Post-hypospadias urethrocutaneous fistulae: no difference in repair success between proximal and distal fistulae.

INTRODUCTION Urethrocutaneous fistulae are the most common complication after hypospadias repair. We sought to compare outcomes of proximal versus distal urethrocutaneous fistula repair and hypothesized that patients with proximal fistulae would have lower rates of success than those with distal fistulae. We also aimed to evaluate factors that affected these outcomes. MATERIAL AND METHODS: Current procedural terminology codes were used to identify patients undergoing urethrocutaneous fistula repair after hypospadias surgery between 2014 and 2017 at an academic, pediatric urology referral center. Characteristics for each initial hypospadias repair and each fistula repair were noted, including location of meatus, location of fistula, type of magnification, suture type, interposition layer and post-operative stenting. The primary outcome was successful fistula repair. Univariate and multivariate analysis was performed. RESULTS: During the study period, 416 hypospadias repairs were performed. Thirty-one of these later presented with a fistula (8% fistula rate). Sixty-eight percent of fistulae were successfully closed with a single repair. There were 17 distal fistulae and 14 proximal fistulae. There was no difference in success between distal (71%) and proximal (64%) fistulae (p = 0.73). There was no statistically significant association between the primary outcome (successful fistula repair) and fistula location (p = 0.71), magnification (p = 0.38), suture type (p = 0.49), interposition coverage layer (0.43), or postoperative stenting (p = 0.92) on univariate or multivariate analysis. CONCLUSION: There is no difference in success when repairing distal versus proximal urethrocutaneous fistulae. Neither fistula location, type of magnification, suture type, interposition layer nor stenting affected outcomes.

Surgical management of recurrent urethrovaginal fistula with a skin island flap.

INTRODUCTION AND HYPOTHESIS: A urethrovaginal fistula is a possible rare complication of tension-free vaginal tape procedures. Surgical management of these fistulas is sometimes complicated, and failure can occur. The operation is difficult when the defect between the urethra and the vagina is larger or scarred, so surgical intervention and the preferred technique are controversial. METHODS: The patient was referred to our department, where the first operation was performed to address the urethrovaginal fistula by the transvaginal and transabdominal approach with interposed omentum. This initial repair failed, resulting in a large urethrovaginal fistula with minimal redundant anterior vaginal wall to provide a tension-free closure. This video presentation describes the second operation-transvaginal repair of a large recurrent urethrovaginal fistula using the skin island flap technique. RESULTS: The video of the procedure shows how to address a recurrent urethrovaginal fistula by employing a skin flap. An examination during the patient's follow-up visit 3 months later revealed excellent healing and persistent stress urinary incontinence (SUI). Six months after the fistula repair, the patient underwent a bulking agent procedure. CONCLUSIONS: The skin island flap procedure allowed the larger defect to heal, though it did not address the SUI, which was later treated by application of a bulking agent.

Rectal ulcer and pseudomalignant epithelial changes after prostate seed brachytherapy: A rare complication with a diagnostic pitfall.

BACKGROUND: Implant brachytherapy (IBT) is a well-recognized treatment modality for early stage prostate cancer. Rectal ulcer and rectourethral fistula complicating IBT may cause an alteration of the normal anatomic landmarks. In this context, pseudomalignant radiation-induced changes within prostatic epithelium may be misinterpreted as a primary rectal malignancy. Such challenging and misleading findings have not been described, and may not be recognized as such. MATERIALS AND METHODS: We present the clinical and pathologic aspects of two patients who underwent IBT for low stage prostate cancer that was complicated by deep rectal ulcer. Both patients underwent extensive palliative surgical resection for disease control. RESULTS: The histologic changes in both cases were noteworthy for extensive necrosis and inflammation of the prostate, associated with loss of recto-prostatic anatomical landmarks. Prostatic glands showed striking radiation-induced atypia and pseudomalignant epithelial changes extending to the rectal ulcer bed, with no residual viable tumor. The first patient had undergone a biopsy of the rectal ulcer bed that was misinterpreted as a rectal adenocarcinoma prior to surgery. The similarity between atypical glands of the biopsy and the benign prostatic tissue with radiation-induced atypia in resection specimen confirmed their benign nature. CONCLUSIONS: Deep rectal ulcer complicating IBT may lead to distortion of the normal recto-prostatic anatomical landmarks, resulting in detection of pseudo-malignant prostatic glands at the ulcer base. Such findings may be mistaken for a primary rectal malignancy in limited biopsy material if not familiar to the pathologist.

