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The tunica-vaginalis flap to prevent postoperative fistula following severe hypospadias repair: Has the search for Holy Grail ended?
Colgajo de túnica vaginal en la prevención de fístulas postoperatorias tras reparación de hipospadias severos: ¿ha terminado la búsqueda del Santo Grial?
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "552" "paginaFinal" => "556" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C.N. Radhakrishnan, V. Radhakrishna" "autores" => array:2 [ 0 => array:3 [ "nombre" => "C.N." "apellidos" => "Radhakrishnan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "V." "apellidos" => "Radhakrishna" "email" => array:1 [ 0 => "vbrps2016@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Paediatric Surgery, Manipal Hospital, Bengaluru, India" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Paediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, India" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Colgajo de túnica vaginal en la prevención de fístulas postoperatorias tras reparación de hipospadias severos: ¿ha terminado la búsqueda del Santo Grial?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1500 "Ancho" => 1500 "Tamanyo" => 567130 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intraoperative image showing the delivering of the testis into the wound (Fig. 1A), harvesting Tunica-Vaginalis flap (Fig. 1B), tucking of the flap between the layers of glanuloplasty (Fig. 1C, D), fixing the rest of the TVF (Fig. 1E), and final appearance (Fig. 1F).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fistula following hypospadias repair remains a bane of the hypospadiologist and it has resulted in the evolution of various techniques. Various tissue covers have been used to buttress the urethroplasty to reduce the chances of fistula formation. Despite all these, the incidence of postoperative fistula varies between 10 and 30% irrespective of the procedure performed.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The incidence of a fistula increases with the severity of the hypospadias.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Hence a study was performed to evaluate the efficacy of Tunica-Vaginalis Flap (TVF) in preventing fistula formation following severe hypospadias repair.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">An observational study was performed in the Department of Paediatric Surgery and Pediatric Urology in a tertiary center between 2008 and 2017. An “Institute Ethical Committee” approval was obtained. All children presented to the Department of Paediatric Surgery and Paediatric Urology with hypospadias were considered for the study. The children with only severe hypospadias (Proximal penile, Penoscrotal, Scrotal, and Perineal) were recruited for the study. All the children were operated by a single surgeon. The children with proximal penile hypospadias underwent Snodgrass repair. The children with Penoscrotal, Scrotal, and Perineal hypospadias underwent two-stage Bracka’s repair. Before the first stage, children with a small penis and/or glans received 100 IU/kg human Chorionic Gonadotropin twice weekly for three weeks and subsequently underwent chordee repair. Preoperative human Chorionic Gonadotropin was given in those patients where the penis was small and it was felt that an increased the size would make the surgery easier and therefore improve the outcome both in terms of function and cosmesis. The second stage repair was performed after six months.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In all the patients, TVF was used to buttress the urethroplasty. On completion of the urethroplasty, the testis was delivered into the wound (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). A flap of the parietal layer of Tunica-Vaginalis was harvested taking care not to damage the vas and vessels. It was ensured that the length of the flap was long enough to prevent any torsion or chordee from the flap itself (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The tip of the flap was tucked between the layers of glanuloplasty using 6−0 polydioxanone suture (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C, D). A few tucking sutures were placed to fix the rest of the TVF (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E). The TVF was covered by skin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>F). The children were discharged home after three days. The urethral catheter was removed after eight days. Patients were followed up for at least a year post-surgery.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The age of the child at the time of surgery, the position of the meatus, and the procedure performed were noted. Postoperatively, the child was examined for wound infection, urinary tract infection, fistula, meatal stenosis, glans breakdown, residual chordee, and final position of the meatus. The child requiring an additional procedure was documented along with the indication.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The age at surgery was presented in mean ± standard deviation. The rest of the parameters were presented in number with a percentage.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">There were a total of 353 children with hypospadias were presented during the study period. One-hundred-and-forty-three children were excluded as they had either a glanular, coronal, distal-penile or mid-penile hypospadias. Hence, a total of 210 children were included in the study.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The mean age at surgery was 22 months ±10 months. Amongst the 210 children included in the study, 30 (14%) children had proximal penile hypospadias. All these 30 children had a mild chordee which was at skin or dartos level corrected by penile degloving. They underwent Snodgrass repair. One hundred and forty-five (47%) had Penoscrotal hypospadias and 35 (11%) had Scrotal hypospadias with significant chordee requiring excision of urethral plate. Hence, all these children underwent Bracka’s two-stage procedure. A total of six doses of human Chorionic Gonadotropin injections twice weekly @ 100 IU/kg were given before the 1st stage procedure.