic urethroplasty for posttraumatic urethral stricture. Urology

urethral strictures: is it clinically relevant? Eur Urol. 2006; 50(3):587-93. [32] El-Ghar MA, Osman Y, Elbaz E, Refiae H, El-Diasty T. MR urethrogram versus

urethral strictures: a preliminary report. J Urol 1988; 139: 294.

urethroplasty:a systematic review. J Urol 2009; 182:1266–1270.

urethral stricture disease? Nat Clin Pract Urol 2005; 2: 538.

urethral strictures: long-term followup. J Urol 1996; 156: 73.

Office 2007; NIH publication No. 07-5512, pp 531–552.

long-term urethroplasty outcome. J Urol 2009; 183:613–617.

based approach. Current opinion in urology 2010; 20:453-458.

normalcontrols. J Urol 1992; 147: 1044.

urethral strictures. J Urol 1995; 154: 72.

stricture . Eur J Radiol.2010; 74(3):193-8.

reported. J Urol 2010; 183:1859-1862.

Urol 2004; 172: 275.

685.

358.

2009; 75:179–182.

uroflowmetry in patients with benign prostatic hyperplasia compared to

urethrography in comparison to retrograde urethrography in diagnosis of male

combined retrograde urethrogram and sonourethrography in diagnosis of urethral

treatment of urethral stricture are neither clinically effective not cost-effective. J

patterns survey of board certified urologists in the United States. J Urol 2007; 177:

**5**

*Egypt*

**Management of**

**Post Hypospadias Urethral Fistula**

*Department of Pediatric Surgery, Tanta University Hospital, Tanta,*

Complications after any surgical procedures are normal consequences within the standard acceptable percentage among surgeons. Complications are higher in hypospadias surgery as compared to other reconstructive operations. Urethrocutaneous fistula after hypospadias surgery repair is the most common complication and remains a frustrating problem for

Generally fistula is defined as a tract connecting two epithelial surfaces. Furthermore, the problem is exacerbated because urethrocutaneous fistula not only occurs but also recurs, sometimes with all the potential harmful physical and psychological consequences. However, with the improvement in suture material and surgical techniques, such complications are increasingly unacceptable. The occurrence of urethrocutaneous fistulae precludes a goal of

The reported incidence of urethrocutaneous fistula ranged, from 0 to 30%, varying with the severity of hypospadias, surgical technique, and experience of the operating surgeon [5]. Unfortunately there is no one single perfect technique to repair any urethrocutaneous fistula. The temptation to simply close the hole without understanding the failure mechanisms is dangerous and often leads to recurrence of the fistula or even worse [29]. Many factors influence the results of fistula repair such as the conditions of local tissue, time after hypospadias repair, the number, location and size of the fistula [29]. These factors can be preventable when considered, experience and surgical tips are needed to improve the

Generally, the incidence of fistula varies from 0 to 30 %. It is less in urethral plate preservation procedures like tabularized incised plate (TIP) and onlay flap as compared to

The incidence of fistula formation has decreased gradually in the past two decades. In 1973, Horton and Devine estimated the incidence of fistula following hypospadias surgery to range between 15 % and 45 % [18]. In 1984, Shapiro found a urethral fistula rate of 6.25 % in

Nowadays, the incidence of fistula was varied among different techniques of repair as some procedures are more prone to fistula formation than others [15]. For example, Durham

a series of 176 hypospadias repairs including various techniques of repair [32].

**1. Introduction**

surgeons [21].

hypospadias surgery [6].

outcomes in cases of hypospadias fistulae.

inner preputial flap and tube urethroplasty.

**2. Incidence of fistula formation**

Sherif Shehata and Mohamed Hashish

### **Management of Post Hypospadias Urethral Fistula**

Sherif Shehata and Mohamed Hashish

*Department of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt*

#### **1. Introduction**

46 Current Concepts of Urethroplasty

[67] Humby G, Higgins T. A one-stage operation for hypospadias. Br J Surg 2009; 29:84–92. [68] Barbagli G, Vallasciani S, Romano G, et al. Morbidity of oral mucosa graft •• harvesting

[69] Mathur RK, Sharma AK, Odiya S. Tunica albuginea urethroplasty for anterior urethral

[70] Xu YM, Qiao Y, Sa YL, et al. Urethral reconstruction using colonic mucosa graft for

[71] Mundy AR, Andrich DE. Entero-urethroplasty for the salvage of bulbo-membranous

[72] Jenkins BJ, Badenoch DF, Fowler CG, Blandy JP. Long-term results of treatment of urethral injuries in males caused by external trauma. Br J Urol 1992; 70:73–75. [73] El-Kassaby A, Aboushwareb T, Atala A. Randomized comparative study between

[74] Ecke TH, Hallmann S, Gerullis H, Ruttloff J. Reconstruction of the urethra with a

[75] Li C, Xu Y, Song L, et al. A preliminary experimental study on urethral reconstruction