A rare complication of ureteral stenting: Case report of a uretero-arterial fistula and revision of the literature.

INTRODUCTION: Uretero-arterial fistulas are a rare condition. The most frequent clinical sign is hematuria. Since these bleedings occur intermittently, the diagnosis is very difficult. If not discovered, uretero-arterial fistulas involve a very high rate of mortality or even results in loss of kidney function. CASE REPORT: The clinical case we describe is an unusual one. After a radical hysterectomy and a subsequent radiotherapy, a hydronephrosis caused by ureteral fibrosis occurred on both sides. Therefore, the patient received bilateral ureteral stents. During a change of the ureteral stents 18 months later, a massive bleeding appeared in the right ureter. Initially, a clear evidence of a fistula was not possible - neither through CT scan nor through selective angiography. There were some indicators of a uretero-arterial fistula, so an endoluminal vessel stent was placed. Subsequently the fistula probably led to an erosion of the vessel stent. DISCUSSION: A fistula between the ureter and the iliac artery (UAF) is a rare complication. The increase in known cases during the last years is linked to the possibility of ureteral stenting since 1978. Until now only 140 cases have been described in literature. The mortality rate through UAF has decreased from 69% in 1980 to 7-23% today. Its development can be traced through the pulsation of the artery and the pressure on the ureter. The most important clinical symptom is bleeding. Diagnosis is generally difficult and represents the real problem. The sensitivity of the standard angiography examination is 23- 41%; it can be improved to 63% using the "provocative" method, which means mobilizing the ureteral stent during examination. The therapy in course of the angiography consists of a simultaneous endovascular stent and/or a co-embolisation. CONCLUSION: Arterial or uretero-arterial fistulas (UAF) are a rare condition; the diagnosis is very difficult and most of the time the treatment requires a multidisciplinary team.

Imperforate anus with rectopenile fistula: a case report and systematic review of the literature.

BACKGROUND: Although anorectal malformations (ARMs) are frequently encountered, rare variants difficult to classify have been reported. METHODS: This study describes a patient with ARM and rectopenile fistula. The literature was reviewed systematically to assess the anatomical characteristics, clinical presentations and operations of this rare type of ARM. RESULTS: Eight patients were reported in the six included articles. In three patients, the fistula extended from the rectum to the anterior urethra without communication with the skin. In one patient, the fistula, located deep in corpus spongiosum, opened to the ventral aspect of the penis without communication with the urethra. In the remaining four patients, the fistula extended from the rectum to the cutaneous orifice in the ventral aspect of penis, with communication or a short common channel with the urethra. CONCLUSIONS: Imperforate anus with fistula extending into the penis is a rare variant of anorectal malformation. Unawareness of this lesion resulted in a delay of correct diagnosis and appropriate management. A thorough examination, including colonourethrography and fistulography, should be performed in all patients with a fistula opening in the ventral aspect of the penis.

Can a graft be placed over a flap in complex hypospadias surgery? An experimental study in rabbits.