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Four (2%) children developed a fistula. All these were following two-stage repairs. Two of them had spontaneous healing, while the rest two were managed with fistula closure after six months. Superficial surgical site infection was seen in 10 (5%) patients, managed with wound care and antibiotic therapy. Two (1%) had pain in the scrotum for the first two days postoperatively, managed with analgesics. Two (1%) had a partial breakdown, requiring residual repair. Meatal stenosis was seen in four (2%) children, two were managed by meatal dilatation, and two with meatoplasty. The final position of the meatus was glanular in all the children. No child had a urinary tract infection, residual chordee or penile torsion (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The follow-up ranged from two years to 11 years with a mean follow-up period of 6.2 years ± 4.1 years.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Hypospadias is one of the most common congenital urogenital anomalies affecting one in 125 live-born male children.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The repair of hypospadias is an art which judges the surgeon’s operative skill and patience. An excess of 150 procedures described in the literature to repair hypospadias.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However irrespective of the position of the meatus, postoperative fistula remains the most common complication in most of the studies.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Various interposition flaps have been used in the repair of hypospadias to prevent fistula. These are inner preputial soft tissue flap, Belman flap, Smith’s flap, spongiosa, dartos flap, Buck’s fascia, and TVF.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–10</span></a> Initially, the TVF was being used to cover the defect in the tunica albuginea following the repair of severe chordee.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The TVF was first introduced by Snow et al. to buttress the urethroplasty.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The reliable blood supply from cremasteric vessels makes this an attractive option.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The commonest causes of fistula formation are tissue ischemia and poor tissue quality.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The other causes of fistula formation are postoperative infection, hematoma, poor tissue handling, inadequate or improper urethral cover/flap, poor suturing technique, urethral stricture, and meatal stenosis.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> The severe (proximal) hypospadias carry a higher rate of fistula compared to the distal hypospadias. Yildiz et al. found a 1.3 fold increase in fistula rate when the hypospadias was mid penile or proximal to it.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Yildiz et al. also found that the rate of a fistula increases with the age of the child.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The TVF reduces the fistula formation by its rich vascularity.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> When no cover was used for urethroplasty the overall fistula rate was 21% and fistula rate in the proximal hypospadias repair was 49%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The studies such as Handoo YR, Snow et al., and Kadian YS et al. which used TVF cover during hypospadias repair achieved lesser incidence of fistula (5.4%, 9.1%, and 4.5% respectively).<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10,13</span></a> In our series, a fistula rate of 2% was achieved despite all being severe degrees of hypospadias. This was achieved by ensuring a tension-free urethroplasty, mobilizing an adequate length of TVF (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) to prevent postoperative torsion, and incorporation of TVF even between the layers of glanuloplasty (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C, D) which provides good blood supply to the entire length of urethroplasty. TVF was also found to be excellent in treating fistula, recurrent fistula, multiple fistulae, and crippled hypospadias.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The surgical site infection in our study was more than Pescheloche et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Most of the studies on hypospadias have neglected surgical site infection in their study. The higher rate of wound infection in our study is contributed to low socio-economic status, poor hygiene, and the severity of the hypospadias requiring prolonged surgery. These patients didn’t develop a fistula, thanks to the good vascular barrier effect of TVF.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Scrotal pain following hypospadias repair is peculiar only to the use of TVF, which can be treated with analgesics.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Residual chordee or torsion is prevented by mobilizing the TVF by adequate length. One more advantage of TVF is that we can mobilize the TVF till the external ring, which gives good length. A short TVF can cause chordee and/or penile torsion. A meticulous dissection of TVF avoids all the complications associated with the use of TVF.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0080" class="elsevierStylePara elsevierViewall">The Tunica-Vaginalis flap is an excellent buttress in severe hypospadias repair. It is readily available, easy to harvest, with its good vascularity helps to significantly reduce the incidence of postoperative fistula.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1581953" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1423945" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1581952" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1423944" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1423945" "palabras" => array:3 [ 0 => "Hypospadias" 1 => "Tunica-vaginalis flap" 2 => "Urethro-cutaneous fistula" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1423944" "palabras" => array:3 [ 0 => "Hipospadias" 1 => "Colgajo de túnica vaginal" 2 => "Fístula uretrocutánea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Fistula following hypospadias repair remains a bane of the hypospadiologist resulting in the evolution of various techniques. Despite all these, the incidence of postoperative fistula varies from 10 to 30% and it increases with the severity of the hypospadias. Hence, a study was conducted to evaluate the efficacy of tunica vaginalis flap in preventing fistula formation following severe hypospadias repair.