[76] Lu MJ, Wang Z, Zhou GD, et al. Construction of urethra mucosa structure in vitro by

[77] Barbagli G, Lazzeri M. Can reconstructive urethral surgery proceed without

[78] Capizzi A. Urethral surgery in the evidence-based medicine (EBM) era:a never-ending

[79] Breyer BN, McAninch JW, Whitson JM, et al. Effect of obesity on urethroplasty outcome.

tissue engineering. Zhonghua Nan Ke Xue 2008; 14:1072–1076.

randomized controlled trials? Eur Urol 2008; 54:709–711.

buccal mucosal and acellular bladder matrix grafts in complex anterior urethral

Surgisis onlay patch in urethral reconstructive surgery:two case reports. J Med Case

using tissue engineered oral mucosa. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi

strictures: a urethroscopic analysis. Int J Urol 2009; 16:751 –755.

stricture disease or trauma. BJU Int 2009; 105:1716–1720.

from a single cheek. Eur Urol 2010; 58:33-41.

complex strictures. J Urol 2009; 182:1040–1043.

strictures. J Urol 2008; 1 79:1432–1436.

story. Urology 2009; 73:1172–1174.

Urology 2009; 73:1352–1355.

Reports 2009; 3:7232.

2008; 22:1 242–1 245.

Complications after any surgical procedures are normal consequences within the standard acceptable percentage among surgeons. Complications are higher in hypospadias surgery as compared to other reconstructive operations. Urethrocutaneous fistula after hypospadias surgery repair is the most common complication and remains a frustrating problem for surgeons [21].

Generally fistula is defined as a tract connecting two epithelial surfaces. Furthermore, the problem is exacerbated because urethrocutaneous fistula not only occurs but also recurs, sometimes with all the potential harmful physical and psychological consequences. However, with the improvement in suture material and surgical techniques, such complications are increasingly unacceptable. The occurrence of urethrocutaneous fistulae precludes a goal of hypospadias surgery [6].

The reported incidence of urethrocutaneous fistula ranged, from 0 to 30%, varying with the severity of hypospadias, surgical technique, and experience of the operating surgeon [5]. Unfortunately there is no one single perfect technique to repair any urethrocutaneous fistula. The temptation to simply close the hole without understanding the failure mechanisms is dangerous and often leads to recurrence of the fistula or even worse [29].

Many factors influence the results of fistula repair such as the conditions of local tissue, time after hypospadias repair, the number, location and size of the fistula [29]. These factors can be preventable when considered, experience and surgical tips are needed to improve the outcomes in cases of hypospadias fistulae.

#### **2. Incidence of fistula formation**

Generally, the incidence of fistula varies from 0 to 30 %. It is less in urethral plate preservation procedures like tabularized incised plate (TIP) and onlay flap as compared to inner preputial flap and tube urethroplasty.

The incidence of fistula formation has decreased gradually in the past two decades. In 1973, Horton and Devine estimated the incidence of fistula following hypospadias surgery to range between 15 % and 45 % [18]. In 1984, Shapiro found a urethral fistula rate of 6.25 % in a series of 176 hypospadias repairs including various techniques of repair [32].

Nowadays, the incidence of fistula was varied among different techniques of repair as some procedures are more prone to fistula formation than others [15]. For example, Durham

Management of Post Hypospadias Urethral Fistula 49

Direct fistula where the tract pass straight in the same level of all repaired layers while serpentine fistula where the tract ruin in different pathway among the different layers

Single fistula are more common and may be presented in different size while the Multiple fistulae are less common; they may occur due to technical factors such as

Infection and ischemia remain the two important factors in fistula production. Incorporation of urethral mucosa in the ventral repair is a substrate for fistula formation with rapid migration of urethral mucosa and skin epithelium into suture tracts. Whether the mucosal or dermal migration along suture tracts can be attenuated or prevented by changing the biochemical environment needs further investigation [7]. Some individuals have abnormal tissue reactivity to the sutures as foreign bodies, thus induce irritation and inflammatory

The actual causes of fistulae formation remain unknown although the most common reasons are technical and avoidable; there are many factors that may cause a high incidence of fistula

The fistula formation rate was significantly higher in the group of patients where neourethra was constructed using 6/0 polyglactine (Vicryl) in a single layer, full-thickness, uninterrupted fashion (16.6 %) compared to group of patients in which 7/0 polydioxanone (PDS) was used in the urethral anastomosis performed in a subcuticular, uninterrupted fashion with fistula rate of 4.9 % [23, 24]. Use of a subcutaneous suture technique utilizing PDS suture material

The numerous factors that have accounted to lower incidence of fistula formation today are

3. According to its track path into:

4. According to number into:

**4. Mechanism of fistula formation**

reaction that initiates fistula formation [34].

**5. Etiology and risk factors**

formation which include: 1. Local infection, 2. Local ischemia,

3. An inadequate procedure, 4. Poor tissue healing, and

6. The type of suture material.

in urethroplasties is advocated [23, 24].

