CORONAL FISTULA REPAIR UNDER THE

GLANS
WITHOUT REOPERATIVE HYPOSPADIAS
GLANSPLASTY OR URINARY
DIVERSION

Paulina

INTRODUCTION

Fistulas are one of the most common

complications
following
hypospadias
surgery.
Coronal fistulas potentially present a
dilemma in management, as repair may
sometimes lead to reoperative glansplasty
when there is glans dehiscence with only a
thin band of tissue separating the urethral
meatus from the fistula, or the fistula tract
leads under the glans.

INTRODUCTION

However, hypospadias reoperations are

associated with higher complication rates
than primary repairs, including recurrent
fistulas
Initially, postoperative urinary diversion was
used as dissection extended under the glans,
but subsequently repair was done without a
catheter.
We now report results of coronal fistula
closure without reoperative glansplasty.

MATERIALS

Patients with fistulas following hypospadias

repair between 2001 and 2013 were identified
from data entered prospectively at the time of
service into a database.
Inclusion criteria were coronal fistula without
glans dehiscence.
Patients with concomitant glans dehiscence or
those with less than 1 month follow-up were
excluded from analysis.
Fistula repairs were scheduled at least 6 months
from the prior hypospadias surgery.
Results were reviewed with internal review board

REPAIR TECHNIQUE

In all cases the distal neourethra was calibrated

intraoperatively to exclude meatal stenosis,
defined as <8Fr in prepubertal patients and
<12Fr in post-pubertal patients, and to evaluate
glans dehiscence, defined as separation of the
glans wings with an intervening band of skin
separating the fistula from the meatus.
Saline or methylene blue was injected through a
urethral stent while compressing the urethra
proximally to confirm the presence of a fistula.

Then a circumferential incision was

made around the fistula, and extended
down the median raphe.
The fistula tract was dissected to the
urethra, elevating the glans cephalad
with skin hooks to facilitate exposure of
the distal urethra beyond the base of
the fistula for subsequent coverage by
a ventral dartos flap.

The fistula tract was then excised and the

urethral defect closed longitudinally or
transversely as needed to avoid narrowing
the
neourethra,
using
interrupted
subepithelial 7-0 polyglactin.
Saline was again injected into the urethra to
confirm watertight closure.
A ventral dartos flap was developed,
advanced beyond the urethral repair, and
sutured into place using 9-0 polyglactin.

A
6Fr
catheter
provided
urinary
drainage for 1 week in all prepubertal
patients
initially
(10e12Fr
in
postpubertal patients).
Our primary outcome, recurrent fistula
rate, was compared in those with and
without diversion using Fishers exact
test (SAS 9.2, Cary, NC, USA), with p <
0.05 considered significant.

RESULT

A total of 122 primary fistula closures were done

by WS during the study period. Of these, 78 were
coronal, with 45 (58%) having fused glans wings
undergoing
repair
without
hypospadias
reoperation.
The 45 fistulas without glans dehiscence
occurred after a mean of 1.7 (1e6) prior
hypospadias operations, comprising 35 TIP, 5 2stage grafts, 1 Mathieu and 4 unknown prior
repairs, and all were 3 mm in greatest
dimension.

Median age at repair was 3 years

(range 1-51 years).
During mean follow-up of 18 months
(1.6-84) in 37/45 (82%) patients,
recurrent coronal fistulas occurred in 2
(5%), 1/17 with urinary diversion and
1/20 without diversion (p Z 1.0).

DISCUSSION

We closed coronal fistulas by dissecting

under the glans, avoiding reoperative
urethroplasty and glansplasty, in
consecutive patients with well-fused glans
wings, with a 5% recurrence rate.
There was no difference in recurrent fistulas
between the first 17 patients who had
postoperative urinary diversion compared
with the subsequent 20 who did not;

Ours is the first report on fistula repair using a standardized

protocol in consecutive patients, and it is difficult to compare
our results to other published series which included fistulas
in various locations, heterogeneity in decision-making based
on simple vs complex designations, and varied use of
urinary diversion. Other reported recurrence rates vary from
4% to 30%.
All our patients had primary fistulas <3 mm in size, and so
we cannot comment on use of this technique for recurrent
fistulas and/or larger defects.
We report outcomes during a mean of 18 months follow up,
and it is possible there will be additional recurrences with
longer follow up.

CONCLUSSION

Primary coronal fistulas 3 mm under

well-fused glans wings can be repaired
by elevating the glans rather than
reopening the wings.
Postoperative urinary diversion did not
impact the recurrence rate (5%) and
we no longer use this.