| BackgroundHypospadias is the most common congenital malformation of male external genitalia.As one of the most important diseases in pediatric urology,the etiology of hypospadias is still unclear.In recent years,the incidence of hypospadias has increased in varying degrees reported at home and abroad.Because it is impossible to contain the occurrence of the disease directly from the fetal period,the surgical treatment after birth has become the only solution.Without timely surgical correction in childhood,many problems such as abnormal urination and erectile function,differences in the appearance of external genitals,and inability to urinate in standing position will cause great inconvenience to the patients,with the growth of their age.These problems can even affect their mental health,making them self-abased,introverted or extreme.At present,there are more than hundreds of surgical methods for hypospadias at home and abroad,but the views of principle have not changed significantly compared with those in the early years,all of which require full straightening of the inferior curvature of the penis,shaping the external orifice of the urethra in the correct position of the glans and no residual complications.Programmatic surgical procedures are still full correction of hypospadias,reconstruction of artificial urethra followed by penile skin plasty and so on.With the advancement of pediatric anesthesia techniques and surgical fine instruments,the surgical treatment of hypospadias in children has become mature.However,no matter what surgical method is used to repair hypospadias,short-term and long-term complications such as urethral fistula and urethral stricture can still not be avoided completely,especially urethral fistula,which is one of the most common short-term complications.Although the solution is not complicated,and the incidence rate has decreased somewhat in recent years,it is still very high compared with other complications.And usually there is still a high possibility of recurrence after a surgery repair for the complication of urethral fistula,so it is particularly important to reduce the incidence of urethral fistula and avoid the occurrence of it after the first urethral fistula repair operation.ObjectsThis study provides a statistical analysis of the suspected influencing factors that may cause single versus multiple urethral fistulas in children after multiple surgical approaches to repair hypospadias,to further clarify the key independent influencing factors for multiple occurrence of urethral fistulas,and to discuss how to prevent its occurrence and treatment methods that may provide a reference for clinical work and improve the prognosis of hypospadias.MethodsIn this study,the clinical data of children with hypospadias treated in the Department of Pediatric Urology of the first affiliated Hospital of Zhengzhou University from January 2014 to August 2021 were collected retrospectively.The following cases were excluded:(1)abnormal development of sex;(2)the first operation that was performed in other hospital;(3)the first operation that was performed in our hospital but the complications were treated in others;(4)patients that with a history of androgen drugs within 3 months before urethroplasty;(5)urethral stricture was associated with urethral fistula after urethroplasty,and proximal urethrostomy was performed for the treatment of urethral stricture;(6)the fistula is located in the ventral part of the head of the penis distal to the coronary sulcus,and the tissue connecting the fistula to the external urethra is cut directly without further penile head formation.A total of 222 children with urethral fistula were collected.They were divided into a single urethral fistula group(n=156)and a multiple urethral fistula group(n=66)according to whether they had multiple postoperative urethral fistulas.All surgeries for hypospadias and complications such as urethral fistula repair were performed by the same treatment team.By combining our clinical experience and relevant domestic and international literature,a total of 26 influencing factors that may be associated with recurrent urinary fistulas were included:the degree of hypospadias,other co-morbidities of the urinary system,length of the formed urethra,surgery time for shaped urethra,weight at urethroplasty,age at urethroplasty,method of urethroplasty,season of urethroplasty,urethral stricture after urethral operation,more urethral secretions after urethroplasty,application of postoperative analgesic or sedative drugs,urinary drainage type after urethroplasty,the time of urethral catheter removal after urethroplasty,the time of urethral dressing removal after urethroplasty,method of the first fistula repair,season of the first fistula,location of the first fistula,diameter of the first fistula,the time of the first fistula repair,weight at the first fistula,the interval between the first fistula and urethroplasty,number of the first fistulas,more urethral secretions after the first fistula repair,analgesia or sedative after the first fistula repair,the time of catheter removal after the first fistula repair and the time of dressing removal after the first fistula repair.There are 12 numerical variables,7 binary variables and 7 multi-classified variables among them,and the related data of these factors are statistically analyzed by SPSS25.0.ResultsUnivariate analysis showed that the time of dressing removal after the first fistula repair,the urethral secretion after the first fistula repair,the type of urinary drainage after urethroplasty(P<0.001),the first fistula repair method(P<0.001)and the position of the first fistula(P<0.001)and the diameter of the first fistula(P<0.001)were considered to be suspected factors related to recurrent urinary fistulas.In addition,in the data of numerical variables,both P values of the age of urethroplasty and length of the formed urethra were close to 0.05,thus they were also included into the list of suspicious influencing factors.By multivariate logistic regression analysis,the independent influencing factors of recurrent urethral fistula after urethroplasty were urinary drainage mode(P<0.001)and more urethral secretion after the first fistula repair(P<0.001).By using these two factors to predict recurrent urethral fistula after urethroplasty,both AUC values of then were more than 0.5.The AUC predicted by the combination of the two factors was 0.678.Among the 222 patients,there was no one combined with urethral diverticula,and 27 cases were combined with urethral strictures,21 of which were treated with urethral dilatation by pediatric urethral probes under general anesthesia with the removing of 8-10 Fr catheters 4 weeks later.And 6 cases were found to have urethral strictures after urethral probes under general anesthesia,witch were treated with scar tissue excision around the urethral orifice and urethral orifice reconstruction,and also they removed the 8-10 Fr catheters 4 weeks later.Among the 222 cases,156 children with single urethral fistula were cured after a single urethral fistula repair,while the remaining 66 children with multiple urethral fistulas were cured after two fistula repairs in 49 cases and three fistula repairs in 16 cases,and one child was completely cured after four fistula repairs over a period of 3 years because of the high urethral discharge after each urethral fistula repair operation.Among the 222 patients,27 cases were complicated with urethral stricture,21 cases were treated with urethral probe urethral dilatation and indwelling 8～10Fr catheter under general anesthesia for 4 weeks,and 6 cases were found to be urethral stricture after urethral exploration under general anesthesia.after resection of scar tissue around external urethral orifice and urethroplasty,8～10Fr catheter was also removed 4 weeks later,and there was no recurrence of dysuria.Among the 222 cases,156 cases of single urinary fistula were cured after one time repair of urinary fistula,and the remaining 66 cases of recurrent urinary fistula were finally cured too,of which 49 cases were cured after secondary fistula repair,16 cases were cured after three times of fistula repair.And 1 case had more urethral secretion after each fistula repair operation,witch was completely cured after 4 fistula repair operations for a period of 3 years.ConclusionsThe mode of urinary drainage after urethroplasty and more urethral secretion after the first fistula repair are independent influencing factors of recurrent urinary fistula after urethroplasty in children with hypospadias.Among them,urinary catheter as the way of urinary drainage after urethroplasty is the independent protective factor of recurrent urinary fistula,while the occurrence of more urethral secretion after the first fistula repair is its independent risk factor. |
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