**6. Tips for fistula prevention**

summarized below: 1. Technical points - Type of suture - Fine instruments

and usually came lateral in position not in the mid line.

ischemia, infection and distal stenosis or in recurrent cases [11].

5. Distal obstruction due to meatal stenosis/encrustation [24, 34].

Smith in 1981 noted that the fistula rate for the meatoplasty and glanuloplasty (MAGPI) procedure ranged from 0.5 % to 10 %, whereas the rate for flip-flap repairs varied from 2.2 % to 35 % and that for island pedicle tube repairs from 4 % to 33 % [37]. Free graft tube-repairs are encountered with higher fistula rates of 15-50 %. While using a two-stage repair, in more than 500 cases, Durham Smith in 1990 reduced his incidence of fistula formation to less than 3 % [36]. Similarly, Greenfield and colleagues reported a urethral fistula rate of 2.5 % with a two-stage repair [12].

#### **3. Classification of fistula**

The Beginning of fistula formation occurs early in the healing process after ventral urethral repair usually between the 7th-10th post operative days [3].

Post hypospadias urethral fistula could be classified according to many aspects into different classifications:

	- Anastomotic fistula
	- Non anastomotic fistula

The urethrocutaneous fistula may occur anywhere along the neourethra. However, the most common sites include the site of the original meatus, glans penis, at the coronal level in tubularization urethroplasty and at the site of anastomosis in flap urethroplasty [8].

	- Pin point fistula
	- Small fistula
	- Mega fistula.

Small tiny fistulas may occur even with experienced surgeons using delicate techniques. Mega fistula with diameter more than 4-5 mm in its largest diameter represents a form of incomplete disruption of the repair [11].

Fig. 1. Description of some types of fistula according to fistula track path: A) Graph of direct ventral fistula, B) Graph of serpentine long lateral fistula and C) Operative photograph of direct post anastomotic fistula. [Courtesy of Prof. Sherif Shehata]

	- Direct

Smith in 1981 noted that the fistula rate for the meatoplasty and glanuloplasty (MAGPI) procedure ranged from 0.5 % to 10 %, whereas the rate for flip-flap repairs varied from 2.2 % to 35 % and that for island pedicle tube repairs from 4 % to 33 % [37]. Free graft tube-repairs are encountered with higher fistula rates of 15-50 %. While using a two-stage repair, in more than 500 cases, Durham Smith in 1990 reduced his incidence of fistula formation to less than 3 % [36]. Similarly, Greenfield and colleagues reported a urethral fistula rate of 2.5 % with a

The Beginning of fistula formation occurs early in the healing process after ventral urethral

Post hypospadias urethral fistula could be classified according to many aspects into

The urethrocutaneous fistula may occur anywhere along the neourethra. However, the most common sites include the site of the original meatus, glans penis, at the coronal level in tubularization urethroplasty and at the site of anastomosis in flap urethroplasty

Small tiny fistulas may occur even with experienced surgeons using delicate techniques. Mega fistula with diameter more than 4-5 mm in its largest diameter represents a form

Fig. 1. Description of some types of fistula according to fistula track path: A) Graph of direct ventral fistula, B) Graph of serpentine long lateral fistula and C) Operative photograph of

(a) (b) (c)

direct post anastomotic fistula. [Courtesy of Prof. Sherif Shehata]

two-stage repair [12].

different classifications:

[8].

**3. Classification of fistula**

2. According to the size into: - Pin point fistula - Small fistula - Mega fistula.

1. According to site or location into: - Anastomotic fistula - Non anastomotic fistula

repair usually between the 7th-10th post operative days [3].

of incomplete disruption of the repair [11].

Direct fistula where the tract pass straight in the same level of all repaired layers while serpentine fistula where the tract ruin in different pathway among the different layers and usually came lateral in position not in the mid line.

	- Single
	- Multiple

Single fistula are more common and may be presented in different size while the Multiple fistulae are less common; they may occur due to technical factors such as ischemia, infection and distal stenosis or in recurrent cases [11].

### **4. Mechanism of fistula formation**

Infection and ischemia remain the two important factors in fistula production. Incorporation of urethral mucosa in the ventral repair is a substrate for fistula formation with rapid migration of urethral mucosa and skin epithelium into suture tracts. Whether the mucosal or dermal migration along suture tracts can be attenuated or prevented by changing the biochemical environment needs further investigation [7]. Some individuals have abnormal tissue reactivity to the sutures as foreign bodies, thus induce irritation and inflammatory reaction that initiates fistula formation [34].