PURPOSE: To develop a rabbit experimental study to test the hypothesis that surgical repair of hypospadias with severe ventral curvatures might be completed in one stage, if a graft, such as buccal mucosa, could be placed over the tunica vaginalis flap used in corporoplasty for ventral lengthening, with the addition of an onlay preputial island. flap to complete the urethroplasty. MATERIALS AND METHODS: The experimental procedure with rabbits included a tunica vaginalis flap for reconstruction of the corpora after corporotomy, simulating a ventral lengthening operation. A buccal mucosa graft was placed directly on top of the flap, and the urethroplasty was completed with an onlay preputial island flap. Eight rabbits were divided into 4 groups, sacrificed at 2, 4, 8 and 12 weeks postoperatively, and submitted to histological evaluation. RESULTS: We observed a large number of complications, such as fistula (75%), urinary retention (50%) and stenosis (50%). There were two deaths related to the procedure. Histological evaluation demonstrated a severe and persistent inflammatory reaction. No viable tunica vaginalis or buccal mucosa was identified. CONCLUSIONS: In this animal model, the association of a buccal mucosa graft over the tunica vaginalis flap was not successful, and resulted in complete loss of both tissues.

Circumferential urethral fistulae in Sub-Saharan Africa, current outcomes and future prospects.

INTRODUCTION AND HYPOTHESIS: Circumferential urethral fistula is a severe form of obstetric injury that is recognized to carry a poor prognosis for eventual continence but this has not been quantified before. METHODS: An analysis of 106 women who had undergone primary repair of a circumferential fistula was carried out with particular reference to whether there complete continence or at least some improvement in remaining dry was reported. RESULTS: Of the 106 women, only 25% reported themselves continent; 19% said there was an improvement. Prognosis was not altered by the distance of the fistula from the external urethral meatus, with 10/62 (16% reporting continence if the fistula was <1.5 cm and 10/44 (13%) if >1.5 cm. There was a 13% primary dehiscence rate. CONCLUSIONS: Current methods of primary urethral fiistula repair carry a poor prognosis for eventual continence. Techniques to lengthen the urethra and provide greater support need to be developed for this unfortunate group of women.

[Evolution aspect of anatomy clinical lesions of urogenital fistula (UGF) in Cocody Teaching Hospital urological unity from 1990 to 2011]. / Aspect évolutif des lésions anatomo-cliniques des fistules urogénitales (FUG) dans le service d'urologie du CHU de Cocody de 1990 à 2011.

PURPOSE: The aim of this study is to compare anatomy pathological lesions seeing in urogenital fistula in Cocody Teaching Hospital between two decades, 1990 to 2000 and 2000 to 2010. MATERIEL AND METHOD: This survey is retrospective and carries on 20 years (January 1990 to December 2011) 190 urogenital fistulas (140 cases between 1990 and 1999; 50 from 2000 to 2011) hospitalized in our unity. Anatomy clinical characteristics of these fistulas were determined by clinical or paraclinical examination. RESULTS: Between 1990 and 1999, fistulas were classified in 20 bladder-uterine fistulas (14.29%), 16 uretro-vaginal fistulas (11.43%) and 104 bladder-vaginal fistulas (74.29%) of whom 80 isolated UGFs and 24 UGFs associated with recto-vaginal fistula. These 104 UGFs were located at: bladder neck 22 cases (21.15%), bladder trigonal 46 cases (44.23%), urethra 14 cases (13.46%). Twenty-two bladder sphincter were destroyed and represented 21.15% of fistula's bladder-vaginal fistula and 15.71% of all UGFs. The average fistula diameter was 3 cm [extremes: 1 and 12 cm]. In 22 cases (15.71%), fistula diameter was more than 10 cm. It was bladder neck and sphincter destruction. Hundred and twenty-six fistulas were isolated (90%). Only 10% (14 cases) were associated. Fistulas were primitive in 85.71% of cases (120/140), recurrent in 7 cases (7.86%) and multi-recurrent (>3 reinterventions) in 9 cases (6.43%). From 2001 to 2011, no bladder-uterine fistulas were seen, but: 6 (13.95%) isolated uretero-vaginal fistulas and 6 (13.95%) uretero-vaginal fistulas associated with bladder-vaginal fistula, 31 (62%) bladder-vaginal fistulas of whom 20 (64.52%) bladder trigonal fistulas, 6 (19.34%) retro-trigonal fistulas and 2 (6.45%) urethral fistulas. Only three (9,68%) recto-vaginal fistulas were associated. The average fistula diameter was 2 cm. The fistulas were isolated in 40 cases (80%) and associated (VVF+uretero vaginal F) in 10 cases (20%). Thirty-five cases (70%) were primitive and 10 cases (20%) recurrent of whom 5 (10%) many recurrent. Fistulas were classified in simple fistula in 7 cases (14%) and complex fistula in 43 cases (86%) CONCLUSION: UGF remained relatively frequent in Cocody Teaching Hospital, but the lesions have favorably evolved in the last decade. Simple type of fistula became more frequent than complex ones. LEVEL OF EVIDENCE: 4.

