# Tunneled Tunica Vaginalis Flap for Recurrent Urethrocutaneous Fistulae

Authors: Jonathan C. Routh; James J. Wolpert; Yuri Reinberg
Journal: Advances in Urology
 (2008)

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## Abstract

The tubularized incised plate (TIP) hypospadias repair is currently the most widely used urethroplasty technique. The most significant post-TIP complication is urethrocutaneous fistula (UCF) development. Tunneled tunica vaginalis flap (TVF) is a well-described technique for the repair of UCF. We retrospectively reviewed all patients undergoing repeat repair of UCF after TIP repair from 2001 to 2005. Twelve boys underwent TVF repair at our institution for recurrent UCF. Fistulae ranged from distal penile to penoscrotal in location. Median surgical time was 45 minutes and no postoperative complications occurred. After a median follow-up of 32 months (range 16–48 months), no patient has yet had a recurrence of UCF. In conclusion, TVF repair is a successful technique for the treatment of UCF after previous failed repair. TVF is technically simple to perform and should be considered for treating UCF following TIP urethroplasty, particularly in a repeat surgical setting.


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## Body

## 1. Introduction

Hypospadias has
been recognized as a surgically treatable condition for nearly two millennia.
Physicians of both the Hellenic (Heliodorus and Antyllus) and Roman worlds
(Celsus and Galen)  described the
condition as well as its possible surgical remedies [1, 2]. Needless to say,
surgical techniques have evolved with time. The most significant recent advance
in this evolution occurred in 1994 with Snodgrass’ description of the
tubularized incised plate (TIP) urethroplasty technique [3].  Since its initial description in cases of
distal hypospadias, TIP urethroplasty has now been applied with notable success
to both proximal [4] and reoperative [5, 6] hypospadias.Despite these
advances in urethroplasty technique, certain complications remain problematic
for the modern hypospadiologist, namely, meatal stenosis, urethral stricture or
diverticulum, wound dehiscence, and, perhaps most importantly, urethrocutaneous
fistulae (UCF). A recent review of TIP urethroplasty reveals a combined UCF
rate of 2.4% across several major centers [7]. The interposition of
vascularized tissue such as tunica vaginalis flap (TVF) or deepithelialized
dartos tissue has been suggested as an effective means of reducing UCF
formation rate in multiple urethroplasty techniques, including TIP [7–9].Successful fistula
repair depends in large part upon meticulous attention to surgical detail, as
well as the use of interposed tissue. In reoperative patients, however, this
can be difficult to achieve, as well-vascularized tissues amenable to
interposition may be sparse. One possibility for interposition graft for UCF
repair is the use of tunneled TVF, which was first described in 1970 by Hosli
[10] and subsequently popularized by
Snow et al. [8, 9]. Despite the widespread use of both TIP
urethroplasty and UCF repair, there is a lack of data describing TVF use for
UCF following TIP urethroplasty. We have previously examined our results with
the use of TVF for UCF following TIP urethroplasty [11]. We now update that
experience in the most difficult patients, those who have undergone multiple
previous penile surgeries including previous failed UCF repair following
TIP.


## 2. Materials and Methods

### 2.1. Patient
Selection

We retrospectively
reviewed all records of patients undergoing TVF repair of post-TIP UCF at our
practice between January 2000 and December 2005. Only patients who had failed
previous UCF repair were included in this study. All final UCF repairs were
performed by the authors, although initial urethroplasty was performed
elsewhere in some patients. Surgeries were performed under general anesthesia
in our outpatient surgical facility with a 6-month minimum healing period
between the previous penile surgery and UCF repair. For each patient, we
abstracted the following data: age, surgeon, number of previous surgeries,
number and location of fistulae, original pre- and postoperative location of
urethral meatus, surgical/anesthetic duration, length of followup, and
postoperative complications. We loosely defined complications to include meatal
stenosis, postoperative wound infection, scrotal hematoma, penile torque,
penile tethering, or recurrence of fistulae.


### 2.2. Surgical
Technique

Our surgical technique has been previously
described [11]. Briefly, all patients undergo calibration of the distal
urethra. Dilute Betadine solution is then instilled into the urethra through
the meatus to visually confirm the exact location and number of all UCF. A
Foley catheter is placed in the bladder. Each UCF tract is excised, and the
urethra is primarily closed in two layers using 7-0 PDS suture. A 1-cm incision
is then made at the penoscrotal junction and a flap of tunica vaginalis is
harvested, taking great care to avoid inclusion of cremasteric muscle
fibers.  Flap length is determined by the
distance from the harvest site to the UCF site. The TVF is then tunneled
underneath the penile skin and brought out through the most distal UCF tract.
The TVF is then fixed at each UCF site using 7-0 PDS. The skin overlying each
UCF tract is then closed.


## 2.1. Patient
Selection

We retrospectively
reviewed all records of patients undergoing TVF repair of post-TIP UCF at our
practice between January 2000 and December 2005. Only patients who had failed
previous UCF repair were included in this study. All final UCF repairs were
performed by the authors, although initial urethroplasty was performed
elsewhere in some patients. Surgeries were performed under general anesthesia
in our outpatient surgical facility with a 6-month minimum healing period
between the previous penile surgery and UCF repair. For each patient, we
abstracted the following data: age, surgeon, number of previous surgeries,
number and location of fistulae, original pre- and postoperative location of
urethral meatus, surgical/anesthetic duration, length of followup, and
postoperative complications. We loosely defined complications to include meatal
stenosis, postoperative wound infection, scrotal hematoma, penile torque,
penile tethering, or recurrence of fistulae.


