尿道下裂術後復發性尿道皮膚瘻管的診斷與治療

林介山^1,2江恆杰¹,王百孚¹,張建祥¹,周明智²

彰化基督教醫院 外科部 泌尿科¹; 中山醫學大學醫研所²

DIAGNOSIS and TREATMENT of RECURRENTLY URETHROCUTANEOUS FISTULAE after HYPOSPADIAS RECONSTRUCTIONS

Jesun Lin^{1, 2}, H-J Chiang¹, B-F Wang¹, J-C Chang¹, M-C Chou²

Divisions of Urology¹, Department of Surgery, Changhua Christian Hospital, Changhua, 

 Institute of Medicine², Chung-Shan Medical University, Taichung, Taiwan

Purpose: Urethrocutaneous fistulae (UCF) after hypospadias repair remain a frustrating problem for urologists. These complications are able to be prevented and corrected more satisfactorily with the improvement in suture materials and surgical techniques. Delicate tissue handling, a multilayer repair with well vascular tissues, avoiding overlapping sutures and non-absorbable or thick suture materials, a tension‐free closure, use of optical magnification are currently considered mandatory. We will share our experience of the diagnosis and treatment of recurrently urethrocutaneous fistulae after hypospadias repairs.

Materials and Methods: 78 postoperatively urethrocutaneous fistulae were found in1126 hypospadias patients from January 1982 to January 2018. The number of operations for their closure ranged from 2 to 8 attempts. A single fistula was present in 56 patients and multiple fistulae were present in 22 patients. There were 18 fistulae distal to coronal sulcus, 60 were penile and perineal fistulae. The method of evaluation of these patients included (1) physical examination and by video image of urination (2) cystourethroscopy, (3) retrograde normal saline demonstration under general anesthesia before operation. The ‘pants‐over‐vest’ technique can be considered the technique of choice in proximal fistulae, whereas it has some limitations for glanular and coronal ones. There is insufficient local tissue and less vascular site to harvest the flaps in glans penis and coronal fistulae. We opened the fistula and converted as distal hypospadias and then performed redo urethroplasty. We have always used double-tubes stents because an indwelling a fine inner catheter in the outer silicon stent and then inserted in the urethra for 2 to 4 weeks. It can support the healing urethra and prevent recurrences of fistula and stricture. We performed the reconstruction in obtaining a tension‐free closure and no distortion of the penile shaft skin after surgery.

Results: The number of redo-operations for their presenting problems ranged from 1 to 8 attempts. Of 7 fistula patients with stenosis or stricture of urethra, we repaired with island onlay flap. The over all successful rate is 76%.

Conclusion: Double-tubes stent was inserted for prevention of stricture and fistula. The vascular subcutaneous layer was covering on the repaired fistula for creating the new corpus spongiosum in order to preventing of recurrence. Experience is by far the best teacher. The technique as taught is suspected, unless the technique and subsequent good results of an individual method are transferable to others