#### **5. Etiology and risk factors**

The actual causes of fistulae formation remain unknown although the most common reasons are technical and avoidable; there are many factors that may cause a high incidence of fistula formation which include:

The fistula formation rate was significantly higher in the group of patients where neourethra was constructed using 6/0 polyglactine (Vicryl) in a single layer, full-thickness, uninterrupted fashion (16.6 %) compared to group of patients in which 7/0 polydioxanone (PDS) was used in the urethral anastomosis performed in a subcuticular, uninterrupted fashion with fistula rate of 4.9 % [23, 24]. Use of a subcutaneous suture technique utilizing PDS suture material in urethroplasties is advocated [23, 24].

#### **6. Tips for fistula prevention**

The numerous factors that have accounted to lower incidence of fistula formation today are summarized below:

	- Type of suture
	- Fine instruments

Management of Post Hypospadias Urethral Fistula 51

Better and finer suture materials are available today with greater tensile strength and less reactivity including 6-0 to 7-0 polyglactin (Vicryl) and polyglycolic acid (Dexon). These sutures can be used on the skin as well as internally. PDS should not be used in the urethra (subcuticular is satisfactory) because it may react with urine and fistula may result [9, 23]. Plastic surgical principles such as ophthalmic and microvascular instruments are advocated and delicate tissue handling are now should be used by most hypospadias surgeons. Also

most surgeons use either the microscope or 2.5 - 3.5 X optical magnification [9, 30].

A

C

D

 Fig. 3. Tips to minimize fistula development or recurrence: A) Preoperative contrast imaging photograph showing urethral stenosis (white arrow) and fistula after distal hypospadias repair, B) Operative photograph of the same case showing the prepared Retik's dorsal subcutaneous preputial flap from the foreskin dorsal as a second protective layer with part of fore skin attached at tip of flap, C) Operative photograph of another case showing the dorsal dartos fascia flap prepared as a second covering layer for the urethroplasty and D) Operative photograph of a case showing the urethral stent at the time of recovery. [Courtesy

**6.1 Technical points**

of Prof. Sherif Shehata]

B

	- De-epithelialized skin
	- Tunica vaginalis
	- Dartos flap
	- Dorsal subcutaneous preputial flap
	- External spermatic fascia

Fig. 2. Shape and Causes of post hypospadias fistulae: A) Preoperative photograph shows disrupted proximal hypospadias with multiple fistulae with operative calibration, B) Operative photograph of a case of direct coronal fistula, C) Photograph of the a case of meatal stenosis as a contributing factor to fistula development and D) Postoperative photograph of another case of distal hypospadias with early infection that predispose to fistula formation later. [Courtesy of Prof. Sherif Shehata]

#### **6.1 Technical points**

50 Current Concepts of Urethroplasty

C

fistula formation later. [Courtesy of Prof. Sherif Shehata]

disrupted proximal hypospadias with multiple fistulae with operative calibration, B) Operative photograph of a case of direct coronal fistula, C) Photograph of the a case of meatal stenosis as a contributing factor to fistula development and D) Postoperative photograph of another case of distal hypospadias with early infection that predispose to

Fig. 2. Shape and Causes of post hypospadias fistulae: A) Preoperative photograph shows

D

3. Urethral stenting

A

B

5. Tisseel (fibrin glue) [15]

4. Dressing

Better and finer suture materials are available today with greater tensile strength and less reactivity including 6-0 to 7-0 polyglactin (Vicryl) and polyglycolic acid (Dexon). These sutures can be used on the skin as well as internally. PDS should not be used in the urethra (subcuticular is satisfactory) because it may react with urine and fistula may result [9, 23]. Plastic surgical principles such as ophthalmic and microvascular instruments are advocated and delicate tissue handling are now should be used by most hypospadias surgeons. Also most surgeons use either the microscope or 2.5 - 3.5 X optical magnification [9, 30].

Fig. 3. Tips to minimize fistula development or recurrence: A) Preoperative contrast imaging photograph showing urethral stenosis (white arrow) and fistula after distal hypospadias repair, B) Operative photograph of the same case showing the prepared Retik's dorsal subcutaneous preputial flap from the foreskin dorsal as a second protective layer with part of fore skin attached at tip of flap, C) Operative photograph of another case showing the dorsal dartos fascia flap prepared as a second covering layer for the urethroplasty and D) Operative photograph of a case showing the urethral stent at the time of recovery. [Courtesy of Prof. Sherif Shehata]

Management of Post Hypospadias Urethral Fistula 53

advantages including dry sealant, transparent and protective water proof as a coated film

Every case of fistula especially if recurrent should be investigated thoroughly prior to surgery either to define possible associated anomalies or causes of recurrence such as presence of a urethral diverticulum or distal urethral stricture, as it may lead to recurrence of the fistula. The distal urethra must be examined for evidence of obstruction by cystoscopy, retrograde urethrography, ascending urethrography or urethral calibration. Intra operative calibration is of paramount importance especially with failure of tube passage. Meticulous penile examination is mandatory to assess the status of local tissue and design the management plan. Any obstruction found has to be corrected simultaneously with the