## 2.2. Surgical
Technique

Our surgical technique has been previously
described [11]. Briefly, all patients undergo calibration of the distal
urethra. Dilute Betadine solution is then instilled into the urethra through
the meatus to visually confirm the exact location and number of all UCF. A
Foley catheter is placed in the bladder. Each UCF tract is excised, and the
urethra is primarily closed in two layers using 7-0 PDS suture. A 1-cm incision
is then made at the penoscrotal junction and a flap of tunica vaginalis is
harvested, taking great care to avoid inclusion of cremasteric muscle
fibers.  Flap length is determined by the
distance from the harvest site to the UCF site. The TVF is then tunneled
underneath the penile skin and brought out through the most distal UCF tract.
The TVF is then fixed at each UCF site using 7-0 PDS. The skin overlying each
UCF tract is then closed.


## 3. Results

Twelve boys (mean
age 2.2 years) underwent TVF repair of recurrent UCF at our institution during
the study period. Six boys had distal shaft and 6 had proximal shaft or
penoscrotal hypospadias. All patients had
originally undergone TIP repair with subsequent UCF formation; 4 patients (33%)
had their initial urethroplasty performed at our institution, with the
remainder being referred after initial TIP repair done elsewhere. Eleven
fistulae (92%) developed spontaneously within the first 2 years after initial
TIP repair. One patient did well postoperatively but ultimately developed a UCF
after direct trauma to the penis.All boys had undergone previous attempted UCF
repair, with 8 (67%) undergoing 1 repair, 2 (17%) undergoing 2 repairs, and 1
each (8%) undergoing 3 and 4 previous repairs. All patients had a subcoronal
UCF, while 8 (67%) were found to have multiple fistulae along the distal shaft:
4 each (33%) with 3 and 4 fistulae, including 1 patient with a penoscrotal
fistula.  Median operative time was 45
minutes (range 30–90).No pre- or postoperative complications have as
yet occurred in any patient, including hematoma, wound infection, abscess, or
secondary chordee or torque. After a mean followup of 32 months (range 16–48 months), no
patient has yet had a recurrence of their UCF.Following our
initial experience with the patients described above, we have since performed
this procedure on an additional 10 children, none of whom have had a fistula
recurrence in followup of less than one year.


## 4. Discussion

The useof TIP urethroplasty has greatly
increased since its initial introduction by Snodgrass in 1994 [3],  with several centers reporting it to, now, be
their primary urethroplasty technique [5, 12].
However, the procedure is not without potential complications, including
meatal stenosis, urethral stricture or diverticulum, wound dehiscence, and UCF.
In a recent review, a UCF rate of 2.4% was
noted [7]. Several reports, however,
show a much higher fistula rate, including those of Chatterjee et al.
(15%) [13],
Amukele et al. (17%) [14],
and Guralnick et al. (16%) [15].Snow et
al. have advocated the preventative use of TVF during primary
hypospadias repair. When combined with use of the operative microscope, their
reported posturethroplasty UCF rate is 0%, with a 2.2% complication rate,
namely, scrotal hematoma and abscess [8]. The utilization of TVF has also been
described as a means of UCF repair following initial urethroplasty using
several techniques, with a combined recurrence rate of 7.9% and no
complications reported [16–20]. Pattaras and  Rushton have reported two patients who developed severe penile torque several
years after primary urethroplasty using TVF in a preventative manner. In both
cases the flap was simply divided with subsequent resolution of the torque [21].The advantages of
TVF are myriad, particularly in the reoperative patient. As the tunica lies
well away from the operative field of the penile shaft, its blood supply
remains uninterrupted even in the setting of numerous reoperations. Operative
access to tunica vaginalis is technically simple, as evidenced by our median
anesthesia time of 45 minutes. The low complication rate in our hands, which is
consistent with previous reports [8, 16–18, 20, 21],
provides further evidence that the procedure is safe and easy to perform, even
in the setting of a reoperative patient with multiple fistulae. Obviously,
strict adherence to the basic principles of UCF and hypospadias repair should
be maintained.The limitations of
this study are primarily a question of length of followup; as noted by Pattaras
and Rushton [21], several years may need to elapse before the development of
truly long-term complications. Our relatively small sample size and average
followup of 32 months may not be adequate to fully demonstrate all
complications and thus may falsely lower our complication rate. However, it
should be noted that complication rates are low even in studies with
significantly longer followup [8]. This lends a measure of reassurance that our
rates are not overly optimistic. Further, we feel that many complications can
be successfully avoided by careful attention to detail—specifically, ensuring that the TVF is of
adequate length in order to avoid secondary chordee and that no cremasteric
fibers are included with the flap in order to avoid penile torque. By following
these simple principles, a technically simple, highly successful repair of
recurrent UCF can be accomplished in minimal operative time.


## 5. Conclusions

Tunneled TVF
repair is a highly successful technique for the treatment of posturethroplasty
recurrent UCF. The technique is simple and quick to perform with no
complications encountered in our experience. TVF repair is particularly useful
as the tissue of choice for treating UCF in the repeat surgical setting
following initial failed TIP urethroplasty, with excellent results at long-term
followup.



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