Urinary tract abnormalities in boys with recurrent urinary tract infections after hypospadias repair.

OBJECTIVE: To examine the development of recurrent urinary tract infections (UTIs) in boys who have undergone hypospadias repair. MATERIALS AND METHODS: We retrospectively reviewed the records of all boys who had recurrent UTIs after primary or redo tubularized incised plate (TIP) or transverse island flap (TVIF) repairs, between 1998 and 2009. Data on age, operating details, postoperative complications and imaging studies were collected. We attempted to identify risk factors for recurrent UTIs after hypospadias repair. RESULTS: During the study period, 43/2249 boys (1.91%) were diagnosed with recurrent UTIs after hypospadias repair. The boys' mean (range) age at repair was 14 (6-24) months and the median (range) follow-up was 6.5 (1.5-11) years. Primary TIP and TVIF were performed in 47% (20/43) and 35% (15/43) of the boys, respectively. Redo surgeries were performed in 18% of the boys (8/43). The initial meatal location was proximal in all TVIF and redo repairs, and in one of the TIP repairs. Postoperative voiding cysto-urethrography, ultrasonography and dimercapto-succinic acid (DMSA) scans were performed in 58% (25/43), 90% (39/43) and 19% (8/43) of the boys, respectively. Abnormalities were noted. Of those boys who underwent a TVIF repair, urethral diverticula were seen in 47% (7/15) and urethral fistulae were also seen in 47% (7/15). Conversely, in those who had a TIP repair, an elevated PVR and vesico-ureteric reflux were more common; they were found in 40% (8/20) and 50% (10/20) of patients, respectively. CONCLUSIONS: The pathophysiology of recurrent UTI is multifactorial, but postoperative complications seem to vary with type of procedure. Recurrent UTIs after hypospadias surgery should prompt a specific assessment for potentially functionally relevant and correctable anatomical abnormalities.

Proximal hypospadias.

Hypospadias results from abnormal development of the penis that leaves the urethral meatus proximal to its normal glanular position. Meatal position may be located anywhere along the penile shaft, but more severe forms of hypospadias may have a urethral meatus located at the scrotum or perineum. The spectrum of abnormalities may also include ventral curvature of the penis, a dorsally redundant prepuce, and atrophic corpus spongiosum. Due to the severity of these abnormalities, proximal hypospadias often requires more extensive reconstruction in order to achieve an anatomically and functionally successful result. We review the spectrum of proximal hypospadias etiology, presentation, correction, and possible associated complications.

Spontaneous resolution of ureterovaginal fistula.

OBJECTIVE: We report one case of a spontaneous resolution of a uretero-vaginal fistula, and we review the current diagnostic and therapeutic features of this condition in the literature. METHODS: We present the case of a 41-year-old woman who, during the late postoperative period of a radical hysterectomy, presented episodes of daily and nocturnal incontinence with episodic flank pain compatible with uretero-vaginal fistula. RESULTS: One month after diagnosis the patient does not report incontinence during day or night, and the lumbar pain has disappeared. An intravenous urography shows that there has been a spontaneous resolution of the uretero-vaginal fistula. CONCLUSIONS: Spontaneous resolution of a uretero-vaginal fistula is rare. Most fistulas require endourological or surgical treatment.

