Association between Head Injury and Serum Sodium Levels

Tim Jumbi,1 Swaleh Shahbal,1 Robert Mugo,1 Francis Osawa,1 Peter Mwika,1 Joel Lessan2
1 University of Nairobi
2 Kenyatta National Hospital
Correspondence to: Dr Jumbi Tim, PO Box 1059–00618, Ruaraka, Nairobi; email:mwaitim@gmail.com

Abstract

Urethro-cutaneous fistula (UCF) is one of the most frequently seen complications of hypospadias surgery requiring re-operation; it occurs with an incidence of between 4% and 28%. Risk factors associated with the development of UCF can be classified as preoperative, intraoperative or postoperative. The aim of this study was to determine the association of peri-operative risk factors and the development of urethrocutaneous fistula after hypospadias repair. A retrospective review of patients who had undergone hypospadias repair at Kenyatta National Hospital between 2013 and 2017 was conducted. 114 patient records were retrieved. The incidence of UCF was 47%. Risk factors that were significantly associated with UCF are hypospadias type (p=0.028), lack of a protective intermediate layer (p=0.002), and presence of postoperative complications (p=0.001). Age at surgery, suture material, type of repair and use of catheter/stents were not significant factors. Multivariate analysis showed wound infection and meatal stenosis as the most significant factors associated with UCF development.

Results: 
Medical records of 248 eyes were reviewed, out of which 132 underwent PHACO and 116 had MSICS. A significant number of the PHACO group had good (6/6 – 6/18) uncorrected visual acuity (UCVA) compared to the MSICS group at 1 -–2 weeks follow –- up (p = 0.003) and at 4 – 6 weeks follow - up (p = 0.002). Both techniques produced comparable best corrected visual acuity (BCVA) at 4 – 6 weeks follow - up (p = 0.084). MSICS resulted in a higher total astigmatic change compared to PHACO (p < 0.001). Rates of intraoperative complications were within the World Health Organization’s (WHO) acceptable standard of less than 5% in both groups. The PHACO group had a higher number of postoperative complications compared to with the MSICS group (p < 0.001). Postoperative borderline and poor uncorrected visual acuity were associated with age, total astigmatic change, and number of postoperative complications.

Key words: Hypospadias, Urethro-cutaneous fistula, Risk factors, Wound infection, Meatal stenosis

Ann Afr Surg. 2019; 16(2):59–63

DOI:http://dx.doi.org/10.4314/aas.v16i2.4

Conflicts of Interest: None

Funding: None

© 2019 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction

Urethro-cutaneous fistula (UCF) is one of the most frequently seen complications of hypospadias surgery (1).Incidence is variable but is commonly reported between 4% and 28% (2). In the Kenyan setting, fistula development remains a significant problem to the paediatric urologist and, coupled with the nature of its recurrence, these fistulae are associated with frequent redo surgeries, increased hospital costs and poor functional and anatomic outcome of the urethra and penile shaft(3). The factors that predispose to fistula development have been proposed to arise from an interplay of pre-operative, intraoperative and postoperative factors (4, 5).While some authors have identified individual factors such as the type of hypospadias and age at surgery as the most significant risk factors, contrary reports state that the surgical technique is the most significant contributor (1, 6). Variability of the surgical technique employed globally makes the association with fistula occurrence challenging. Nevertheless, breaking down the surgical technique into measurable components allows for statistical analysis. Such components include type of repair, tissue handling, use of vascularized tissue layers, and type and size of suture material (1, 2, 7).Fistula formation is multifactorial and the risk factors for fistula development vary. The management approach to UCF requires knowledge of the factors that contribute to their formation. The purpose of this study was to determine the association of peri-operative risk factors with the development of urethro-cutaneous fistula after hypospadias repair.

 

Methods

This study was a retrospective review of patients who had undergone hypospadias repair at Kenyatta National Hospital (KNH), a tertiary teaching hospital in Nairobi, Kenya. Peri-operative data were collected from medical records of patients between 2013 and 2017. All records of patients who had undergone the initial hypospadias repair in KNH were included in the study. Excluding criteria were redo surgery, missing files and incomplete records. Preoperative variables included age at surgery and hypospadias type. Intraoperative variables included the type of repair, use of protective intermediate layer, suture material used, and use of stents/catheters. Data collected on postoperative complications related to fistula formation included meatal stenosis, urethral stricture and wound infection. These complications were recorded from the documented clinical record and voiding cysto-urethrogram reports. All surgeries were done by competent pediatric urologists with more than 15 years of experience in hypospadias repair. Measures to reduce infection included a perineal wash on the morning of surgery, observing aseptic technique with antibiotic prophylaxis, and site preparation with iodine solution before skin incision. Postoperatively, antibiotics were administered and the dressing was kept for 3 days. Data were analysed using SPSS (V.21.0 Chicago-Illinois). Univariate and multivariate analyses were used. The Chi-square test, Fisher’s exact test and logistic regression were used to ascertain association among clinical variables. P-values, odds ratio (OR) and 95% confidence intervals (CI) were calculated where applicable. A p-value of less than 0.05 was considered statistically significant. Institutional approval to conduct the study was sought and granted.

 

 

Results

A total of 174 records of patients who had undergone hypospadias surgery were recorded. The retrieval process was electronic and could only retrieve 148 files; 26 files were missing. Only complete records were considered; 114 out of the 148 files were complete. Figure 1 shows the recruitment flow chart. Figure 2 shows the incidence grouped according to location. The median age at surgery was 2 years with a range between 8 months and 16 years. The overall incidence of UCF was 47%. Table 1 summarizes the characteristics of UCF.

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Click to view Table 1

Table 2 shows the association between risk factors and fistulae occurrence. Type of hypospadias (p=0.028), the use of a protective intermediate layer (p=0.002) and the presence of postoperative complications (p=<0.001) were statistically significant risk factors for UCF development. Age at surgery, suture material, and type of repair and use of catheter/stents were not significant factors. The factors that were significant in univariate analysis were entered on to a logistic regression model for multivariate analysis (Table 3). This confirmed that the presence of wound infection (OR 66.26; 95% CI 10.41–421.62) and meatal stenosis (OR 54.20; 95% CI 4.78–615.72) were the most significant risk factors for UCF development. Trends in UCF incidence between 2013 and 2017 showed direct proportionality to the rates of wound infection and meatal stenosis, evidenced by the reduction in incidence of UCF as the rates of wound infection and meatal stenosis declined (Fig. 3).

Click to view Table 2

Click to view Figure 3

Click to view Table 3

 

Discussion

The goal of hypospadias surgery is to correct the penile curvature, form a neo-urethra of adequate size, bring the new meatus to the tip of the glans, if possible, and achieve an overall acceptable cosmetic appearance (8). The occurrence of uretho-cutaneous fistula therefore prevents the achievement of this goal. The mechanism of UCF development lies in the incorporation of urethral mucosa or neo-urethra in ventral repair with rapid migration of urethral mucosa and skin epithelium into suture tracts, usually due to infection, ischemia or both (9). The pooled incidence of UCF in our study was 47%, which is high compared with other reports in the literature (2, 4).Most fistulae are reported to occur within the first month of surgery (2,4); similarly, we found 70.3% of UCF