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">An observational study was carried out in a tertiary center between 2008 and 2017. The study included children with severe hypospadias (Proximal penile, Penoscrotal, scrotal, and Perineal). In all the patients, a Tunica-Vaginalis flap was used to buttress the urethroplasty. All the patients were followed up for at least a year after the completion of treatment.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A total of 210 patients were included in the study. Bracka’s two-stage repair was performed in 180 patients who had either Penoscrotal hypospadias or a meatus even more proximal. The rest 30 patients with proximal penile hypospadias underwent a single-stage Snodgrass repair. Four (2%) patients developed a fistula, all following two-stage repairs, and half of them required surgical repair. Two (1%) patients had a partial breakdown of repair and underwent a residual repair after six months.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The Tunica-Vaginalis flap is an excellent buttress in severe hypospadias repair. It is readily available, easy to harvest, with its good vascularity helps to significantly reduce the incidence of postoperative fistula.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La fístula posterior a la reparación del hipospadias sigue siendo un desafío para el hipospadiólogo, por lo que se han desarrollado diversas técnicas. Sin embargo, la incidencia de la fístula postoperatoria sigue estando entre el 10 y el 30%, y aumentando de acuerdo con la severidad del hipospadias. Hemos realizado un estudio para evaluar la eficacia del colgajo de túnica vaginal en la prevención de la formación de fístulas tras la reparación de casos severos de hipospadias.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio observacional en un centro terciario entre 2008 y 2017. El estudio incluyó a niños con hipospadias severos (proximal, penoescrotal, escrotal y perineal). En todos los pacientes se usó un colgajo de túnica vaginal para reforzar la uretroplastía. Todos los pacientes recibieron seguimiento durante al menos un año tras finalizar el tratamiento.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Se incluyó un total de 210 pacientes en el estudio. Se realizó reparación en dos etapas de Bracka en 180 pacientes con hipospadias penoescrotal o un meato aún más proximal. Los 30 pacientes restantes con hipospadias proximales se sometieron a la reparación de Snodgrass de una sola etapa. Cuatro (2%) pacientes desarrollaron fístulas, todos después de la reparación en dos etapas, y la mitad de ellos requirieron corrección quirúrgica. Dos (1%) pacientes tuvieron una avería parcial de la reparación y se sometieron a una reparación residual a los seis meses.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El colgajo de túnica vaginal es un excelente refuerzo en la reparación de hipospadias severos. Es fácilmente accesible, fácil de extraer, y su buena vascularización ayuda a reducir significativamente la incidencia de fistulización postoperatoria.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Radhakrishnan CN, Radhakrishna V. Colgajo de túnica vaginal en la prevención de fístulas postoperatorias tras reparación de hipospadias severos: ¿ha terminado la búsqueda del Santo Grial? Actas Urológicas Españolas. 2021;45:552–556.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1500 "Ancho" => 1500 "Tamanyo" => 567130 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intraoperative image showing the delivering of the testis into the wound (Fig. 1A), harvesting Tunica-Vaginalis flap (Fig. 1B), tucking of the flap between the layers of glanuloplasty (Fig. 1C, D), fixing the rest of the TVF (Fig. 1E), and final appearance (Fig. 1F).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number (Percentage) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Management \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spontaneous resolution (2 patients)Surgical closure after six months (2 patients) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wound infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 (5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wound care and antibiotic therapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain in the scrotum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Analgesics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Partial breakdown of repair \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Residual repair \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meatal stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Meatal dilatation (two patients), Meatoplasty (two patients) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urinary tract infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Residual chordee \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Penile torsion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urethral stricture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 (10%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2709834.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Complications of urethroplasty.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors for the development of urethrocutaneous fistula after hypospadias repair: a retrospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.W. Chung" 1 => "S.H. Choi" 2 => "B.S. Kim" 3 => "S.K. Chung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4111/kju.2012.53.10.711" "Revista" => array:6 [ "tituloSerie" => "Korean J Urol." "fecha" => "2012" "volumen" => "53" "paginaInicial" => "711" "paginaFinal" => "715" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23136632" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tunica vaginalis flap for urethrocutaneous fistula repair after proximal and mid-shaft hypospadias surgery: a 12-year experience" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Pescheloche" 1 => "B. Parmentier" 2 => "T. Hor" 3 => "O. Chamond" 4 => "M. Chabaud" 5 => "S. Irtan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jpurol.2018.03.026" "Revista" => array:3 [ "tituloSerie" => "J Pediatr Urol." "fecha" => "2018" "volumen" => "14" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Partially de-epithelialized preputial flap (triangular soft tissue flap): an aid to prevent coronal urethrocutaneous fistulae" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.B. Singh" 1 => "N.M. Pavithran" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00383-003-0998-1" "Revista" => array:7 [ "tituloSerie" => "Pediatr Surg Int." 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