Bilateral Ureterovaginal Fistulas and Vesicovaginal Fistula in Setting of Retained Pessary.

Urogenital fistulas in the setting of foreign body are rare. Isolated vesicovaginal fistula is the most common and has been reported in the setting of retained intraureterine device,1,2 neglected pessary3,4 and atypical insertions related mostly to sexual activity or underlying psychiatric disorders.5-7 Combined vesicovaginal and ureterovaginal fistulas related to foreign body are extremely rare. To our knowledge, we present the first reported case of bilateral ureterovaginal fistula and concurrent vesicovaginal fistula in the setting of retained pessary.

Ureterocolic fistula detected by mercaptoacetyltriglycine (MAG-3) diuretic renography including single photon emission CT and low-dose CT (SPECT-CT).

We describe the case of a 60-year-old man with a ureterocolic fistula following laparoscopic sigmoid resection. The fistulous tract between the left ureter and sigmoid colon was detected by mercaptoacetyltriglycine diuretic renography including single photon emission CT with low-dose CT. Ureteroneocystostomy was successfully performed.

[Case of male accessory urethra with orifice in the scrotal skin].

A 67-year-old male had an innate fistular orifice at the scrotal skin. In spite of occasional pus discharge from the orifice, no treatment had been performed for the fistula because it improved spontaneously. Due to increasing pus discharge, the fistula was resected at a dermatology clinic, but a persistent fistula tract was confirmed postoperatively by MRI. The fistula adjoined the bulbar urethra and was considered an accessory urethra. We performed resection of the fistula to resolve the frequent pus discharge and pain due to infection of the fistula. The isolated fistula did not communicate with the urethra and the proximal edge ended blindly. Pathological examination showed that the proximal end consisted of transitional epithelium and the distal end consisted of stratified squamous epithelium which meant an accessory urethra. Accessory urethra is not a rare condition, but cases like this one with an orifice that opened at the scrotal skin are extremely rare. As the treatment for the fistula, complete resection should be indicated.

[Treatment of urethral fistulas in children with application of allogenic fibroblasts].

The study was aimed at upgrading the results of conservative treatment of children with urethral fistulas using methods of tissue engineering. A total of 126 operations for closure of urethral fistulas (UF) were made from 1986 to 2007. The patients were divided into four groups. A conservative therapy was given to 25 children of group 1 aged 5-15 years. Group 2 of 60 patients were operated according to Smith. 39 children entered group 3. They were treated conservatively with application of allogenic fibroblasts. In 1 child UF was closed by a combined method when application of fibroblasts was made upon the sutures. Use of cell technologies for closure of urethral fistulas demonstrates high efficacy of the method for conservative management of long urethral fistulas of a small diameter. Application of allogenic fibroblasts has definite indications and contraindications. In some cases it cannot be used for correction of postoperative complications. Adequate preoperative examination of the patients should be made to formulate optimal therapeutic policy.

Pyeloduodenal Fistula in Xanthogranulomatous Pyelonephritis: A Series of Two Cases.

Xanthogranulomatous inflammation, characterized by destruction and replacement of tissues with chronic inflammatory cells, including foamy histiocytes and hemosiderin-laden macrophages, is uncommon. In patients with xanthogranulomatous pyelonephritis, inflammation may extend from the kidney to the overlying duodenum, creating a pyeloduodenal fistula that further complicates medical and surgical management. We present two cases with recurrent kidney infections who each ultimately received a nephrectomy and repair of their duodenal fistula.

Intravenous urography findings in women with ureteric fistula.

