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PATIO Repair for Urethrocutaneous Fistula

PATIO means preserving the fistula tract and turning it inside out. The tract is mobilized and inverted into the urethral lumen rather than excised. Malone's 2009 report introduced the name for this tissue-sparing approach; the proposed mechanism is a passive flap valve aligned with the urinary stream. The initial experience was only five fistulas in four patients.[1]

PATIO is an option for selected small urethrocutaneous fistulas (UCFs), including after hypospadias surgery. It does not replace assessment for distal obstruction, broader urethral breakdown or deficient tissue requiring reconstruction. Compare Simple Closure and Skin Advancement, Double Dartos, Tunica Vaginalis Flap and the male fistula atlas.

Selection and limitations​

The published experience is concentrated in small fistulas, often under 4 mm. A tract must be sufficiently intact and mobile to permit inversion without injury or tension. There is no validated size-only algorithm establishing PATIO as first-line, and evidence for larger defects is sparse.[2][5]

Map the fistula or fistulas and assess the meatus and distal urethra for obstruction. A fistula associated with stricture, diverticulum, major dehiscence or a need for urethroplasty requires a plan for those problems; closing the external opening alone is insufficient. Allow inflammation and tissue quality to guide timing rather than using one compulsory waiting interval for every repair.[2][8]

Coronal and more proximal sites have been treated. The available studies did not identify a clear location-related difference, but small numbers and nonrandomized comparisons do not establish equivalent success at every site. Reports after genital piercing or gender-affirming reconstruction are limited and should not be extrapolated to all adult neourethral fistulas.[2]

Operative principles​

  1. Expose and define the tract. Plan preservation from the outset. Use gentle traction to distinguish its wall from surrounding scar.
  2. Dissect circumferentially to the urethral wall. Free the tract while maintaining its integrity. Buttonholing, crushing or devascularizing it may prevent a reliable inversion repair.
  3. Invert toward the urinary meatus. Bring the tract into the lumen in the intended orientation without twist or tension. The proposed valve mechanism depends on an intact, adequately mobilized tract.
  4. Choose the fixation and coverage strategy. Classic descriptions maintain inversion with a suture secured at the glans; modified approaches omit this fixation. Ligation or additional vascularized coverage has also been used.
  5. Close the superficial tissues. Reassess the reconstruction and determine whether urinary drainage is appropriate. If the tract cannot be preserved or inverted satisfactorily, reconsider the repair rather than relying on the name of the technique.[1][2][3]

Classic inversion avoids a direct urethral closure suture line, but it does not eliminate breakdown, leakage or recurrence. Modified ligation techniques also show why “PATIO uses no sutures” is an inaccurate description of the entire family.[1][2]

Described modifications​

Rathod and colleagues reported a modified approach in 15 boys, with follow-up available for 12. Gigola and colleagues later described four stay sutures to guide tract dissection without fixing the tract at the urethral meatus. These are technical variants supported by small series, not proof that fixation is always unnecessary or that four sutures are superior.[3][4]

Tunica vaginalis or local tissue may be added when indicated. In Nerli's series, four of ten children received tunica vaginalis interposition. The absence of a statistically significant benefit from extra coverage in heterogeneous pooled data is not evidence that a flap cannot help a selected patient.[2][5]

Clinical outcomes​

SourceDenominator and outcomeScope
Malone 2009Five repairs in four patients; all closed at mean follow-up 18 months, range 2–50 months.Initial case series, including previously failed repairs.[1]
Nerli 2011Ten children with a solitary fistula under 4 mm; no recurrence reported. Four received a tunica vaginalis flap.Small selected series; the result does not isolate inversion alone.[5]
Rathod 2017Fifteen boys underwent modified PATIO; 12 had follow-up, with two recurrences. One recurrence was subsequently repaired with repeat PATIO.Ten initial successes among 12 followed, not a complete 15-patient success estimate.[4]
Gigola 2024Twenty-five patients underwent repair; 24 had follow-up. Five recurred at median three years; one was successfully treated with repeat PATIO.Nineteen initial successes among 24 followed; no control group.[3]

