Simple Closure with Skin Advancement Flap for Urethrocutaneous Fistula
Local tissue can close a selected urethrocutaneous fistula (UCF) while separating the urethral and superficial suture lines. In Santangelo and colleagues' series, 66/69 simple repairs succeeded with de-epithelialized or full-thickness advancement coverage. This is a selected case-series result, not a guaranteed success rate or proof of superiority to other operations.[1]
See the male fistula atlas, PATIO, Scrotal Flaps and Tunica Vaginalis Flap for alternative repairs.
Assessment and selection
Assess the fistula or fistulas, urinary stream, meatus and distal urethra, tissue quality and associated dehiscence. A fistula accompanied by stenosis or a substantial urethral defect may require meatoplasty or urethroplasty rather than closure alone. The ability to obtain a viable, tension-free repair matters alongside size and location.[1][2][10]
Local advancement and de-epithelialized flaps have been used at coronal and shaft sites, including selected recurrent fistulas. A small fistula is not automatically suitable for simple closure, and a larger or coronal fistula does not automatically mandate a particular flap. Size-based recommendations in older series reflect their selection strategies.[2][6][7]
Reconstruction options
The objectives are a sound urethral closure, vascularized coverage where appropriate, and skin closure without excessive tension. Overlapping suture lines can be avoided, but recurrence also depends on obstruction, tissue quality and the overall reconstruction; no single maneuver eliminates failure.[1][4][5]
De-epithelialized coverage
After defining and repairing the urethral defect, a viable local flap can be de-epithelialized and positioned over the closure while retaining its blood supply. Superficial skin is then approximated or advanced with its suture line displaced from the underlying repair. This is distinct from simple closure without a planned interposed flap.[1][3][6]
The older Belman 1988 report describes coverage during primary hypospadias urethroplasty, not isolated UCF repair. Its result should not be substituted for the outcomes of treating established fistulas.[3]
Skin advancement
Adjacent skin is mobilized sufficiently to cover the urethral repair without traction or devascularization. Adequate mobilization does not mean indiscriminate undermining. Reassess whether the available tissue can close safely before completing the reconstruction.[1][4][9]
A longitudinal relaxing incision was described by Chen and colleagues in 34 patients with 46 fistulas. This is a specific adjunct supported by an uncontrolled series, not a mandatory incision at a fixed distance from every closure or proof that it is the single key to success.[4]
Hinged turnover dartos variant
Ahuja described closing the inner fistula edges with an inverting subcuticular stitch, raising adjacent de-epithelialized skin with dartos on a preserved tissue hinge, and turning this flap over the first layer. A penile or scrotal skin flap, or an overlapping skin closure, completed coverage. Thus, the exact tissue retained or excised depends on the variant; routine complete tract excision followed by this skin-edge inversion should not be prescribed as one universal sequence.[8]
Use fine absorbable sutures suited to the tissue and the chosen technique; select the material and filament structure deliberately. Preserve perfusion and avoid unnecessary cautery or traction. For the broader material principles, see Sutures.
Clinical outcomes
| Source | Finding | Interpretation |
|---|---|---|
| Santangelo 2003 | Six failures among 94 repairs overall; three failures among 69 simple repairs with local advancement or de-epithelialized coverage. | The 25 complex repairs included different urethral reconstructions. Report repair denominators rather than calling all 99 reviewed patients treated successes.[1] |
| Geltzeiler and Belman 1984 | No recurrence in 19 midshaft repairs using an overlapping de-epithelialized technique; 10/11 coronal advancement repairs succeeded. | Small historical subgroups; 13/19 and 10/11, respectively, were performed without diversion as outpatient procedures.[6] |
| Cimador 2003 | Retrospective comparison reported first-attempt success of 74% with simple closure and 94% with layered repair. | Groups were not randomized. The abstract describes 72 children but lists 39 and 32 in the treatment groups; no unsupported denominator reconciliation is imposed.[10] |
| Dekalo 2020 | Seventy-two children underwent 81 local-tissue repairs; 17 recurred at mean follow-up 7.9 years. | This “simple” technique included subcutaneous coverage. Patients needing revision urethroplasty, other fistula techniques or concomitant meatoplasty were excluded.[7] |
| Ahuja 2009 | Nine of ten healed without complications; one residual pinpoint fistula closed spontaneously. | Final closure in ten is different from ten uncomplicated initial repairs.[8] |
A pooled “skin-flap” category in a heterogeneous systematic review is not interchangeable with one particular advancement technique. Conversely, favorable single-center results do not establish that meticulous technique will reliably produce a success rate over 90% for every patient.[5]
Urinary drainage and recovery
Some uncomplicated repairs can be performed as day surgery without a stent, as in the Santangelo, Geltzeiler and Dekalo series. Those selected populations do not establish a catheter-free rule for every fistula, particularly when another urethral procedure is needed.[1][6][7]
Elbakry's retrospective series observed recurrence in 4/25 patients receiving suprapubic diversion versus 10/22 without it. However, diversion was selected for large or multiple fistulas, and repair techniques differed. The comparison cannot establish a causal reduction from 45% to 16% or mandate suprapubic drainage solely because a fistula exceeds 4 mm.[2]
Tailor urinary drainage, dressings, analgesia and recovery restrictions to the operation. Assess wound healing and recurrence, and evaluate a weak stream, straining or other signs of distal obstruction. Early closure is not the only outcome: the long-follow-up Dekalo cohort also included later meatoplasty and additional penile reconstruction.[7]
Videos
References
1. 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
2. Elbakry A. "Management of urethrocutaneous fistula after hypospadias repair: 10 years' experience." BJU Int. 2001;88(6):590–595. doi:10.1046/j.1464-4096.2001.02390.x
3. Belman AB. "De-epithelialized skin flap coverage in hypospadias repair." J Urol. 1988;140(5 Pt 2):1273–1276. doi:10.1016/s0022-5347(17)42022-2
4. Chen W, Ma N, Wang W, Ju M. "The application of multilayer direct closure with a longitudinal relaxing incision in urethrocutaneous fistula repair." Ann Plast Surg. 2020;84(3):317–321. doi:10.1097/SAP.0000000000002056
5. 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
6. Geltzeiler J, Belman AB. "Results of closure of urethrocutaneous fistulas in children." J Urol. 1984;132(4):734–736. doi:10.1016/s0022-5347(17)49846-6
7. Dekalo S, Ben-David R, Bar-Yaakov N, et al. "In support of a simple urethrocutaneous fistula closure technique following hypospadias repair." Urology. 2020;143:212–215. doi:10.1016/j.urology.2020.06.015
8. Ahuja RB. "A de-epithelialised 'turnover dartos flap' in the repair of urethral fistula." J Plast Reconstr Aesthet Surg. 2009;62(3):374–379. doi:10.1016/j.bjps.2008.03.031
9. Zagula EM, Braren V. "Management of urethrocutaneous fistulas following hypospadias repair." J Urol. 1983;130(4):743–745. doi:10.1016/s0022-5347(17)51434-2
10. Cimador M, Castagnetti M, De Grazia E. "Urethrocutaneous fistula repair after hypospadias surgery." BJU Int. 2003;92(6):621–623. doi:10.1046/j.1464-410x.2003.04437.x