Accepted Manuscript

Temporary re-catheterization as a treatment for early fistulas after hypospadias repair

V.V.S. Chandrasekharam

PII: S1477-5131(16)00017-6
DOI: 10.1016/j.jpurol.2016.01.005
Reference: JPUROL 2112

To appear in: Journal of Pediatric Urology

Received Date: 20 August 2015

Accepted Date: 18 January 2016

Please cite this article as: Chandrasekharam VVS, Temporary re-catheterization as a treatment for early
fistulas after hypospadias repair, Journal of Pediatric Urology (2016), doi: 10.1016/j.jpurol.2016.01.005.

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 ACCEPTED MANUSCRIPT

Temporary re-catheterization as a
treatment for early fistulas after
hypospadias repair

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V. V. S. Chandrasekharam a,*
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Pediatric Surgery, Pediatric Urology & MAS, Rainbow Children’s Hsopitals,

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Hyderabad, Telangana, India

*Corresponding author: Pediatric Surgery, Pediatric Urology & MAS, Rainbow

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Children’s Hsopitals, Hyderabad, Telangana, India. Phone Office: 91 40 44665555;
mobile: 91 9849010175.

E-mail address: vvsssekharam@yahoo.co.in

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Summary

Objective: To present the results of temporary urethral re-catheterization in order to

aid spontaneous closure of early fistulas after hypospadias repair.

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Methods and technique: Children presenting with early fistulas (within 2 weeks of
initial catheter removal) after hypospadias repair underwent urethral calibration and

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re-insertion of a urethral catheter under intravenous anesthesia. The catheter was
removed after 2 weeks.

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Results: Nine children (age 1-9 years) with early fistulas had re-catheterization: six
(66%) had spontaneous healing of the fistula by 2 weeks, which remained closed at
subsequent follow-up.
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Conslusion: The simple technique of urethral re-catheterization may allow
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spontaneous healing of some early fistulas after hypospadias repair.

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Keywords: Hypospadias; Fistula; Catheter; Early

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Introduction
Urethro-cutaneous fistula (UCF) is the commonest complication after hypospadias
repair [1,2]. Traditionally, UCFs are surgically repaired after 6-12 months [1,2]. Many
UCFs present early after surgery [3]; they may be caused by infection, tissue edema
or other technical reasons and, in most cases, the fistula tract is not yet completely
epithelized [3,4]. In the present study, it was hypothesized that early re-catheterization

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of the urethra may aid the UCF to heal spontaneously before it becomes epithelized;
the results of this approach are presented.

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Methods
All children who underwent hypospadias repair and presented with UCF within 2
weeks after initial catheter removal (the catheter is routinely kept in for 7-10 days

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after primary hypospadias repair) were subjected to urethral calibration and re-
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insertion of urethral catheter. Under intravenous anesthesia, the urethra was gently
calibrated (up to 8-10 F) with metal dilators; no attempt was made to force the
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dilators. After calibration, an 8-10 F silicone Foley catheter was inserted

transurethrally into the bladder. The cases with overt wound infections received
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appropriate antibiotics; others received co-trimoxazole prophylaxis while the catheter

was in place. All children received oral anticholinergic medication for 2 weeks. The
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catheter was removed after 2 weeks, and the children were followed after 1 month, 3
months and yearly thereafter. The closure or persistence of fistula was noted based on
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history and clinical examination.

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Results
Over a 2.9-year period, 10 children (aged 1-9 years) presented with early UCF
following hypospadias repair; two of them had clinical evidence of wound infection.
The size of the fistula ranged from 2-4 mm. Urethral calibration and re-catheterization
were successfully performed in nine children; in one child, the dilator could not be
easily passed into the proximal urethra, hence, the procedure was abandoned. The
initial procedure for hypospadias repair and the location of the fistula are summarized
in Table 1. After removal of the catheter, the fistula was healed in six of the nine
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children (66%) at 1-month follow-up, and remained closed at subsequent (3-24
months) follow-up. Of the three children with persistent UCF, two were surgically
closed 6 months after the primary repair, while one child was awaiting surgery.

Discussion

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Lapointe, et al. [4] treated early UCFs by cyanoacrylate glue application, followed by
an indwelling urethral catheter for 7 days, and reported success in 62.5% cases. In the

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present study, simple re-catheterization for 2 weeks also resulted in similar success
with spontaneous UCF closure. Temporary re-catheterization may help spontaneous

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UCF closure in many ways: it gives rest to the neourethral suture line, keeps the UCF
dry, gives time for neourethral edema and inflammation to subside, and allows
healing of infected wounds. Daher, et al. [5] reported that following primary

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hypospadias repair, 3-weeks of catheterization resulted in significantly less
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complications than 1-week of catheterization. Experimental studies have also
demonstrated that urethral healing is a slow process and may continue for 21 days [5].
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Thus, at least in some cases, increasing the duration of catheterization may help better
healing of the neourethra.
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In conclusion, this simple technique may allow spontaneous healing of some early
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UCFs, thus avoiding another formal surgical procedure in these children.

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Conflict of interest: nil.

Funding: nil.
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Ethical approval: none required.

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References

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1. Muruganandham K, Ansari MS, Dubey D, Mandhani A, Srivastava A, Kapoor
R, et al. Urethrocutaneous fistula after hypospadias repair: outcome

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of three types of closure techniques. Pediatr Surg Int 2010; 26: 305-8.
2. Elbakry A Management of urethrocutaneous fistula after hypospadias
repair: 10 years’ experience. BJU Int 2001; 88: 590-5.

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3. Wood HM, Kay R, Angermeier KW, Ross JH. Timing of the presentation of
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urethrocutaneous fistulas after hypospadias repair in pediatric patients. J Urol 2008;
180: 1753-6.
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4. Lapointe SP, N-Fekete C, Lortat-Jacob S. Early closure of fistula after hypospadias

surgery using N-Butyl Cyanoacrylate: preliminary results. J Urol 2002; 168: 1751-3.
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5. Daher P, Khoury A, Riachy E, Atallah B. Three-week or one-week catheterization

for hypospadias repair: a retrospective-prospective study of 189 patients. J Pediatr
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Surg 2015; 50: 1063-66.

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Table 1.

Number of cases Closed after re- Success of re-

(n) catheterizaion (n) catheterization (%)
Initial procedure Duplay 5 3 60
Onlay island flap 4 3 75
Location of Coronal 4 2 50
fistula Midpenile 3 2 66
Penoscrotal 2 2 100

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Total 9 6 66

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