The retrospective comparison​

Singh's study reported 21/26 successful PATIO repairs versus 8/18 standard repairs (P = .023), with eight successful PATIO repairs after failed standard repair. These repair episodes came from 44 patients and are not three independently randomized cohorts. Selection, technique, calendar period and experience can influence the difference; the eight salvage successes do not establish a 100% expected salvage rate.[6]

Interpreting the 2023 reviews​

The PATIO-focused review identified 18 reports, including two duplicate abstract/manuscript entries. Its overall 314/356 success (88.2%) combines three different groups: 47 patients with inversion alone, 84 with ligation plus inversion, and 225 with ligation without inversion. Therefore, 88.2% is not the success rate of classic PATIO alone. Reported subgroup success was 87.2%, 86.9% and 88.9%, respectively; non-significant between-group tests do not prove equivalence.[2]

A separate review of 71 UCF-repair studies reported 93.5% for PATIO alongside other technique-specific estimates. These overlapping, heterogeneous evidence sets should not be treated as independent trials or used to rank PATIO below tunica vaginalis or above simple closure for otherwise identical patients.[7]

Recovery and surveillance​

Selected uncomplicated cases can be managed without a urethral catheter and as day surgery. In Malone's initial report, four operations used this approach; one child stayed overnight with a catheter because of retention concerns after caudal anesthesia. This does not establish that every patient should avoid drainage or require admission after a caudal block.[1]

Choose catheter use, fixation-suture removal and activity restrictions according to the repair and local protocol. Assess wound healing, recurrence and urinary stream; investigate symptoms suggesting obstruction or another urethral problem. Repeat PATIO is possible in selected failures, but subsequent repair should be chosen after reassessing the anatomy and cause of failure.[2][3][4]

References​

1. Malone PR. "Urethrocutaneous fistula: preserve the tract and turn it inside out — the PATIO repair." BJU Int. 2009;104(4):550–554. doi:10.1111/j.1464-410X.2009.08350.x

2. Choudhury P, Phugat S, Jain V, et al. "Defining the indications of PATIO technique for urethrocutaneous fistula repair." J Indian Assoc Pediatr Surg. 2023;28(5):375–386. doi:10.4103/jiaps.jiaps_25_23

3. Gigola F, Mantovani A, Zulli A, et al. "Modified PATIO technique for urethrocutaneous fistula after hypospadias repair: experience from a tertiary referral hospital." J Pediatr Urol. 2024;20(3):437.e1–437.e6. doi:10.1016/j.jpurol.2024.01.031

4. Rathod K, Loyal J, More B, Rajimwale A. "Modified PATIO repair for urethrocutaneous fistula post-hypospadias repair: operative technique and outcomes." Pediatr Surg Int. 2017;33(1):109–112. doi:10.1007/s00383-016-3983-1

5. Nerli RB, Metgud T, Bindu S, et al. "Solitary urethrocutaneous fistula managed by the PATIO repair." J Pediatr Urol. 2011;7(2):166–169. doi:10.1016/j.jpurol.2010.04.016

6. Singh J. "Urethrocutaneous fistula repair following hypospadias surgery using the PATIO technique for small fistulae: a single centre experience." J Pediatr Urol. 2022;18(1):60.e1–60.e7. doi:10.1016/j.jpurol.2021.11.014

7. Choudhury P, Saroya KK, Jain V, et al. "'Waterproofing layers' for urethrocutaneous fistula repair after hypospadias surgery: evidence synthesis with systematic review and meta-analysis." Pediatr Surg Int. 2023;39(1):165. doi:10.1007/s00383-023-05405-1

8. Santangelo K, Rushton HG, Belman AB. "Outcome analysis of simple and complex urethrocutaneous fistula closure using a de-epithelialized or full thickness skin advancement flap for coverage." J Urol. 2003;170(4 Pt 2):1589–1592. doi:10.1097/01.ju.0000084624.17496.29