INTRODUCTION: Ureteric fistula is one of the major morbidities that can arise from pelvic surgeries. It mainly results from gynaecological and obstetric procedures. Intravenous urography is an imaging modality for the upper urinary tract. Its features may be suggestive of ureteric fistula and it is of great value when medicolegal issues arise. It is however expensive and requires expertise. There are other useful and cheap methods for evaluating ureteric fistula including the use of dye test. There is need to determine if IVU (Intravenous urography) should be recommended for women with this disease. The aim of this study was to determine the features of intravenous urography among women with ureteric fistula and therefore determine its relevance in the management of such patients. METHODS: This was a retrospective study conducted at the National Obstetric Fistula Centre, Abakaliki between January 2012 and March 2017. All patients with ureteric fistula during the study period who were assessed with intravenous urography before surgery were included in this study. RESULTS: The mean age was 38 ± 16 years. Twelve (92.3%) were Christians. IVU showed hydroureters in 46.15% hydronephrosis in 53.85%, non-functioning kidney in 46.15% and ureteric stricture in 7.69%. IVU gave an insight into the side with ureteric fistula except in one who had normal result. CONCLUSION: Hydronephrosis, hydroureters and silent (non-functioning) kidneys are features of IVU in women with ureteric fistulas, however these features are not pathognomonic for the disease.

Renocolic fistula secondary to urothelial carcinoma.

A 77-year-old man presented with watery, bloody diarrhoea, symptomatic anaemia and signs of sepsis. He was well known to our unit with a history of extensive low-grade urothelial carcinoma involving a solitary kidney. CT performed on admission demonstrated a new finding of renocolic fistula. Due to his multiple medical and surgical comorbidities conservative management was elected. He passed away after 1 year of follow-up.

Evaluation of renal defect healing, hemostasis, and urinary fistula after laparoscopic partial nephrectomy with oxidized cellulose.

BACKGROUND AND PURPOSE: Laparoscopic partial nephrectomy (LPN) has been performed at several institutions using oxidized cellulose (OC) as a means of bleeding and urinary fistula (UF) prevention. However, a foreign-body reaction mimicking either abscess or tumor recurrence has been associated with the use of OC. We evaluated renal-defect healing after LPN with and without OC. MATERIALS AND METHODS: Sixteen female Landrace pigs underwent lower-pole excision; all the collecting systems were entered and then closed with absorbable running suture. In group 1, hemostatic U-shaped stitches were the only method of hemostasis. In group 2, a bolster of OC was added to the renal defect. The pigs were sacrificed at 1, 4, 7, or 21 days, and gross findings such as perirenal collection were observed. A catheter was advanced up to the kidney, and methylene blue was injected with collecting system pressure observation; burst pressure was defined as the appearance of extravasation. High risk for UF was defined as burst pressure <10 mm Hg. RESULTS: Neither hemorrhage nor urinoma was observed during sacrifice. One pig from group 2 had a burst pressure of 4 mm Hg At 7 days (high risk for UF). At 21 days in group 2, the tissue was grossly solid, apparently a granuloma. Suppuration tended to be greater in group 2. The foreign-body reaction was more intense in group 2 and was strongly present at 4, 7, and 21 days. CONCLUSIONS: The use of OC is associated with higher scores of suppuration and foreign-body reaction. After LPN with OC, postoperative day 7 might be a critical time for the development of urinary leakage.

Nephrobronchial fistula - a case report.

We report the case of a 58-year-old woman with a hydronephrotic left kidney who presented with a 4-month history of anorexia, weight loss and intermittent left loin pain associated with cloudy urine. Her urine grew lactose fermenting coliforms, and was treated with antibiotics. A computerized axial tomography scan (CT scan) was equivocal and she underwent retrograde ureteric stenting, which drained a pyonephrosis. She went on to develop a chest infection due to a lung abscess. A CT scan revealed a left perinephric collection extending across the diaphragm into the lower lobe of the left lung. She responded to antibiotics and awaits a nephrectomy.