urethrocutaneous rate of oral mucosa to be superior

fistula resolved conservatively 44. Central embedding of the neourethra and
glandular resections , a novel technique was developed by Ardelt 45.They have
reported 4% urethrocutaneous fistulas and 4% meatal or urethral stricture in a
series of 112 proceduresm.Cosmetically impeccable slit-like meatus was present
in 84% of cases and this neomeatus was located at the tip of glans in 98% of


Graft Substitution Of The Urethral Plate

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modern two-staged “terminalising” repair technique was introduced by Aivar
Bracka 46,47 . By this technique ,one can produce a natural slit-like
meatus and hair free , even calibre neo-urethra . Since then, this technique
has gained widespread acceptance. In the first stage , there is creation of a
neourethral plate by skin grafting. In this procedure the urethral plate is
excised; the glans is clefted; chordee released and the resulting defect is
covered with a Wolfe graft . The graft can be taken from inner layer of prepuce
, buccal mucosa  or posterior auricular
skin . The tubularization of this reconstructed urethral plate is done in the
second stage 48. In Bracka’s own words; “Almost any hypospadias can now be corrected
to optimum standard using a simple protocol consisting only of the
popular one-stage TIP (‘Snodgrass’), the graft-augmented TIP
(‘Snod-graft’) and the Bracka two-stage repair. These three methods form
a natural progression”. The same success rate was reported by Alsikafi
et al 49 with using oral mucosa and penile skin in reconstructing neo
urethral plate wwhere as  Barbagli
et al 50,51, reported the success rate of oral mucosa to be superior to
skin in one-stage bulbar urethroplasty (82.8% vs 59.6%) and in one-stage penile
urethroplasty (80% vs. 67%). Other options include mixed interposition. This
can be achieved by using inner preputial skin 52 or dorsal shaft skin 53  . For hypospadias cripples Gill
et al 54 recommended two-staged Bracka’s technique. Histological
changes before grafting and at six months after graft uptake in the buccal
mucosa and exposure to air was studied by Mokhless et al 55 and he found
epithelial hyperplasia with focal keratinisation in the  buccal mucosa . Slightly oedematous lamina
propria with minimal mononuclear cell infiltration was also noticed .  The papillae presented over lamina propria
were elongated and they extended to 75% of the mucosal thickness. The vascularity
of grafted buccal mucosa was good like the normal mucosa .

Fistula closure of hypospadias surgery

of many development in hypospadias surgery , complications still occurs and Urethrocutaneous
fistula (UCF) is one of the most common complication. Many techniques have been
used for its management . Primary repair by separating the skin and urethral
layers and closing them separately is possible only in simple fistula.This has
high success rate(reported success rate 80 – 82.6%)33. In cases of larger
fistula , closure in three layers and coverage with subcutaneous flaps should
be done.  In patients of re-do surgeries
with scarred penis or in patients who lacks prepuce ,interposition of a
vascular intermediate layer is necessary for preventing the fistula formation.
Use of tunica vaginalis flap as a interpositioning intermediate layer during
primary repair and for fistula closure as well was done by Snow et al56. Tunica
vaginalis is thin, elastic , highly vascular expandable , close to penile shaft
and easy to harvest. Due to these properties tunica vaginalis has gained the
world wide acceptance 57-59 .

Dartos and external spermatic fascia from scrotum  have also been used as interposition layer
with appreciable success rates60,61. Classification of fistula based on their
size into three groups was done by Muruganandham et al 62 . He had divided
those fistulas in Group 1 whose size was less than 2mm and he managed it with
excision and simple closure with failure rate of 25.4%. In Group 2, fistulae of
2 – 4 mm in size had been placed and they were managed with flip-flap technique
with dartos flap interposition with failure rate of 9.5%. Fistulae size  >4mm were placed in Group 3 and they were managed
with flip-flap technique with tunica vaginalis flap as a interposition layer with
failure rate of 0% . In patients who have underwent many surgeries for
hypospadias and its complication ,have scarred penis with compromised
vascularity , local tissues can not be used . Nahas et al have used  buccal mucosa grafts in repair of such cases of
urethrocutaneous fistula in 1994 with a success rate of more than 80% 63-66. Fibrin
glue was successfully used by Gopal et al 67  as a sealent of suture-line during primary
surgery . It causes reduction in fistula rate from 32% (controls) to 10% (study
cohort). Single donor fibrin glue was used by Kajbafzadeh et al 68
.Autologus Platelet rich fibrin was used by 
Soyer et al 69  in a 3-
year-old boy with hypospadiac fistula. Platelet rich fibrin not only  supports collagen synthesis and tissue repair
but also accelerates wound healing process .There is no best or universally
accepted technique for fistula repair . It depends on individual cases and
surgeons choice .


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