Timing of the repair of post hypospadias fistula remains one of the most important issues in the outcome of repair. Once a fistula has formed, there may be inflammation and urine extravasation and urethral tissues quickly become edematous and friable. There is little point in attempting to close a newly formed fistula by means of secondary sutures, and in fact further inflammation will result in a larger fistulous opening [15, 26]. Once a fistula has formed, it is recommended that no surgical repair be considered for 6-12 months. Evermore, should all remnants of suture materials disappeared before any attempt for repair. This is the minimum time required for complete wound healing and to allow for full resolution of scar tissue. When we encountered with a recurrent fistula, the waiting time should be a minimum of one year lapse from the former repair. In some recurrent or mega fistulae the

The classic management consist of small fistula which may heal spontaneously within 10 - 21 days of urinary diversion, with appropriate antibiotics until tissue induration and inflammation disappears when there is no meatal stenosis. Spontaneous closure of fistula has been reported in up to 30% cases. During this time, meatus can be dilated with an ophthalmic ointment tube tip to ensure an adequate meatal caliber. Dilation protocol is helpful in pin point cases of fistula provided that there is no distal or meatal stenosis [17, 20]. However, some hypospadias surgeons deny the importance of catheter as it is possible that fistulas which heal in this way would have healed in any case, without a catheter which

As common in hypospadias surgery, there are no perfect surgical techniques for repairing urethrocutaneous fistulae. Many variable factors could influence the surgical management and outcome of urethrocutaneous fistula repair as the time of occurrence after urethroplasty, the location (glanular, coronal, mid-shaft, etc.), size (pin-point, large), the number and the

During the last decade many principles of an ideal repair of fistulae have been clarified. We use the same principles that apply exactly to hypospadias repair in fistula closure and/or repair. Delicate tissue handling, delicate instruments, healthy tissue should be incorporated, a multilayer repair with well-vascularized tissues, avoiding overlapping sutures and non absorbable or thick suture materials, a tension-free closure, use of optical magnification and

may cause irritation that diminishes the chances of spontaneous healing [17, 28].

cheaper sealant dressing from our current experience [1, Shehata, submitted].

**7. Management of fistula**

fistula repair [8, 15].

two – stage repair is advocated [35].

**8. Surgical treatment**

condition of local tissue [26].

#### **6.2 Protective intermediate layer**

Multiple layer closure has a major role in lowering the incidence of fistula formation. The introduction of a protective intermediate layer is the most important single factor in reducing the incidence of fistula and other complications of hypospadias repair. One or more layers was essential as a protective intermediate layer between the neo urethra and the skin layer.

Types of protective intermediate layer including the following as summarized below:

Nowadays the use of spongioplasty is important to be added as an intermediate layer and is helpful to protect the urethroplasty. Another point is the two layers closure of the glans as additional support as proved statistically in hypospadias surgery whether primary or complicated case [33].

#### **6.3 Urethral stenting**

In a prospective comparative study in Cairo University, the role of stenting and catheterization has been evaluated. The study included 100 patients divided randomly into a silicone stent group and a no stenting group. Although the difference was not statistically significant, the incidence of complications and fistula formation was higher in the stented group [13, 16]. However, if the surgeon prefers to use catheters or stents, non-reactive silicone stents or catheters are better employed. A stent or catheter one size smaller than the urethra should be selected to permit voiding around the tube should it become plugged or should bladder spasms occur. Urethral stent is superior to catheterization in post operative period regarding the surgical outcome [13, 33, 34].

#### **6.4 Dressing**

Another major factor is the use of different types of dressings. In a comparative prospective study in Cairo University, the role of dressing has been evaluated. The study concluded that dressings in general statistically increase the incidence of complications and fistula formation in hypospadias repair [14, 33]. Our experiences with others advocate the non wetting or even dryness of wound by no dressing [13, 14, 22]. Other authors showed that dressings should be omitted from routine use after hypospadias repair [13, 14, 22, 40]. For those surgeons who still prefer to use dressings, modern hypospadias dressings with materials such as Duoderm or silicone foam have also aided in reducing the incidence of fistula [15].

#### **6.5 Tisseel**

A fibrin glue preparation is used to augment hypospadias repairs in children. When this adjunct was used, the fistula rate was lowered to 9% versus 28% as reported [28, 29]. Use of fibrin sealant reduces the overall complication rate in hypospadias repair [1, 22]. Recently, the use of butyl cyanoacrylate tissue glue for post hypospadias repair dressing is of many advantages including dry sealant, transparent and protective water proof as a coated film cheaper sealant dressing from our current experience [1, Shehata, submitted].

