V12-05: The PATIO-repair for urethrocutaneous fistula: Preserve the tract and turn it inside out

Video

Introductions and Objectives
Urethrocutaneous (UC) fistulae after hypospadias surgery have been a serious problem for patients and surgeons since repair was first attempted. We present a technique for repairing penile UC fistula by dissecting out the fistula tract, but instead of excising it, to preserve it and turn it inside out (PATIO); this creates a flap valve inside the urethral lumen that prevents the ingress of urine allowing the fistula to heal.

Methods
Initially the UC fistula tract is mobilized down to the urethra by sharp dissection after a circumferential incision around the skin. Meticulous dissection is important to prevent the formation of a hole in the tract that might invalidate the technique. A 2/0 nylon suture is passed down the tract and brought out through the external urinary meatus. A fine polyglactin suture is then passed through the tip of the fistula tract and tied to the nylon, leaving a length of polyglactin suture sufficient to allow it to be pulled out of the tip of the urethra. As the nylon is pulled out of the urethra the fistula tract is pulled inside out into the lumen of the urethra. The end of the polyglactin suture is sutured to the tip of the external urinary meatus to keep the fistula tract inverted. The subcutaneous tissue and skin are then closed using fine polyglactin.

Results
All repairs were done as day-cases with no catheter; 1 child was catheterized and kept in hospital overnight to prevent retention after a caudal anaesthetic. During a follow-up of 2 years all repairs were successful with no complications/recurrence.

Conclusions
PATIO-repair is easy to perform and can be done as a day-case with no need for urethral catheterization. Early results are encouraging, particularly as it has been used on UC fistulae most liable to recur.

Funding: none