#### **7. Management of fistula**

52 Current Concepts of Urethroplasty

Multiple layer closure has a major role in lowering the incidence of fistula formation. The introduction of a protective intermediate layer is the most important single factor in reducing the incidence of fistula and other complications of hypospadias repair. One or more layers was essential as a protective intermediate layer between the neo urethra and the

Nowadays the use of spongioplasty is important to be added as an intermediate layer and is helpful to protect the urethroplasty. Another point is the two layers closure of the glans as additional support as proved statistically in hypospadias surgery whether primary or

In a prospective comparative study in Cairo University, the role of stenting and catheterization has been evaluated. The study included 100 patients divided randomly into a silicone stent group and a no stenting group. Although the difference was not statistically significant, the incidence of complications and fistula formation was higher in the stented group [13, 16]. However, if the surgeon prefers to use catheters or stents, non-reactive silicone stents or catheters are better employed. A stent or catheter one size smaller than the urethra should be selected to permit voiding around the tube should it become plugged or should bladder spasms occur. Urethral stent is superior to catheterization in post operative

Another major factor is the use of different types of dressings. In a comparative prospective study in Cairo University, the role of dressing has been evaluated. The study concluded that dressings in general statistically increase the incidence of complications and fistula formation in hypospadias repair [14, 33]. Our experiences with others advocate the non wetting or even dryness of wound by no dressing [13, 14, 22]. Other authors showed that dressings should be omitted from routine use after hypospadias repair [13, 14, 22, 40]. For those surgeons who still prefer to use dressings, modern hypospadias dressings with materials such as Duoderm or silicone foam have also aided in reducing the incidence of

A fibrin glue preparation is used to augment hypospadias repairs in children. When this adjunct was used, the fistula rate was lowered to 9% versus 28% as reported [28, 29]. Use of fibrin sealant reduces the overall complication rate in hypospadias repair [1, 22]. Recently, the use of butyl cyanoacrylate tissue glue for post hypospadias repair dressing is of many

Types of protective intermediate layer including the following as summarized below:

• Snow's tunica vaginalis wrap from the testicular coverings, • Retik's dorsal - subcutaneous preputial flap from the foreskin,

**6.2 Protective intermediate layer**

• Smith's de-epithelialised skin,

• Dorsal dartos fascia flap, and

• Motiwala's dartos flap from the scrotum

• The external spermatic fascia flap [16, 30].

period regarding the surgical outcome [13, 33, 34].

skin layer.

• Buck`s fascia,

complicated case [33].

**6.3 Urethral stenting**

**6.4 Dressing**

fistula [15].

**6.5 Tisseel**

Every case of fistula especially if recurrent should be investigated thoroughly prior to surgery either to define possible associated anomalies or causes of recurrence such as presence of a urethral diverticulum or distal urethral stricture, as it may lead to recurrence of the fistula. The distal urethra must be examined for evidence of obstruction by cystoscopy, retrograde urethrography, ascending urethrography or urethral calibration. Intra operative calibration is of paramount importance especially with failure of tube passage. Meticulous penile examination is mandatory to assess the status of local tissue and design the management plan. Any obstruction found has to be corrected simultaneously with the fistula repair [8, 15].

Timing of the repair of post hypospadias fistula remains one of the most important issues in the outcome of repair. Once a fistula has formed, there may be inflammation and urine extravasation and urethral tissues quickly become edematous and friable. There is little point in attempting to close a newly formed fistula by means of secondary sutures, and in fact further inflammation will result in a larger fistulous opening [15, 26]. Once a fistula has formed, it is recommended that no surgical repair be considered for 6-12 months. Evermore, should all remnants of suture materials disappeared before any attempt for repair. This is the minimum time required for complete wound healing and to allow for full resolution of scar tissue. When we encountered with a recurrent fistula, the waiting time should be a minimum of one year lapse from the former repair. In some recurrent or mega fistulae the two – stage repair is advocated [35].

The classic management consist of small fistula which may heal spontaneously within 10 - 21 days of urinary diversion, with appropriate antibiotics until tissue induration and inflammation disappears when there is no meatal stenosis. Spontaneous closure of fistula has been reported in up to 30% cases. During this time, meatus can be dilated with an ophthalmic ointment tube tip to ensure an adequate meatal caliber. Dilation protocol is helpful in pin point cases of fistula provided that there is no distal or meatal stenosis [17, 20]. However, some hypospadias surgeons deny the importance of catheter as it is possible that fistulas which heal in this way would have healed in any case, without a catheter which may cause irritation that diminishes the chances of spontaneous healing [17, 28].

#### **8. Surgical treatment**

As common in hypospadias surgery, there are no perfect surgical techniques for repairing urethrocutaneous fistulae. Many variable factors could influence the surgical management and outcome of urethrocutaneous fistula repair as the time of occurrence after urethroplasty, the location (glanular, coronal, mid-shaft, etc.), size (pin-point, large), the number and the condition of local tissue [26].

During the last decade many principles of an ideal repair of fistulae have been clarified. We use the same principles that apply exactly to hypospadias repair in fistula closure and/or repair. Delicate tissue handling, delicate instruments, healthy tissue should be incorporated, a multilayer repair with well-vascularized tissues, avoiding overlapping sutures and non absorbable or thick suture materials, a tension-free closure, use of optical magnification and

Management of Post Hypospadias Urethral Fistula 55

A C

 Fig. 4. Identification and techniques of fistula repair: A) Operative photograph of a case of coronal fistula treated by Koff's urethral mobilization, B) Operative photograph of a coronal fistula case converted into coronal type of hypospadias and repaired by TIP procedure, C) Preoperative photo of a coronal mega fistula with methylene blue come out of the fistula, and D) Post operative photo of small coronal fistula with skin bridge. [Courtesy of Prof.

B D

Most surgeons preferred converting large coronal fistulae developed after hypospadias repair, followed by tabularization of the urethral plate with or without a dorsal midline relaxing incision [2, 26, 35]. The Thiersch tube repair with or without the relaxing urethral plate incision, as described by Reddy [25], Rich et al [27] and Snodgrass [38] had a success rate of 92%. Secrest et al [31], reported on the successful urethrocutaneous fistula repair in 53 (91.4%) of the total 58 patients after hypospadias repair with converting the fistula in the primary hypospadias repair. We recently reported success rate of mega fistula by TIP

Sherif Shehata]

principle of nearly 90 % [35].

needle-point cautrey or bipolar cautery for coagulation are currently considered mandatory [28]. A pivotal factor is the operating surgeon that should have a fast experience in the field of hypospadiology not the surgeon who operate occasionally such cases [Warren Snodgrass, Personal Communication].

Before attempting any surgical repair of a fistula, it is important to identify the presence of a urethral diverticulum or distal urethral stricture, so the intra operative calibration of the distal urethra and distension of the repaired hypospadias to search for a diverticulum with meticulous penile examination is mandatory to assess the status of local tissues and design the management plan. Any obstruction found has to be corrected simultaneously with the fistula repair [28].

The next step is to identify the location of the fistula and to exclude any further fistulas by retrograde injection of a diluted povidone-iodine solution or methylene blue dye in to the meatus while the bulbous urethra is being compressed to prevent instillation into the bladder [13, 28].

Generally, the repair of post hypospadias fistulae depends on the size and location of the fistula. However there are many golden principles of the fistula repair which must be followed as the debridement, dissection of the fistula; elaborate excision of the fistulous tract – including the fistula cornu- down to healthy thin urethral tissue, closing by inverting suture, and protective layer closure with lastly coverage using small skin flap [8].

Many techniques advocated included; the trap door technique, simple closure, envelop like closure, using of any of the hypospadias repair techniques like TIP principle or Koff's urethral mobilization in special indications. No single technique is ideal, so the hypospadiologist should tailor the technique according to each case individually. The main two bases are tension free urethral closure and multi layer closure for protection. Also, the former technique employed in hypospadias repair is important with the status of the urethral plate to build up our technique of repair accordingly [34].

Some surgeons advised the use of purse string sutures as a simple method to close fistula which may be of value in small sized fistulae only. Although this principle carries the risk of tension at the edge of the fistula opening also its interrupted sutures; in spite of its simplicity it also had the possibility of impeded urethral epithelium in between the sutures [10].

For a small fistula, simple transverse approximation of healthy urethral tissue is often possible. Subcuticular continuous sutures of 7-0 Vicryl are used to close the urethral edges and had the benefits for preventing the leakage of the urine and passing the urethral epithelium through the sutures. Some surgeons prefer to irrigate the urethra with proximal compression intra operatively to ensure water - tight closure although it is not really necessary [19].

A protective intermediate layer plays an important part in avoiding recurrence as described before since many types of protective intermediate layer are available including; Buck's fascia, Smith's de-epithelialized skin, Snow's tunica vaginalis wrap from the testicular coverings, Retik's dorsal - subcutaneous flap from the foreskin, Motiwala's dartos flap from the scrotum, and the external spermatic fascia flap [16]. Even, the use of urethral mobilization without any suture line for distal fistulae is advocated to resolve the problem of distal fistula [17, 20, 28].

Many of the techniques used in primary repair of hypospadias are exactly used in the repair of post hypospadias urethral fistula especially if multiple or mega fistulae. In the large fistulae, the temptation to simply close the fistula is dangerous, as recurrent fistulae are quite common. Mega fistula should be managed as disrupted case of repair. Often it is advisable to repeat the whole urethroplasty [7, 34, 35].

needle-point cautrey or bipolar cautery for coagulation are currently considered mandatory [28]. A pivotal factor is the operating surgeon that should have a fast experience in the field of hypospadiology not the surgeon who operate occasionally such cases [Warren Snodgrass,

Before attempting any surgical repair of a fistula, it is important to identify the presence of a urethral diverticulum or distal urethral stricture, so the intra operative calibration of the distal urethra and distension of the repaired hypospadias to search for a diverticulum with meticulous penile examination is mandatory to assess the status of local tissues and design the management plan. Any obstruction found has to be corrected simultaneously with the

The next step is to identify the location of the fistula and to exclude any further fistulas by retrograde injection of a diluted povidone-iodine solution or methylene blue dye in to the meatus while the bulbous urethra is being compressed to prevent instillation into the

Generally, the repair of post hypospadias fistulae depends on the size and location of the fistula. However there are many golden principles of the fistula repair which must be followed as the debridement, dissection of the fistula; elaborate excision of the fistulous tract – including the fistula cornu- down to healthy thin urethral tissue, closing by inverting

Many techniques advocated included; the trap door technique, simple closure, envelop like closure, using of any of the hypospadias repair techniques like TIP principle or Koff's urethral mobilization in special indications. No single technique is ideal, so the hypospadiologist should tailor the technique according to each case individually. The main two bases are tension free urethral closure and multi layer closure for protection. Also, the former technique employed in hypospadias repair is important with the status of the

Some surgeons advised the use of purse string sutures as a simple method to close fistula which may be of value in small sized fistulae only. Although this principle carries the risk of tension at the edge of the fistula opening also its interrupted sutures; in spite of its simplicity it also had the possibility of impeded urethral epithelium in between the sutures [10]. For a small fistula, simple transverse approximation of healthy urethral tissue is often possible. Subcuticular continuous sutures of 7-0 Vicryl are used to close the urethral edges and had the benefits for preventing the leakage of the urine and passing the urethral epithelium through the sutures. Some surgeons prefer to irrigate the urethra with proximal compression intra operatively to ensure water - tight closure although it is not really necessary [19]. A protective intermediate layer plays an important part in avoiding recurrence as described before since many types of protective intermediate layer are available including; Buck's fascia, Smith's de-epithelialized skin, Snow's tunica vaginalis wrap from the testicular coverings, Retik's dorsal - subcutaneous flap from the foreskin, Motiwala's dartos flap from the scrotum, and the external spermatic fascia flap [16]. Even, the use of urethral mobilization without any suture line for distal fistulae is advocated to resolve the problem of distal fistula

Many of the techniques used in primary repair of hypospadias are exactly used in the repair of post hypospadias urethral fistula especially if multiple or mega fistulae. In the large fistulae, the temptation to simply close the fistula is dangerous, as recurrent fistulae are quite common. Mega fistula should be managed as disrupted case of repair. Often it is

suture, and protective layer closure with lastly coverage using small skin flap [8].

urethral plate to build up our technique of repair accordingly [34].

advisable to repeat the whole urethroplasty [7, 34, 35].

Personal Communication].

fistula repair [28].

bladder [13, 28].

[17, 20, 28].

Fig. 4. Identification and techniques of fistula repair: A) Operative photograph of a case of coronal fistula treated by Koff's urethral mobilization, B) Operative photograph of a coronal fistula case converted into coronal type of hypospadias and repaired by TIP procedure, C) Preoperative photo of a coronal mega fistula with methylene blue come out of the fistula, and D) Post operative photo of small coronal fistula with skin bridge. [Courtesy of Prof. Sherif Shehata]

Most surgeons preferred converting large coronal fistulae developed after hypospadias repair, followed by tabularization of the urethral plate with or without a dorsal midline relaxing incision [2, 26, 35]. The Thiersch tube repair with or without the relaxing urethral plate incision, as described by Reddy [25], Rich et al [27] and Snodgrass [38] had a success rate of 92%. Secrest et al [31], reported on the successful urethrocutaneous fistula repair in 53 (91.4%) of the total 58 patients after hypospadias repair with converting the fistula in the primary hypospadias repair. We recently reported success rate of mega fistula by TIP principle of nearly 90 % [35].

Management of Post Hypospadias Urethral Fistula 57

techniques, the most common maneuver is to place some intervening layer of tissue between neo-urethra and the skin [4]. For multiple fistulae, a single-stage procedure is still a valid option. Two-stage procedures may be reserved for recurrent fistula where there is a deficiency of adequate healthy local tissue. In cases of serpentine, tortuous or long fistulae, it is advisable to make endoscopic treatment either by laser coagulation and fibrin glue as dissection between layers can destroy the original repair in cases of minute fistulae [16, 31]. Suture tracks (or sinuses) occur when epithelium grows along skin sutures before they dissolve or are removed postoperatively. These sinuses subsequently fill with desquamated keratin, producing unsightly marks. The likelihood that wound closure will leave suture tracks depends upon a variety of factors, including the size and composition of suture

Recently, some surgeons have recommended the use of cyanoacrylate for repair of early fistula after hypospadias surgery and found effective. However the results are lacking the

Fistulae may recur because of technical errors. Contributing factors include inadequate layers of closure, ischemic tissue, and overlapping suture lines. Infection, tension such as is created by edema or hemorrhage, pressure of dressings and occlusion of catheters with urinary extravasation all contribute to fistula recurrence that should be prevented and revised step by step during repair [28]. Hence despite that some literature reports did not advocate the use of stents, our experience collected over 25 years in hypospadias field recommend the use of urethral stents for a minimum of 48 hours in distal cases following